TNCC Trauma Nursing Review Notes
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ScribdTranslationsTNCC Trauma Nursing Review Notes
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ScribdTranslationsTNCC Review Notes 1
TNCC: Trauma Nursing Core Course
A = Airway
- Check for:
Tongue obstruction
Teeth
Vocalization
Blood/vomit in airway
Edema
- If obstruction suction...then reassess
- Maintain C-spine precautions
- Prepare for intubation
Once intubated assess tube placement by auscultating over
epigastric area first then over lung fields
Secure endotracheal tube
Breathing
- Is it spontaneous?
- Accessory muscle use?
- Rate and Pattern?
- Skin color
- Check for bilateral breath sounds
If breath sounds are not bilateral consider: tube
placement/tension pneumothorax
If there is JVD (jugular vein distention) or tracheal deviation
perform needle thoracentesis…..
Insert large bore needle into the 2ndintercostal space at the
midclavicular line…..prepare for chest tube insertion.
C = Circulation
- Palpate central pulses (carotid/femoral)
- Check color/temperature/moisture of skin
- Check prehospital IVs for patency
- Start 2ndlarge bore IV.
Obtain basic labs.
Begin infusion of warmed fluid bolus
- Check for obvious signs of external bleeding
If obvious signs of external bleeding Control bleeding
D = Disability
- Check AVPU
Alert?
Verbal?
Responsive to Pain?
Unresponsive?
- Check pupils. Are they PERRL?
Equal
Round
TNCC Review Notes 2
Reactive to
Light
E = Expose the patient
- Remove all clothes
- Examine patient for obvious injuries/bleeding
- Cover the patient
Use warm blankets
Increase room temperature
F = Full Set of Vitals/Family Presence/Foley
- Obtain a full set of vitals
- Question about family presence and allowing them into the room
- Insert foley and/or gastric tube if indicated
G = Give Comfort
- Obtain a pain rating
- Obtain an order and provide analgesics
- Provide comfort care for injuries.
Ice
Elevation
Splinting
Dressings
H = History/Head-to-Toe
- Obtain a medical history
- Perform a Head-to-Toe assessment noting all injuries
Inspect
Auscultate
Palpate
I = Inspect posterior surface/Identify Injuries/Interventions
- Log roll patient maintaining C-spine precautions
Inspect and palpate the posterior surface
MD to check rectal tone
- Identify all injuries to patient
- Consider Interventions
CT scan
X-ray
Basic Labs
Ultrasound
REEVALUATE THE PATIENT
- Primary Assessment
- Vitals
- Pain Level
- Interventions performed
TNCC Review Notes 3
MNEMONICS TO KNOW
Medications for Intubation: LOAD
- L = Lidocaine (decreases intracranial pressure)
- O = Opiates
- A = Atropine (especially children)
- D = Defasiculating (paralytic)
Pre-Arrival History: MIVT
- Mechanism
- I = Injury
- Vitals
- Treatment
Chest Tube/Intubation Trouble Shooting: DOPE
- D = Dislodgement
- O = Obstruction
- P = Placement/Pneumothorax
- E = Equipment
Disaster: DISASTER
- D = Detection
- I = Incident Command
- S = Safety/Security
- Assess Hazards
- T = Triage & Treatment
- E = Evacuation
- R = Recovery
6 P's of Compartment Syndrome
- Pain
- Pallor
- Pulses
- Paresthesia
- Paralysis
- Pressure
TNCC Review Notes 4
Review Information
Chapter 3: Initial Assessment
- Remove any headgear e.g. football helmet immediately to allow
access to airway and cervical spine
- ALL trauma patients should receive oxygen, regardless of their
preexisting history
- Data collection should take place in a quiet, safe, private
environment away from family members or other individuals.
Chapter 4: Airway and Ventilation
- A nasopharyngeal airway can be used in responsive or
unresponsive patients, but not with facial trauma or suspected
basilar skull fracture
- An oropharyngeal airway can be used in unresponsive patients.
Chapter 5: Shock
- Shock is a syndrome resulting from inadequate perfusion of
tissues, leading to a decrease in the supply of oxygen and nutrients
required to maintain the metabolic needs of cells
- Types of shock:
Hypovolemic:
Most common shock syndrome to affect a trauma patient.
