TNCC Study Guide-converted

Initial Assessment ● Preparation and Triage ○ Use universal precautions and don PPE ○ Consider any possible patient exposure to hazardous material that puts the trauma team at risk ○ Safe practice, safe care ○ Ensure resuscitation equipment is readily available ● Across the room observation to identify any uncontrolled external hemorrhage ○ Need to reprioritize to Circulation and Control of Hemorrhage ○ Uncontrolled hemorrhage is the major cause of preventable death in trauma patients ● Primary Survey - Inspect, Auscultate, Palpate ○ A: Airway and alertness with cervical spine stabilization ■ AVPU (Alert/verbal stimuli/painful stimuli/unresponsive) ■ Jaw-thrust maneuver to open the airway and assess for obstruction ● Tongue obstruction ● Loose teeth, foreign objects ● Blood, vomitus, secretions ● Edema ■ Listen for obstructive airway sounds (snoring, gurgling, stridor) ■ Feel for subcutaneous emphysema or deformities ■ Definitive Airway devices = ET tube ● Assess for proper placement (ETCO2, bilat breath sounds, absence of gurgling over the epigastrium) ■ Suction the airway if needed, then reassess ○ B: Breathing and ventilation ■ Are they breathing? How well are they breathing? How long can they keep it up? ■ Spontaneous breathing? Symmetrical rise and fall? ■ Depth, pattern, and rate ■ Skin color ■ Breath sounds ■ Palpate bony structures for possible rib fractures, subcutaneous emphysema, soft tissue injury ■ Open the airway if needed ● Use oral airway adjunct, assist ventilations, then prepare for definitive airway ○ C: Circulation and Control of Hemorrhage ■ Any signs of uncontrolled external bleeding? ● Apply direct pressure or use a tourniquet ■ Skin color, temp, and moisture? ■ Listen to heart and lung sounds ■ Palpate central pulses for rate, rhythm, and strength ■ 2 large-bore IVs ● IO if needed ■ Initiate Warmed isotonic crystalloid solution infusion at a controlled rate ● Consider balanced resuscitation needs ● Rapid infusion protocols ■ Component Therapy = replacing patient loss by administering RBCs, plasma, and platelets = balanced approach ● Suggested for fluid resuscitation instead of standard approach (large volumes of IV fluids) ○ D: Disability (Neuro status) ■ GCS (not accurate if patient is intubated) and trends ● Eye Opening • 4 spontaneous • 3 to speech • 2 to pain • 1 none ● Verbal Response • 5 oriented • 4 confused conversation • 3 inappropriate words • 2 incomprehensive words • 1 none ● Motor Response • 6 obeys commands • 5 localizes pain • 4 withdrawal (normal flexion) • 3 abnormal flexion (decorticate) • 2 extension (decerebrate) • 1 none ■ Assess pupils ■ Need for CT of head and cervical spine? ○ E: Exposure & Environment ■ Remove all clothing ■ Inspect for any uncontrolled bleeding or any obvious injuries ■ Keep the patient warm ● Blankets, fluids, room temp, O2 ● Aggressive measures are to be taken to prevent loss of body heat ■ Hypothermia + coagulopathy + acidosis = TRAUMA TRIAD OF DEATH ● Decreased Coagulopathy: • Trauma induced • Resuscitation related ● Increased Acidosis • Reduced pH • Elevated lactate level • Excessive fluids (can lead to DIC) ● Hypothermia, decreased heart performance • Exposure • Excessive bleeding • Worsens acidosis ● ** avoiding excess fluids, initiating hemostatic resuscitation, keep pt warm ○ F: Full set of VS and Family presence ■ Monitor effectiveness of resuscitation efforts and trend VS ■ Facilitate family presence as soon as a member of the trauma team is available to act as a liaison to the family ○ G: Get Resuscitation Adjuncts (Get Stuff!) ■ L: Labs (ABGs, Type and Screen, Lactic Acid) ● Lactic acid is an excellent reflection of tissue perfusion ● Base deficit of -6 is associated with poor outcomes ■ M: Monitor cardiac Rhythm ■ N: Naso or Orogastric tube ■ O: Oxygenation and Ventilation = Pulse ox and ETCO2 ● SpO2 95% ● ETCO2 norm = 35-45 mmHg ■ P: Pain ● Assess for pain using appropriate pain scale ● Give nonpharmacologic comfort measures ○ Repositioning, ice therapy, padding, etc. ● Order appropriate analgesic medication ● Reevaluation for signs of internal uncontrolled hemorrhage and consider the need for patient transfer ○ Portable radiograph ○ Initiate steps for transfer to another facility ● Secondary Survey ○ H: History and Head to toe assessment ■ History from EMTs, Patient, Family ■ MIST = MOI, Injuries, S/S, Tx ■ SAMPLE = Symptoms, Allergies, Meds, PMH, Last oral intake, Events/environmental ■ Head ● Eyes, Ears, Nose ■ Neck & cervical spine ● Tracheal deviation = late sign of tension pneumothorax ■ Chest ● Assess heart, lungs, and bones ● Work of breathing ■ Abdomen & FLANKS ● Presence or absence of bowel sounds ■ Pelvis/Perineum ● Palpate instability of pelvis (gentle pressure over the iliac wings downward and medially and over the symphysis pubis) ● Assess any contraindications for foley catheter ○ Insertion of foley is no longer part of primary assessment due to high risk of CAUTI ■ Inspect and palpate all four Extremities ● Neurological status, color/temp/moisture, sensation, pulses, etc. ○ I: Inspect Posterior surfaces ■ Team assist with log rolling the patient ■ Rectal examination ○ Re Evaluation of adjuncts ■ What injuries were found? ■ What tests were ordered? ■ Abx and Tetanus ■ Wound care ■ Pain meds ■ Splints ● Reevaluation and Post-resuscitation Care ○ Repeat Primary Survey (ABCDE) ○ Vital signs ○ Pain and response to medications ○ Injuries and effectiveness of treatment ● Definitive care or Transfer ○ Need for specific subspecialty care ■ Neurosurgery or orthopedics ■ ICU ■ Trauma surgeon Chapter 1: Teamwork and Trauma Care ● Vital Roles to the trauma team ○ Patient: ■ The trauma nurse’s highest priority is to ensure the patient remains the focus of the provision of the trauma care ○ Team leader ■ Organizes the team; sets clear goals; makes decisions through input of other team members; empower other members; model teamwork behaviors ■ Responsible for maintaining situational awareness, clear communication, and encouraging mutual support