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Trauma Nursing Core Course -TNCC Verified 2024
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Trauma Nursing Core Course -TNCC Verified 2024
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Trauma Nursing Core Course -TNCCVerified 2024
A (AVPU) - ANSWER-Alert. Will be able to maintain airway once clear.
A (Primary Survey) - ANSWER-Airway and alertness with simultaneous cervical spinal
stabilization.
Airway Assessment - ANSWER-Inspect: tongue obstruction, loose/missing teeth,
foreign objects, blood, vomitus, secretions, edema, burns or evidence of inhalation
injury
Auscultate: listen for obstructive airway sounds (ie. snoring, gurgling, stridor)
Palpate: palpate for possible occlusive maxillofacial bony deformity, subcutaneous
emphysema
Airway Interventions: - ANSWER-Suction
Remove foreign body if noted
Jaw thrust maneuver (maintain cspine)
Nasopharyngeal airway (can be conscious) Oropharyngeal airway (no gag)
Consider definitive airway
Alertness Assessment - ANSWER-A-Alert
V-Verbal
P-Painful
U-Unresponsive
B (Primary Survey) - ANSWER-Breathing and Ventilation
Breathing and Ventilation Assessment - ANSWER-Inspect: spontaneous breathing,
symmetrical rise and fall, depth/pattern/rate of respirations, accessory muscle use,
diaphragmatic breathing, skin color (normal, pale, flushed, cyanotic),
contusions/abrasions/deformities (signs of underlying injury), open pneumothoraces
(sucking chest wound), JVD, tracheal position, signs of inhalation injury
Auscultate: presence, absence and equality of breath sounds at 2nd intercostal space
midclavicular line and bases at the fifth intercostal space anterior axillary line
Palpate: bony structures, possible rib fractures, SQ emphysema, soft tissue injury, JV
pulsations at suprasternal notch or supraclavicular area
, Life-threatening pulmonary injuries requiring immediate intervention: open
pneumothorax, tension pneumothorax, flail chest, hemothorax.
Breathing and Ventilation Intervention - ANSWER-Breathing absent: jaw-thrust
maneuver, oral airway adjunct, assist ventilation with bag-mask device, prepare for
definitive airway
Breathing present: NRB. Determine if ventilation effective: etCO2 35-45, SpO2 94% or
higher. If ineffective: assist with bag-mask and determine need for definitive airway
C (Primary Survey) - ANSWER-Circulation and Control of Hemorrhage
Cardiogenic Shock - ANSWER-Results from pump failure in the presence of adequate
intravascular volume. There is a lack of cardiac output and end-organ perfusion
secondary to a decrease in myocardial contractility and/or valvular insufficiency.
Acute causes - myocardial infarction, dysrhythmias or toxicologic pathologies. Heart
failure is a chronic cause.
Blunt cardiac injury may present similar to MI.
Excess of volume administration or increased after load can result in pulmonary edema
and increased myocardial ischemia.
Inotropic support to improve contractility.
Circulation and Control of Hemorrhage Assessment - ANSWER-Inspect: Uncontrolled
external bleeding, skin color
Auscultate: Muffled heart sounds - may indicate pericardial tamponade
Palpate: carotid and/or femoral pulses for rate, rhythm, strength
Circulation and Control of Hemorrhage Interventions - ANSWER-Control and treat
external bleeding: apply direct pressure, elevate bleeding extremity, apply pressure over
arterial sites, consider use of a tourniquet.
2 large bore IVs, if unable consider IO, obtain labs and crossmatch.
Initiate IVF of warmed isotonic crystalloid solution. Consider blood products after 2L.
**Large volumes of fluid lead to dilution coagulopathy which worsens metabolic acidosis
and may cause hypothermia. Component therapy, including administering RBC, plasma
and platelets is a balanced approach so that O2 delivery is optimized, acidosis
corrected and coagulopathy prevented.
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