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Initial Assessment
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TNCC Day One
Initial Assessment o Preparation and triage o Primary Survey Resuscitation adjuncts (F, G) o Reevaluation o Secondary Survey (H, I) Reevaluation adjuncts o Reevaluation and post resuscitation care o Definitive care or transport A-I Mnemonic o A- AVPU--airway and alertness with C spine o B- breathing and ventilation (rate) o C- circulation and control of hemorrhage o D- disability ( neuro status) o E- exposure and environmental control o F- full set of vital signs and family presence o G- get resuscitation adjuncts (LMNOP- labs, monitor (ekg), OG tube, pain) o H- history and head to toe o I- inspect posterior surfaces Prep and Triage o Safe practice PPE Hazardous exposure o Safe care Right care- if gunshot wound to chest, get chest tube Right trauma facility- EMS decides this Right time- is patient stable enough to transfer
Right resources Across-the-room- Observation o Uncontrolled hemorrhage is a major cause of preventable death after injury o On arrival, determine the need to reorder ABC to ABC o Look for uncontrolled EXTERNAL hemorrhage Look before you start Look during letter C and E Also look when doing head-to-toe assessment/roll o First priority is to treat the greatest threat! A- airway and alertness o Cervical spinal immobilization o Manual stabilization o Spine board primarily a transportation device o First thing we ask, “Is the patient alert and can the patient speak?” Alert Verbal Pain Unresponsive o Can the patient open and protect the airway? o If patient is unable to open airway Manually open airway using jaw-thrust Two person procedure o Inspect for: Tongue obstructing, loose teeth, foreign objects, blood, vomitus, secretions, edema, burns o Auscultate for: Obstructive airway sounds- snoring or stridor o Palpate for: Bony deformity o If a definitive airway is in place, assess for placement and continue assessment (and assess for co2 detector)
Determine ventilation effectiveness Use end-tidal CO2 monitoring (best way to monitor ventilation in the quickest way) If ventilation is ineffective: Assist ventilations with bag mask 10-12 breaths per min C- circulation and control of hemorrhage o Hemorrhage: leading cause of preventable death after injury o Continued assessments and high index of suspicion during: Across the room observation Primary survey at C Reevaluation directly following the primary survey Reevaluation following the second survey o Inspect for: Uncontrolled EXTERNAL hemorrhage- first step put direct pressure, then tourniquet Skin color Palpate for: Presence of central pulse Skin temp and moisture Pulses absent Initiate basic life support Assess for cause related to injury o Uncontrolled INTENRAL hemorrhage- we can’t do much about it but we can take them to a trauma surgeon. If pulses are present, is circulation effective? Inspect for external hemorrhage, sin color Palpate for central pulses, rate and rhythm, temp, and moisture If circulation is ineffective: Assess for signs of uncontrolled internal hemorrhage
Consider such common sites the chest, abdomen, and pelvis o Cannulate two veins o Initiate infusion of warmed isotonic crystalloid solution o Use blood administer tubing o Obtain sample for type and cross match o Consider balanced resuscitation needs o Consider a rapid infusion device o Intervene in life- threatening situations D- disability (neurologic status) o Inspect pupils PERRL So important to get a baseline o Assess Glasgow coma scale Best eye opening (4) Best verbal response (5) Best motor response (6) o Get head CT as quick as can o ABGs- o Glucose E- exposure ad environmental control o Assessment Remove all clothing Uncontrolled bleeding Note obvious injuries o Interventions Evidence of collection Keep warm F- Resuscitation adjuncts o Full set of vitals Trend for changes o Facilitate family presence Preferred by patients and family
gentle pressure over iliace crests gentle pressure on symphysis pubic IF pelvis fx has been identified, do not perform o Extremities Soft tissue Temp, moisture, pulses o Neurovascular status or CSM Circulation, sensory function, motor function o Posterior surfaces Logroll patient STABILIZE C SPINE Inspect for blood, edema, wounds Palpate for defpormity, tenderness Rectal tone/ ability to squeeze gluteal muscles Consider removed from the grid spine board o Reorder/reevaluation adjunct Radiographs CT, anigoigraphy, MRI Labs Wound care Applications of splints Tetanus, abx, sedation Contrast urography or angiography Bronchoscopy and esopophagoscy o Document All assessments, interventions, resuscitation, and patients response Family support Reevaluation: ongoing assessment and care o primary survey o Vital signs o Pain o Interventions o Definitive care?
