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TNCC Test Preparation Notes for Trauma Assessment and Management, Exams of Nursing

Comprehensive notes for the tncc (trauma nursing core course) test preparation, focusing on trauma assessment and management. It covers various symptoms, signs, and interventions related to aortic injuries, intracerebral hematoma, pulmonary contusions, and other life-threatening pulmonary injuries. The document also includes guidelines for assessing alertness, breathing and ventilation, and palpating for bony structures, rib fractures, and other injuries.

Typology: Exams

2023/2024

Available from 05/22/2024

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Download TNCC Test Preparation Notes for Trauma Assessment and Management and more Exams Nursing in PDF only on Docsity! TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition - ansPrehospital shock index pg. 85 .. activation: .... are found in the carotid sinus and along the aortic arch, are sensitive to the degree of stretch in the arterial wall. When the receptors sense a decrease in stretch, they stimulate the sympathetic nervous system to release Epi, norepi, causing stimulation of cardiac activity and constriction of blood vessels, which causes a rise in heart rate and diastolic blood pressure - ansBaroreceptors: 1. A- airway and Alertness with simultaneous cervical spinal stabilization 2. B- breathing and Ventilation 3. circulation and control of hemorrhage 4. D - disability (neurologic status) 5. F - full set of vitals and Family presence 6. G - Get resuscitation adjuncts L- Lab results (arterial gases, blood type and crossmatch) M- monitor for continuous cardiac rhythm and rate assessment N- naso or orogastric tube consideration O- oxygenation and ventilation analysis: Pulse oxygemetry and end-tidal caron dioxide (ETC02) monitoring and capnopgraphy H- History and head to toe assessment I- Inspect posterior surfaces - ansABCDEFGHI 1. Apnea 2. GCS 8 or less 3. Maxillary fractures 4. Evidence of inhalation injury (facial burns) 5. Laryngeal or tracheal injury or neck hematoma 6. High risk of aspiration and patients inability to protect the airway 7. Compromised or ineffective ventilation - ansFollowing conditions might require a definitive airway 1. bony fractures and possible rib fractures, which may impact ventilation 2. palpate for crepitus 3. subcutaneous emphysema which may be a sign for a pneumothorax 4. soft tissue injury - ansPalpate the chest for 1. Check the presence of adequate rise and fall of the chest with assisted ventilation 2. Absence of gurgling on auscultation over the epigastrium 3. Bilateral breath sounds present on auscultation 4. Presence of carbon dioxide (CO2) verified by a CO2 device or monitor - ansIf the pt has a definitive airway in what should you do? TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition 1. Dyspnea 2. Tachycardia 3. Decreased or absent breath sounds on the injured side 4. CP - ansSimple Pneumo assessment: 1. equal breath sounds bilaterally at the second intercostal space midclavicular line and the bases for fifth intercostal space at the axillary line - ansAuscultate the chest for: 1. Get a CT 2. Consider ABG 's if decreased LOC 3. Consider glucose check - ansD Interventions 1. Hypotension 2. JVD 3. Muffled heart sounds - ansBecks Triad: 1. open the airway, use jaw thrust 2. insert an oral airway 3. assist ventilations with a bag mask 4. prepare for definitive airway - ansIf breathing is absent.. 1. pain - hallmark sign, early sign 2. pressure - early sign 3. pallor, pules, paresthesia, paralysis - late sign - ansSix P's of compartment syndrome: 1. Preparation 2. Preoxygenation 3. Pretreatment 4. Paralysis and Induction 5. Protecting and positioning - v 6. Placement of proof - secure the tube 7. Post intubation - secure ETT Tube, get X-ray for placement - ansSteps of Rapid Sequence Intubation 1. Preparation and Triage 2. Primary Survery (ABCDE) with resuscitation adjuncts (F,G) 3. Reevaluation (consideration of transfer) 4. Secondary Survey (HI) with reevaluation adjuncts 5. Reevaluation and post resuscitation care 6. Definitive care of transfer to an appropriate trauma nurse - ansInitial Assessment TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition apply splint and elevate above the level of the heart - ansa 37 y/o F has a deformity of the L wrist after a fall. She is reluctant to move her hand due to pain. Which of the following is the most appropriate intervention? ask pt to pen his or her mouth - ansWhile assessing airway the patient is alert and responds to verbal stimuli you should.. bardycardia and absent motor function below the level of injury - ansA pt with a complete spinal cord injury in neurogenic shock will demonstrate hypotension and which other clinical signs? Before the arrival of the pt - ansWhen should PPE be placed: Biomechanics - ansIs the general study of forces and their effects. bowel - ansWhich of the following injuries is LEAST likely to be promptly identified? brachial pulse - ansUnder age of 1 where do you find a pulse Breathing: To assess breathing expose