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TNCC 10th Edition brief chapter
explanation, questions and detailed
answers
50+ questions & detailed answers
Chapter 1: Primary Assessment (ABCDE)
Core Concept: Life-Threatening Priorities
The primary assessment follows the ABCDE approach to identify and manage immediate life threats: A - Airway with Cervical Spine Protection Assess airway patency while maintaining c-spine immobilization Look for: Foreign bodies, blood, vomit, teeth, swelling Listen for: Stridor, gurgling, hoarseness KEY POINT: Assume c-spine injury in all trauma patients until cleared B - Breathing and Ventilation Assess respiratory rate, depth, symmetry Look for: Chest wall movement, use of accessory muscles Listen for: Breath sounds bilaterally NORMAL VALUES: RR 12 - 20/min, SpO2 >95% C - Circulation and Hemorrhage Control Assess pulse rate, quality, rhythm Control external bleeding with direct pressure CRITICAL: Identify and stop life-threatening hemorrhage immediately D - Disability (Neurological) Assess level of consciousness using GCS Check pupil size and reactivity GCS SCORING: Eyes (4) + Verbal (5) + Motor (6) = 15 total E - Exposure and Environmental Control Remove clothing to assess for injuries
Prevent hypothermia with warming measures HYPOTHERMIA RISK: Core temp <36°C (96.8°F)
Practice Questions - Primary Assessment
Question 1: A 25-year-old male arrives after motorcycle crash. He is unconscious, has stridor, and blood around his mouth. What is your FIRST priority? A) Insert IV and obtain blood samples B) Perform neurological assessment C) Establish airway with c-spine protection D) Apply oxygen via non-rebreather mask ANSWER: C - Establish airway with c-spine protection RATIONALE: Stridor indicates airway compromise. In trauma, airway management with c-spine protection is always the first priority. Question 2: During primary assessment, you note absent breath sounds on the right side with tracheal deviation to the left. This most likely indicates: A) Pneumothorax B) Tension pneumothorax C) Hemothorax D) Pulmonary contusion ANSWER: B - Tension pneumothorax RATIONALE: Absent breath sounds + tracheal deviation = tension pneumothorax. This is a life-threatening condition requiring immediate needle decompression. Chapter 2: Secondary Assessment
Systematic Head-to-Toe Evaluation
The secondary assessment is a comprehensive evaluation performed after life-threatening conditions are addressed. H - Head and Face Inspect for lacerations, contusions, deformities Palpate skull for step-offs, crepitus RED FLAGS: Battle's sign, raccoon eyes, CSF leak N - Neck Maintain c-spine immobilization Inspect for wounds, distended veins ASSESSMENT: JVD may indicate cardiac tamponade or tension pneumothorax C - Chest Inspect for symmetry, wounds, deformities Palpate for tenderness, crepitus, instability
CAUSE: Spinal cord injury SIGNS: Hypotension WITHOUT tachycardia, warm skin TREATMENT: Vasopressors, careful fluid management Obstructive Shock CAUSE: Tension pneumothorax, cardiac tamponade SIGNS: Depends on cause TREATMENT: Remove obstruction
Hemorrhage Classification
Class Blood Loss HR BP Mental Status I <15% (750ml) <100 Normal Normal II 15 - 30% (750-1500ml) 100 - 120 Normal Anxious III 30 - 40% (1500-2000ml) 120 - 140 Decreased Confused IV >40% (>2000ml) >140 Decreased Lethargic CRITICAL: Class III and IV require immediate intervention
Practice Questions - Shock
Question 4: A 30-year-old female has BP 90/60, HR 130, and is anxious after abdominal trauma. This represents which class of hemorrhage? A) Class I B) Class II C) Class III D) Class IV ANSWER: C - Class III RATIONALE: HR >120, decreased BP, and altered mental status (anxious/confused) indicate Class III hemorrhage. Chapter 4: Airway Management
Airway Assessment Priorities
Immediate Assessment Look: For foreign bodies, blood, vomit, facial trauma Listen: For stridor, gurgling, hoarseness, snoring Feel: For air movement EMERGENCY INDICATORS: Stridor (upper airway obstruction) Absent air movement Severe facial trauma
Inhalation injury signs
Airway Management Techniques
Basic Techniques (with C-spine protection)
- Jaw Thrust - preferred method in trauma
- Chin Lift - only if no c-spine injury suspected
- Suction - remove blood, vomit, debris
- Oral/Nasal Airways - maintain patency Advanced Techniques
- Endotracheal Intubation - definitive airway
- Surgical Airway - when intubation fails
- Bag-Mask Ventilation - temporary measure KEY POINT: All airway maneuvers in trauma patients must maintain c-spine immobilization
Practice Questions - Airway