Oxygenation and ventilation o Ineffective ventilation Altered mental status Prolonged loss of consciousness Increased ICP Hypoxia High cervical spinal trauma Blunt chest trauma Penetrating trauma Medications Substance or alcohol use Comorbidities Interventions A- airway and alertness o If airway is patent: note potential risks o If the airway is not patent: Suction Remove debris Insert an airway adjunct: OPA and NPA Consider definitive airway Reassess after intervention B- breathing and ventilation o Spontaneous breathing o Symmetric and adequate chest rise and fall o Depth, pattern, and general rate of respirations o Work of breathing o Skin color o JVD: position of the trachea o Open pneumothoraxes o Signs of inhalation injury
Severe maxillofacial fractures Laryngeal or tracheal injury or neck hematoma o Surgical airway: Cricothyrotomy (unable to bag patient bc air cannot get passed the blocking—then cric) Alternative when ETT cannot be placed Rarely the first choice Incision made through cricothyroid membrane Complications Hemorrhage Pneumomediastinum Laceration of cricoid ring Tracheal trauma Subglottic stensosis Vocal cord damage Mass in neck o Rapid sequence intubation (RSI) Preparation Preoxygenation Pretreatment Paralysis with induction (sedate first, then paralyze) Protection and positioning Placement with proof Post intubation management o Breathing intervention reassessment Attached co2 detective device to ETT Assess for symmetrical rise/fall of the chest AT THE SAME TIME- Auscultate for gurgling over epigastrium Auscultate bilateral breath sounds Resuscitation adjuncts: L- labs o ABGs Oxygenation Ventilation
Acid base balance (PH) o O- oxygenation and ventilation Brain, Cranial, and Maxillofacial Trauma- chapter 9 Fall is number one cause of TBI o MVC o Sports injuries o Assault Concurrent injuries o Cervical spine injuries o Vertebral column o Facial fractures Types of injuries o Primary Direct injury to brain Hemorrhage Hematoma o Secondary injury (what happens to body after primary) Hypotension Hypoexemia Hypercarbia Cerebral edema increased ccp or decreased Jobs as nurses to fix these Cerebral blood flow o Cerebral blood flow relies on CPP o CPP (cerebral perfusion pressure)= MAP-ICP o Brain autoregulates bloow flow to the brain when CPP is kept between 60 and 160mmHg. o One episode of systolic bp less than 90 can be detrimental Carbon dioxide: primary regulator of cerebral blood flow to the brain o Hypercapnia causes vasodilation
Signs of icp Decline in level of consciousness Pupil abnormalities Abnormal motor posturing Epidural hematoma (ARTERIAL BLEED) o Fractures of temporal or parietal skull o Laceration of middle meningeal artery o Bleeding between the dura mater and skull o Rapid accumulation from arterial blood o The artery is bleeding really rapidly and compressing fast o Patient will need craniotomy, control the bleed o Assessment findings: Transient loss of consciousness with lucid period HA N/V Dizziness Contralateral hemiparesis or hemiplegia Unilateral fixed and dilated pupil Rapid neuro deterioration o Immediate surgical intervention Subdural hematoma (venous bleed) o Acceleration or deceleration o Injury to bridging veins o Acute o Chronic Anticoagulants Older adults Chronic alcohol use o Supratentorial herniation (SECONDARY INJURY) Uncal- shifts over and down Central- shifts straight down o Assessment findings Asymmetrical pupil reactivity
Unilateral or bilaterally pupillary dilation Abnormal motor posturing Secondary impact syndrome o Usually seen in athletes o Second traumatic brain injury Cerebral edema o Rare, but usually fatal o Repeated inuury that causes sudden cerebral edema Postconcussive syndrome- happens over months o Assessment findings Persistent headache Nausea Dizziness Memory impairment Difficulty concentrating Attention deficit Irritability Insomnia Anxiety Depression Diffuse axonal injury o Widespread microscopic hemorrhage o Rotation or acceleration/deceleration o Shearing or tearing o Significant morbidity and mortality o Cognitive deficits or prolonged coma o Assessment findings Unconsciousness Increased ICP Abnormal posturing Skull fractures o Linear skull fx Non displaced fracture of cranium