Decrease in amount of circulating blood volume
Hemorrhage, Burns
Cardiogenic
Ineffective perfusion caused by inadequate contractility of
cardiac muscle
Myocardial infarction/Dysrhythmias/Blunt Cardiac Injury
Obstructive
Inadequate circulating blood volume due to obstruction or
compression.
Cardiac tamponade/Tension pneumothorax/Tension
hemothorax
Distributive:
disruption of the SNS control of the tone of blood vessels
which leads to vasodilation and maldistribution of blood
volume or flow
Neurogenic/Anaphylactic/Septic
- There is an immediate vascular response to shock. The venous
capacitance system vasoconstricts to improve venous return to the
right atrium. This can be detected by a rise in the patient’s diastolic
blood pressure
TNCC Review Notes 5
- If BP drops below 50mmHg, cerebral ischemia occurs. Altered
LOC may indicate cerebral ischemia
- The renal response (renin-angiotensin mechanism) takes
approximately 10-60 minutes to fully activate. Decreased urinary
output may be an early sign of renal hypoperfusion, but it is also an
indicator that there is systemic hypoperfusion.
- The pulmonary response: The patient in shock may have
tachypnea for two reasons:
maintain acid-base balance
2. maintain an increased supply of oxygen
- Trends in blood pressure are extremely important.
Early shock is characterized by a normal level or fall in
systolic pressure and a rising diastolic pressure. The pulse
pressure narrows as cardiac output falls and blood vessels
constrict. A narrowing pulse pressure is an ominous sign.
- Type O-negative packed cells are the universal donor. They should
be given to women of childbearing age first due to Rh factor issues.
Chapter 6: Brain and Cranial Trauma
- Herniation occurs as a result of uncontrolled increases in ICP.
Symptoms include:
Unilateral or bilateral pupillary dilatation
Asymmetric pupillary reactivity
Abnormal motor posturing
Other evidence of neurologic deterioration
- Diffuse Brain Injuries:
Concussion
Postconcussive Syndrome
Diffuse Axonal Injury
- Focal Brain Injury
Cerebral contusion
Epidural Hematoma
Hallmark sign Lucid period lasting a few minutes to
several hours
Subdural Hematoma
Intracerebral Hematoma
- Skull Fractures:
Linear
Depressed
Palpable depression over fracture site
Basilar Fracture
Periorbital ecchymosis (raccoon eyes), mastoid
ecchymosis (Battle’s sign), or blood behind tympanic
membrane (hemotypanum)
- Consider hyperventilation BRIEFLY in cases in which increased
ICP is clinically evident and other methods to decrease it are
TNCC Review Notes 6
unsuccessful (ex. Sedation, paralysis, CSF drainage, and osmotic
Diuretics) Prolonged hyperventilation is NOT recommended
- Mannitol is a hyperosmolar volume-depleting diuretic. It decreases
cerebral edema and ICP. It is indicated if the patient has signs of
herniation or progressive neurologic deterioration.
Chapter 7: Ocular, Maxillofacial, and Neck Trauma
- Average normal intraocular pressure is about 15mm Hg with a
range of 10-22mmHg.
- Patients with intraocular pressure >30 mmHg may have glaucoma
or retrobulbar hemorrhage.
- Patients with intraocular pressure < 30 mmHg may have perforated
globe or severe intraocular trauma
Chapter 8: Thoracic Trauma
- Patients with an accumulation of blood or air within their chest
cavity will exhibit respiratory distress, tachycardia, hypotension,
unilateral absence of breath sounds.
- Even small amounts of blood in the pericardial sac can result in
decreased cardiac output. The patient will demonstrate
hypotension, tachycardia, muffled heart sounds, and neck vein
distension.
- Pericardial Tamponade:
Beck's Triad
Muffled heart sounds
Hypotension
Distended neck veins
Chapter 9: Abdominal Trauma
- Positive seatbelt sign means there is the potential for significant
abdominal trauma and hollow organ rupture
- The most commonly injured organs from stab wounds include the
liver, small bowel, diaphragm, and colon.
- Signs and symptoms associated with abdominal injury are blood
loss, abdominal tenderness, specific pain patterns, and absent
bowel sounds
- Pain, rigidity, guarding, or spasms of the abdominal musculature
are classic signs of intra-abdominal pathology
- Hepatic and splenic injuries can indicate significant hemorrhage.