the chest: 1. Inspect for a. spontaneous breathing b. symmetrical rise and fall c. depth, pattern, and rate of respiration d. signs of difficulty breathing such as accessory muscle use e. skin color (normal, pale, flushed, cyanotic) f. contusions, abrasions, deformities (flail chest) g. open pneumothoraces (sucking chest wounds) h. JVD i. signs of inhalation injury (singed nasal hairs, carbonaceous sputum) - ansB calcium - ansif a pt has received multiple transfusions of banked blood preserved with citrate, which electrolyte is most likely to drop and require supplementation? can be caused by blunt trauma. air escapes from injured lung to pleural space and negative intrapleural pressure is lost causing partial or collapsed lung - ansSimple Pneumothorax can result from penetrating wound through chest wall causing air to be trapped in to the intrapleural place. Might hear "sucking" TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition Tx: nonporous dressing tapes on 3 sided, then Chest tube and would closure surgical repair. - ansOpen Pneumo: Capnography monitors numeric value, as well as continuous waveform, indicating real- time measurement and trending over time. - ansQuantitative: Caused by blood in the intrapleural space/ May also occur from lac to live or spleen combined with injury to the diaphragm. Ensure two large bore IVS are placed. Prepare for thoracentesis and chest tube insertion. If open thoracotomy is done chest tube is deferred. - ansHemothorax: Circulation and Control of Hemorrhage Inspect first for any uncontrolled bleeding Skin color palpate for central pulses - carotid and femoral - rate, rhythm, and strength Skin temp: cool, diaphoretic, or warm and dry - ansC Colorimetric CO2 detectors provide info about the presence or absence of CO2. A chemically treated indicator strip changes color revealing the presence or absence of exhaled CO2 - ansQualitative compensated - ansA trauma pt is restless and repeatedly asking "where am i?" VS upon arrival: BP 110/60, HR96, RR 24. Her skin is cool and dry. Current VS are BP 104/84, HR 108, RR 28. The pt is demonstrating s/sx of which stage of shock? Complete - ansEMS brings a pt from MVC. VS: BP 90/49, HR 48, RR 12, temp 97.2F (36.2 C). The pt exhibits urinary incontinence and priapism. These assessment findings are most consistent with which of the following types of spinal cord injury? D displaced tube O obstructed or kinked P pneumothorax E equipment failure , such as becoming detached from the equipment or loss of capnopgrahy - ansDOPE TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition Define central or transtentorial herniation. - ansA downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium. Define central or transtentorial herniation. - ansA downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium. Define Cushing's triad - ansBradycardia, progressive hypertension (widening pulse pressure), and decreased respiratory effort Define Hemothorax. - ansAccumulation of blood in the pleural space. Define Hemothorax. - ansAccumulation of blood in the pleural space. Define Minor Head Trauma. - ansGCS 13-15 Define Minor Head Trauma. - ansGCS 13-15 Define Moderate Head Trauma - ansPostresuscitative state with GCS 9-13. Define Moderate Head Trauma - ansPostresuscitative state with GCS 9-13. Define Pneumothorax. - ansResults when an injury to lung leads to accumulation of air in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of lung may ensue. An open pneumothorax results from wound through chest wall. Air enters pleural space both through the wound and trachea. Define Pneumothorax. - ansResults when an injury to lung leads to accumulation of air in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of lung may ensue. An open pneumothorax results from wound through chest wall. Air enters pleural space both through the wound and trachea. Define Severe Head Trauma. - ansPostresuscitative state with GCS score of 8 or less. Define Severe Head Trauma. - ansPostresuscitative state with GCS score of 8 or less. TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition can include low blood pressure increase heart rate and respiratory rate chest pain shortness of breath dysrhythmias increase troponin and pale cool moist skin Describe the characteristics of distributive shock. - ansDistributive shock occurs as a result of Mel distribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability. This can occur with spinal cord injuries, sepsis, or anaphylaxis. Symptoms include low blood pressure heart rate respiratory rate preload and afterload, spinal tenderness, difficulty breathing, warm pink and dry skin with a cool core temperature. Describe the characteristics of hypovolemic shock - ansHypovolemia is caused by a decrease in the amount of circulating volume usually caused by massive bleeding, but also can be from vomiting and diarrhea. Characteristics include low blood pressure and preload, increase heart rate respiratory rate and afterload, with contractility unchanged. Signs include obvious bleeding, weak peripheral pulses, pale cool and moist skin, distended abdomen, pelvic