Shock- chapter 7 Shock- inadequate tissue perfusion Mismatch between oxygen supply and demand Dynamic relationship- cold, pale, clammy Four types of shock o Hypovolemic o Obstructive o cardiogenic o distributive hypovolemic shock o hypovolemic and hemorrhagic shock loss of circulating blood loss of plasma from intravascular space decreased preload decreased cardiac output o goal directed therapy replace lost volume obstructive shock o non-hemorrhagic shock does not involve circulating blood o obstruction and prevention of vasculate or heart tension pneumo cardiac tamponade o when pressure increases in thorax, or when pericardial sac fills with blood, it prevents heart from adequately contracting o goal directed therapy relieve the obstruction thoracentesis- second intercostal space chest tube cardiogenic shock
o inability to pump blood effectively o causes include: blunt cardiac injury myocardial infarction dysrhythmias toxicological pathologies o goal directed therapy support the pump administer inotropes and thyroid medications distributive shock o maldistribution of adequate circulating blood volume anaphylactic shock histamine: vascular permeability and vasodilation septic shock endotoxins: vascular permeability and vasodilation neurogenic shock loss of sympathetic tone: circulatory vasodilation o goal directed therapy volume replacement (IV FLUIDS) and vasoconstriction (PRESSORS) cardiac output-> stroke volume X heart rate o preload (venous return), afterload (peripheral vascular resistance), and contractility (strength of contraction) make up stroke volume o hypertension makes it harder to pump blood and a decreased afterload initial changes may be subtle body has effective compensatory mechanisms o baroreceptors- respond to decreased stretch in arterial walls o chemoreceptors- responds to an imbalance in oxygen and carbon dioxide early recognition is essential!!! o Altered mental status
Stages of shock o Stage one: compensated Anxiety, confusion, restlessness Systolic BP within normal range Rising diastolic BP from vasoconstriction causing narrowing pulse pressure Slightly tachy or bounding pulse Decreasing urine output o Stage two: progressive, decompensated Confusion, disorientation, unconsciousness Decreasing systolic BP Narrowing pulse pressure Tachycardia with weak pulses Tachypnea Cool, clammy, cyanotic skin Rising serum lactate o Stage three: irreversible Ischemia at cellular level escalates Obtunded or comatose Profound hypotension Bradycardia and possible dysrhythmias Slow, shallow respirations Worsening kidney, liver, and heart failure Rising lactate, falling acidosis level Current management strategies of shock o Damage control Hypotensive resuscitation Hypertension may pop the clot Hemostatic resuscitation Replace losses Avoid hemodilution Fluid resuscitation Smaller amount of isotonic crystalloid
o Massive transfusion protocol 1:1:1 (one PRBC, one plasma, and one platelet) monitor calcium levels because if we give too citrate (from bagged blood) it drops calcium levels o autotransfusion hemothorax to transfusion take from chest tube and put right back into patient most often for penetrating trauma o damage control surgery brief, control bleeding extensive repair deferred o tranexamic acid (TXA) antifibrinolytic Disaster- chapter 22 o mitigation o what are the vulnerabilities? Looking at what you’re vulnerable to and get ready for that just in case. In Midwest we are vulnerable to weather. o Things have changed after Joplin, mitigation is what we learned o Preparedness o Homeland security works on preparedness o NIMS o ICS Common terminology Modular organization Integrated communications Unity of command Consolidated incident action plan o Hospital disaster preparedness plan Manageable scope of supervision Flexible, incremental, scalable Job action sheets