- The small bowel is the hollow organ most frequently injured, this
can be indicated by gross blood from the rectum
- Esophageal injuries can cause subcutaneous emphysema
Chapter 10: Spinal Cord and Vertebral Column Trauma
- Mechanisms of injury to the vertebral column:
Hyperextension: backward thrust of the head
Rear-end MVC "whip-lash"
TNCC Review Notes 7
Hyperflexion: forceful forward flexion
Head-on MVC, head striking windshield
Rotational: combination of forward flexion with lateral
displacement of cervical spine
MVC resulting in forward and spinning motion
Axial Loading: direct force along length of vertebral column
diver striking head on bottom of pool
- Secondary damage to the spinal cord can occur from:
Hypovolemic shock and resulting hypoperfusion
Hypoxia
Neurogenic shock, resulting in bradycardia, peripheral
vasodilation, and hypotension
Injury due to inadequate spinal immobilization
Endogenous biochemical responses causing edema and
cellular necrosis
- Cord concussion: temporary loss of function lasting 24-48 hours.
- Cord contusion: bruising of the neural tissue causing edema and
possible necrosis of tissue from cord compression
- Cord transaction: complete or incomplete disruption of the spinal
tracts
- Interruption in the vascular supply: cord ischemia or necrosis (can
be permanent or temporary depending on the length of interruption
- Neurogenic shock is a form of distributive shock.
temporary loss of sympathetic tone (often less than 72
hours)
hypotension, bradycardia, loss of ability to sweat below level
of injury
- Spinal Shock:
spinal cord injury at any level
loss of reflex function below level of injury
flaccidity
loss of reflexes
Chapter 11: Musculoskeletal Trauma
- Amputation care: keep cool and dry…do not freeze!!
- All open fractures are considered contaminated.
- Be aware of large volume blood loss especially from:
Humerus fracture: <750mL
Femur fracture: <1500mL
Pelvis fracture: >1500mL
- Compartment Syndrome:
Six P’s! (Pain, Pallor, Pulses, Paresthesia, Paralysis,
Pressure
TNCC Review Notes 8
Elevate limb to level of heart to promote venous outflow and
prevent further swelling. Do NOT elevate it above the heart
because this may decrease perfusion to a compromised
extremity
Prepare for fasciotomy as indicated
NO ICE!
Chapter 12: Surface and Burn Trauma
- Because of fluid volume loss, the pathophysiologic response to the
burn leads to the following changes to the vascular system:
Hemoconcentration of the blood through the loss of plasma
volume
Increased blood viscosity
Increased peripheral resistance
Greater percentage of red blood cells
- Prepare for early intubation as needed, especially when signs of
inhalation injury are present.
- The primary goal of fluid resuscitation is to maintain adequate
tissue perfusion and organ function.
- Fluid resuscitation:
Adults: 2-4 ml of crystalloid solution x body weight in kg x
% of TBSA burned
Children 3-4 ml of crystalloid solution x body weight in kg x
%age of TBSA burned
Half the amount calculated should be infused within the first 8.
hours FROM THE TIME OF BURN. The remaining half over
the subsequent 16 hours postburn.
- Urine Output
Infant: 2mg/kg/hr
Child: 1 mg/kg/hr
Chapter 13: Special Populations: Pregnant, Pediatric, and Older
Adult Trauma Patients
- Attempt to place pregnant females on their left side to increase
venous return
Chapter 14: Disaster Management
- Pulmonary Agents:
Phosgene
Irritation to the respiratory tract, coughing, sneezing, watery
eyes, tachypnea, dyspnea
Treat with decontamination, aggressive airway and
breathing management
TNCC Review Notes 9
- Blood Agents:
Cyanide
Occasional almond smell
Cellular anoxia, rapid breathing, dizziness, weakness, rapid
heart rate
Treat with cyanokit, decontamination
- Vesicants:
Mustard, Lewisite
Rhinorrhea, itching, skin irritation, blisters, cough, shortness of breath
Treat with decontamination, aggressive airway and
breathing management. Antidote for Lewisite: dimercaprol
(BAL)
- Nerve Agents:
Tabun, Sarin, VX
Miosis, rhinorrhea, lacrimation, salivation, fasciculations,
seizures
"Juicy" symptoms
Treat with decontamination, ATROPINE, pralidoxime
- Incapacitating agents:
BZ
Treat with Decontamination
- Riot-Control Agents:
Mace
Irritation of respiratory tract, tearing
Treat with decontamination
Common questions
Powered by AIIn the TNCC framework, if a tension pneumothorax is suspected in a trauma patient, as indicated by symptoms such as jugular vein distention (JVD) or tracheal deviation, needle thoracentesis should be performed immediately. A large-bore needle is inserted into the second intercostal space at the midclavicular line to relieve pressure, followed by chest tube insertion to ensure air or fluid can continually escape the chest cavity. This procedure is critical to prevent further respiratory and cardiovascular compromise .
