TNCC Review Notes

TNCC: Trauma Nursing Core Course

A = Airway
- Check for:
Tongue obstruction
Teeth
Vocalization
Blood/vomit in airway
Edema
- If obstruction Suctionthen reassess
- Maintain C-spine precautions
- Prepare for intubation
Once intubated assess tube placement by auscultating over
epigastrum first then over lung fields
Secure endotracheal tube
B = 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 thoracentisis..
Insert large bore needle into the 2nd intercostal 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 2nd large 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

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 allow them into room
- Insert foley and/or gastric tube if indicated
G = Give Comfort
- Obtain a pain rating
- Obtain an order and provide analgesics
- Provide comfort cares of 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 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

MNENOMICS TO KNOW

Medications for Intubation: LOAD

- L = Lidocaine (decreases intracranial pressure)
- O = Opiates
- A = Atropine (especially children)
- D = Defasiculating (paralytic)
Pre-Arrival History: MIVT
- M = Mechanism
- I = Injury
- V = Vitals
- T = 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
- A = Assess Hazards
- T = Triage & Treatment
- E = Evacuation
- R = Recovery
6 Ps of Compartment Syndrome
- Pain
- Pallor
- Pulses
- Paresthesia
- Paralysis
- Pressure

TNCC Review Notes

Review Information

Chapter 3: Initial Assessment

- Remove any headgear ex) 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
- A 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 patients diastolic
blood pressure

TNCC Review Notes

-

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:
1. 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 signLucid 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 (Battles 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

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:
Becks 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

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 24-48hours.
- 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 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 drydo not freeze!!
- All open fractures are considered contaminated
- Be aware for large volume blood loss especially from:
Humerus fx: <750mL
Femur fx: <1500mL
Pelvis fx: >1500mL
- Compartment Syndrome:
Six Ps! (Pain, Pallor, Pulses, Paresthesia, Paralysis,
Pressure)

TNCC Review Notes

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 trough 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
%age of TBSA burned
Children 3-4ml of crystalloid solution x body weight in kg x
%age of TBSA burned
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, Chlorine
Irritation to the respiratory tract, coughing, sneezing, watery
eyes, tachypnea, dyspnea
Treat with decontamination, aggressive airway and
breathing management

TNCC Review Notes

-

Blood Agents:
Cyanide
Occasional almond smell
Cellular anoxia, rapid breathing, dizziness, weakness, rapid
heart rate, apnea, cardiac arrest
Treat with cyanokit, decontamination
Vesicants:
Mustard, Lewisite
Rhinorrhea, pruritis, skin irritation, blisters, cough, dyspnea
Treat with decontamination, aggressive airway and
breathing management. Antidote for Lewisite: dimercaprol
(BAL)
Nerve Agents:
Tabun, Sarin, VX
Miosis, rhinorrhea, lacrimination, 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