Question 5: The preferred method to open the airway in a trauma patient is: A) Head tilt-chin lift B) Jaw thrust C) Finger sweep D) Oral airway insertion ANSWER: B - Jaw thrust RATIONALE: Jaw thrust maintains c-spine alignment while opening the airway in trauma patients. Chapter 5: Breathing and Ventilation
Assessment of Breathing
Visual Assessment Rate, depth, symmetry of chest movement Use of accessory muscles Skin color and perfusion Physical Assessment Palpation for crepitus, instability Percussion for dullness/hyperresonance Auscultation for breath sounds NORMAL VALUES:
TOURNIQUET INDICATIONS:
Severe extremity hemorrhage Multiple casualties Amputation Direct pressure ineffective
Internal Hemorrhage Recognition
Chest SIGNS: Decreased breath sounds, dullness, shock CAPACITY: Each hemithorax can hold 3000ml Abdomen SIGNS: Distension, guarding, shock CAPACITY: Can accommodate entire blood volume Pelvis SIGNS: Pelvic instability, shock CAPACITY: Can hold 4-6 units of blood Retroperitoneum SIGNS: Grey Turner's sign, shock CAPACITY: Can hold 4+ units of blood
Fluid Resuscitation
Initial Fluid Therapy ADULT: 1 - 2L crystalloid bolus PEDIATRIC: 20ml/kg crystalloid bolus GOAL: Maintain perfusion, not normal BP Blood Product Therapy Massive Transfusion Protocol - 1:1:1 ratio (PRBC:FFP:Platelets) Type O Negative - universal donor for emergencies Type Specific - when time allows for crossmatch
Practice Questions - Circulation
Question 7: The maximum blood loss capacity of the abdomen is approximately: A) 1500ml B) 3000ml C) Entire blood volume D) 500ml
ANSWER: C - Entire blood volume RATIONALE: The abdomen can accommodate the entire blood volume, making internal abdominal bleeding extremely dangerous. Chapter 7: Neurological Assessment
Glasgow Coma Scale (GCS)
Eye Opening (E) 4 = Spontaneous 3 = To voice 2 = To pain 1 = None Verbal Response (V) 5 = Oriented 4 = Confused 3 = Inappropriate words 2 = Incomprehensible sounds 1 = None Motor Response (M) 6 = Obeys commands 5 = Localizes to pain 4 = Withdraws from pain 3 = Flexion to pain 2 = Extension to pain 1 = None SEVERE TBI: GCS ≤8 MODERATE TBI: GCS 9- 12 MILD TBI: GCS 13- 15
Pupil Assessment
Normal Findings Equal size (2-4mm) Round and reactive to light Accommodate to distance Abnormal Findings Unilateral dilation: Ipsilateral mass lesion Bilateral dilation: Severe brain injury, drugs Pinpoint pupils: Opioid overdose, pontine lesion
Quaternary: Burns, inhalation
High-Risk Mechanisms
Motor Vehicle Crashes HIGH RISK: Speed >40 mph, rollover, ejection, death in same vehicle INJURY PATTERNS: Head/neck, chest, abdomen based on impact type Falls HIGH RISK: >20 feet or 3x patient height INJURY PATTERNS: Lower extremity, spine, head Motorcycle Crashes HIGH RISK: Speed >20 mph, no helmet INJURY PATTERNS: Head, extremities, road rash
Practice Questions - Mechanisms
Question 9: A fall from what height is considered high-risk in adults? A) 10 feet B) 15 feet C) 20 feet D) 30 feet ANSWER: C - 20 feet RATIONALE: Falls >20 feet or 3x patient height are considered high-risk mechanisms. Chapter 9: Special Populations
Pediatric Trauma Considerations
Anatomical Differences Larger head-to-body ratio More elastic ribs Shorter airway Less fat/muscle protection Physiological Differences VITAL SIGNS: Higher HR and RR, lower BP SHOCK: Can maintain BP until 25% blood loss HYPOTHERMIA: Higher risk due to larger surface area Assessment Modifications
Pain Scale: FACES scale for children GCS: Modified for infants/toddlers Restraint: Child-friendly techniques
Geriatric Trauma Considerations
Age-Related Changes Decreased physiological reserve Multiple comorbidities Medication effects Fragile skin Assessment Considerations BASELINE: May have abnormal "normal" vitals MEDICATIONS: Beta-blockers mask tachycardia COGNITIVE: Baseline dementia vs. injury
Pregnancy Trauma
Physiological Changes Increased blood volume Displaced organs Increased oxygen demand Assessment Priorities TWO PATIENTS: Mother and fetus POSITIONING: Left lateral tilt after 20 weeks MONITORING: Fetal heart rate if viable
Practice Questions - Special Populations
Question 10: The normal heart rate range for a 2-year-old child is: A) 60-100 bpm B) 80-130 bpm C) 100-150 bpm D) 120-180 bpm ANSWER: C - 100 - 150 bpm RATIONALE: Toddlers (1-3 years) have normal HR of 100- 150 bpm. Chapter 10: Practice Scenarios
Scenario 1: Multi-System Trauma
Patient: 28 - year-old male, motorcycle vs. car at 50 mph
Chapter 11: Key Formulas and Values
Critical Vital Signs