Spinal shock and neurogenic shock are distinct phenomena in spinal cord injury management. Spinal shock is characterized by the loss of reflex function below the level of injury, resulting in flaccidity and the loss of reflexes. Neurogenic shock, on the other hand, is a type of distributive shock secondary to spinal cord injury that causes hypotension, bradycardia, and loss of the ability to sweat below the level of injury due to disrupted sympathetic tone. Understanding their differences is crucial for appropriate management and prognosis prediction .
Beck's Triad, associated with pericardial tamponade, consists of muffled heart sounds, hypotension, and distended neck veins. Recognition of these symptoms is critically important because pericardial tamponade restricts cardiac output by compressing the heart due to fluid accumulation in the pericardium. Rapid intervention, typically via pericardiocentesis, is necessary to relieve this pressure and restore adequate cardiac function, preventing cardiovascular collapse and improving patient survival .
In the management of compartment syndrome, TNCC advises elevating the affected limb to the level of the heart to promote venous outflow without compromising arterial inflow, and preparing for possible fasciotomy. It specifically cautions against using ice or elevating the limb above the heart, as these actions can further decrease perfusion to the compromised extremity, exacerbating ischemia and tissue damage. Prompt recognition and adherence to protocol are vital to prevent irreversible muscle and nerve damage .
When treating a pregnant trauma patient, TNCC guidelines recommend placing the patient on her left side to reduce the risk of supine hypotensive syndrome and increase venous return, thus improving cardiac output. This position also helps to protect uteroplacental circulation. It's crucial to regularly monitor both maternal and fetal signs, adjusting interventions as needed to prevent complications and ensure the safety of both mother and fetus .
Adhering to fluid resuscitation guidelines is critical in burn trauma to ensure adequate tissue perfusion and organ function. TNCC suggests 2-4 ml of crystalloid solution multiplied by body weight and the percentage of TBSA burned, with half administered in the first 8 hours post-burn. Improper fluid management can lead to complications such as inadequate perfusion, organ failure due to hypovolemia, or fluid overload causing edema and respiratory distress, all of which adversely affect patient outcomes .
For a trauma patient showing signs of intra-abdominal bleeding, such as blood loss, tenderness, or absent bowel sounds, TNCC recommends urgent interventions including stabilizing the patient with fluid resuscitation, monitoring vital signs, and preparing for surgical evaluation. These interventions are critical to prevent further deterioration due to hemorrhagic shock, facilitate rapid assessment and definitive treatment, and mitigate associated risks of infection or organ dysfunction due to delayed intervention .
Following severe hypotension, cerebral ischemia can occur if the blood pressure drops below 50mmHg. Indicators critical to monitor include the patient's level of consciousness, as altered LOC can suggest cerebral ischemia. Additionally, trends in blood pressure should be closely watched, as an abnormal fall in systolic pressure with a rising diastolic pressure and a narrowing pulse pressure can indicate worsening shock, contributing to cerebral ischemia. Early detection and intervention in shock are essential to prevent this condition .
In trauma care, managing a patient's airway involves several systematic steps to ensure it is clear and maintained. The key steps include assessing for obstructions like the tongue or foreign materials, maintaining C-spine precautions, and preparing for intubation if necessary. If intubation is performed, it is crucial to assess tube placement by auscultating the epigastric area and lungs. Suctioning may be needed if obstructions are present. Reassessment is essential after each intervention to ensure continued airway patency, correct placement of tubes, and to identify any changes as they can quickly impact the patient’s oxygenation status .
TNCC guidelines outline several types of shock: hypovolemic, cardiogenic, obstructive, and distributive. Hypovolemic shock, the most common in trauma patients, results from decreased blood volume due to hemorrhage or burns. Cardiogenic shock arises from insufficient cardiac contractility, often due to myocardial infarction or dysrhythmias. Obstructive shock occurs when blood flow is physically impeded, by conditions like cardiac tamponade or tension pneumothorax. Distributive shock involves abnormal blood vessel dilation, seen in neurogenic, anaphylactic, or septic shock, disrupting normal circulation .