Adult Normal Values HR: 60 - 100 bpm RR: 12 - 20/min BP: 90 - 140/60-90 mmHg SpO2: >95% Temperature: 36 - 37.5°C (96.8-99.5°F) Pediatric Normal Values (Age-Specific) Infant (0-1 year): HR 100-160, RR 30-60, BP 70-100/40- 65 Toddler (1-3 years): HR 100-150, RR 24-40, BP 80-110/50- 80 Preschool (3-6 years): HR 90-120, RR 22-34, BP 90-120/60- 80 School age (6-12 years): HR 70-110, RR 18-30, BP 90-120/60- 80
Fluid Calculations
Parkland Formula (Burns) 4ml × kg × %TBSA burned Give 1/2 in first 8 hours, 1/2 in next 16 hours Maintenance Fluids (Pediatric) First 10kg: 100ml/kg/day Next 10kg: 50ml/kg/day Each kg >20: 20ml/kg/day
Drug Calculations
Epinephrine Cardiac Arrest: 1mg (1:10,000) IV/IO Anaphylaxis: 0.3-0.5mg (1:1,000) IM Atropine Bradycardia: 0.5-1mg IV q3-5min (max 3mg) Chapter 12: Critical Actions Checklist
Primary Assessment Actions
Airway ☐ Assess patency while maintaining c-spine ☐ Suction if needed ☐ Insert airway adjunct or intubate if indicated ☐ Confirm tube placement Breathing ☐ Assess rate, depth, symmetry ☐ Auscultate breath sounds ☐ Apply oxygen as needed ☐ Assist ventilation if inadequate Circulation ☐ Control obvious external bleeding ☐ Assess pulse and perfusion ☐ Establish IV access ☐ Initiate fluid resuscitation if indicated Disability ☐ Assess GCS and pupils ☐ Check for spinal cord injury signs ☐ Maintain c-spine immobilization Exposure ☐ Remove clothing systematically ☐ Prevent hypothermia ☐ Log roll for posterior assessment ☐ Cover patient appropriately
Documentation Priorities
Essential Elements ☐ Mechanism of injury ☐ Time of injury ☐ Initial vital signs and GCS ☐ Interventions performed ☐ Patient response to treatments ☐ Any deterioration in condition
Communication Priorities
High-Yield Facts
- Tension pneumothorax is the only pneumothorax that causes tracheal deviation
- Neurogenic shock is hypotension WITHOUT tachycardia
- Flail chest requires 3+ adjacent rib fractures in 2+ places
- Beck's triad (cardiac tamponade): JVD, muffled heart sounds, hypotension
- Golden hour emphasizes rapid assessment and treatment
- Cushing's triad (increased ICP): Hypertension, bradycardia, irregular respirations
- Raccoon eyes and Battle's sign indicate basilar skull fracture
- Three-sided occlusive dressing for open pneumothorax
- Log roll maintains spinal alignment during movement
- Hypotension is a late sign of shock in children
Critical Don'ts
DON'T remove impaled objects DON'T give fluids to penetrating torso trauma unless hypotensive DON'T compress pelvis multiple times DON'T forget c-spine precautions DON'T delay treatment for complete assessment Practice Test Section
Questions 11- 25
Question 11: The most common cause of shock in trauma patients is: A) Cardiogenic B) Hypovolemic C) Neurogenic D) Septic ANSWER: B - Hypovolemic Question 12: Cushing's triad includes all EXCEPT: A) Hypertension B) Bradycardia C) Tachypnea D) Irregular respirations ANSWER: C - Tachypnea Question 13: The preferred IV fluid for trauma resuscitation is: A) D5W B) Normal saline C) Lactated Ringer's D) D5 1/2 NS ANSWER: C - Lactated Ringer's Question 14: A patient with spinal cord injury at C5 level would be expected to: A) Have normal breathing B) Require mechanical ventilation C) Have normal arm movement D) Be completely paralyzed ANSWER: B - Require mechanical ventilation
Question 15: The maximum amount of blood that can accumulate in each hemithorax is: A) 1500ml B) 2000ml C) 3000ml D) 4000ml ANSWER: C - 3000ml
Additional Practice Questions (16-50)
Question 16: A 45-year-old construction worker falls 30 feet. On arrival, he is conscious but complains of back pain and cannot move his legs. His BP is 85/50, HR 60. This most likely represents: A) Hypovolemic shock B) Cardiogenic shock C) Neurogenic shock D) Septic shock ANSWER: C - Neurogenic shock RATIONALE: Spinal cord injury with hypotension BUT bradycardia (not tachycardia) indicates neurogenic shock from loss of sympathetic tone. Question 17: During log roll of a trauma patient, you notice a penetrating wound to the back with an object still impaled. Your action should be: A) Remove the object immediately B) Stabilize the object in place C) Push the object in further D) Partially remove the object ANSWER: B - Stabilize the object in place RATIONALE: Never remove impaled objects as they may be tamponading bleeding. Stabilize in place and transport. Question 18: A patient presents with a rigid, distended abdomen after blunt trauma. Bowel sounds are absent. This most likely indicates: A) Gastric distension B) Bowel obstruction C) Intraperitoneal bleeding D) Retroperitoneal bleeding ANSWER: C - Intraperitoneal bleeding RATIONALE: Rigid, distended abdomen with absent bowel sounds after trauma suggests significant intraperitoneal bleeding with peritoneal