fracture, or bruise swollen and deformed extremities especially long bones. Describe the characteristics of obstructive shock - ansObstructive shock is it mechanical problem that results from hypoperfusion of the tissue due to an obstruction in either the vasculature or the heart resulting in decreased cardiac output. Some causes include a tension pneumothorax, cardiac tamponade, or venous air embolism on the right side of the heart during systole in the pulmonary artery.Signs include anxiety, muffled heart sounds, JVD, hypertension, chest pain, difficulty breathing, or pulses paradoxes. Describe the fluid resuscitation of an older adult patient related to fluid overload, when to administer red blood cells, and the use of anticoagulant medication. - ans Describe the four types of spinal cord injury - ansCentral cord injury results in greater weakness distally, anterior injury includes motor loss or weakness below the cord level of injury yet sensory is intact, Brown-Sequard (hemicord) is weak on one side with sensory deficit on opposite side, posterior cord syndrome although rare is when the patient is unable to use sense vibration in proprioception Describe the measurement of an NPA - ansMeasure from the tip of the patient's nose to the tip of the patients earlobe. Describe the pathophysiologic changes of the systems of the bariatric patient and the effects on trauma resuscitation efforts. - ans Describe the three impacts in the motor vehicle impact sequence - ans1. First Impact: Vehicle hits another object TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition 2. Second Impact: Occupant hits the interior of the vehicle 3. Third Impact: Organcs hit other internal structures Describe the types of abuse and the associated signs of each. - ans Describe the usefulness of the Haddon Matrix in prevention and reduction of injury - ansLooks at 3 phases of the event: Pre-event, event, and post-event. Looks at 4 factors involved in the event: The host (patient), the agent (cause), the physical evironment, and the socioeconomic environment. Countermeasures can be applied at each phase to help reduce injury. Differentiate between the three impacts of motor vehicle impact sequence. - ansThe first impact occurs when the vehicle collided with another object. The second impact occurs after the initial impact when the occupant continues to move in the original direction of travel until they collide with the interior of the vehicle or meet resistance. The third impact occurs when internal structures collide within the body cavity. Differentiate family and intimate partner violence from community violence. - ans Disability - Neurologic Status 1. Assess pupils for equality, shape, and reactivity (PERRL) 2. Assess GCS (eye opening, verbal response, and motor response) - ansD Discuss the use and insertion of nasogastric tubes in the bariatric patient. - ans Disruptions of the bony structures of the skull can result in what? - ansDisplaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF. CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria. Also: meningitis or encephalitis or brain abscess Disruptions of the bony structures of the skull can result in what? - ansDisplaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF. CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria. Also: meningitis or encephalitis or brain abscess TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition don't forget flanks!!! inspect of lacs, puncture wounds, contusions, auscultate then palpate: bowel sounds? any rigidity, guarding? begin with light palpation start to palpate with side that does not hurt maybe do a fast scan? - ansHead to toe assessment: Abdomen dressing removal - ansA patient arrives with a large open chest wound after being assaulted with a machete. Prehospital providers placed a nonporous dressing over the chest wound and taped it on three sides. he is now showing signs of anxiety, restlessness, severe respiratory distress, cyanosis and decreasing blood pressure. Which of the following is the MOST appropriate immediate intervention? dysrhythmias - ansPatients with a crush injury should be monitored for which of the following conditions? elevating the extremity to the level of the heart - ansA pt with a lower extremity fracture complains of severe pain and tightness in his calf, minimally by pain medications. Which of the following is the priority nursing intervention? endotracheal tube - ansThe trauma nurse knows that placing a bariatric patient in a ramped position providers better visualization during the insertion of which device? Expedite transfer to the closest trauma center - ansA 56 y/o M pt involved in a motor vehicle crash is brought to the ED of a rural critical access facility. He complains of neck pain, SOB, and diffuse abd pain. His GCS is 15. His VS: BP 98/71, HR 125, RR 26, SpO2 94% on high-flow O2 via NRB mask. Which of the following is the priority intervention for this patient? Explain adrenal gland response. - ansWhen adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase. TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition As shock progresses, glycogenolysis is activated by epi to break down glycogen into glucose. In a compensatory response to shock, hepatic vessels constrict to redirect blood flow to other vital areas. Explain Hypovolemic Shock. - ansMost common to affect a trauma pt cause by hypovolemia.. Hypovolemia, a decrease in amount of circulating blood volume, may result from significant loss of whole blood because of hemorrhage or from loss of semipermeable integrity of cellular membrane leading to leakage of plasma and protein from intravascular space to the interstitial space (as in a burn). Some causes: - Blood loss - Burns, etc. Explain Hypovolemic Shock. - ansMost common to affect a trauma pt cause by hypovolemia.. Hypovolemia, a decrease in amount of circulating blood volume, may result from significant loss of whole blood because of hemorrhage or from loss of semipermeable integrity of cellular membrane leading to leakage of plasma and protein from intravascular space to the interstitial space (as in a burn). Some causes: - Blood loss - Burns, etc. Explain Irreversible Shock. - ansShock uncompensated or irreversible stages will cause compromises to most body systems. - Inadequate venous return - inadequate cardiac filling - decreased coronary artery perfusion - Membranes of lysosomes breakdown within cells and release digestive enzymes that cause intracellular damage. Explain Irreversible Shock. - ansShock uncompensated or irreversible stages will cause compromises to most body systems. - Inadequate venous return - inadequate cardiac filling - decreased coronary artery perfusion - Membranes of lysosomes breakdown within cells and release digestive enzymes that cause intracellular damage. TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition Explain Obstructive Shock. - ansResults from inadequate circulating blood volume because of an obstruction or compression of great veins, aorta, pulmonary arteries, or heart itself. Some causes: - Cardiac tamponade (may compress the heart during diastole to such and extent that atria cannot adequately fill, leading to decreased stroke volume). - Tension pneumothorax may lead to inadequate stroke volume by displacing inferior vena cava and obstructing venous return to right atrium. - Air embolus may lead to obstruction of pulmonary artery and subsequent obstruction to right ventricular outflow during systole, with resulting obstructive shock Explain Obstructive Shock. - ansResults from inadequate circulating blood volume because of an obstruction or compression of great veins, aorta, pulmonary arteries, or heart itself. Some causes: - Cardiac tamponade (may compress the heart during diastole to such and extent that atria cannot adequately fill, leading to decreased stroke volume). - Tension pneumothorax may lead to inadequate stroke volume by displacing inferior vena cava and obstructing venous return to right atrium. - Air embolus may lead to obstruction of pulmonary artery and subsequent obstruction to right ventricular outflow during systole, with resulting obstructive shock Explain Pulmonary Response. - ansTachypnea happens for 2 reasons: 1. Maintain acid-base balance 2. Maintain increased supply of oxygen * Metabolic acidosis from anaerobic metabolism will be a stimulus for the lungs to increase rate of ventilation. Increased RR is an attempt to correct acidosis + augments oxygen supply to maximize oxygen delivery to alveoli. Explain Pulmonary Response. - ansTachypnea happens for 2 reasons: 1. Maintain acid-base balance 2. Maintain increased supply of oxygen * Metabolic acidosis from anaerobic metabolism will be a stimulus for the lungs to increase rate of ventilation. Increased RR is an attempt to correct acidosis + augments oxygen supply to maximize oxygen delivery to alveoli. Exposure and Environmental Control TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition Remove all clothes and assess for any obvious injuries and uncontrolled bleeding - ansE fat embolism - ansa pt has been in the ED for several hrs waiting to be admitted. He sustained multiple rib fractures and a femur fracture after a fall. He has been awake, alert, and complaining of leg pain. His wife reported that he suddenly became anxious and confused. Upon reassessment, the pt is restless with respiratory distress and petechiae to his neck. The pt is exhibiting s/sx most commonly associated with which of the following conditions? Flail chest - ansParadoxical chest wall movement flucuation in the water seal chamber - ansWhich of the following is an expected finding in a pt with a tube thoracstomy connected to a chest drainage system? from hemorrhage is leading cause. Hypovolemia is caused by decrease in the amount of circulating volume. Goal is to replace volume. - ansHypovolemic Shock Full set of vitals and family presence - ansF Get Resuscitation Adjuncts L - Labs (maybe a lactic acid), a b g 's, blood type M - monitors N - naso or oro gastric tubes O Oxygen and ETC02 monitors P - pain assessment and management - ansG globe rupture - ansA 35 y/o M presents with facial trauma after being struck in the face with a baseball. A teardrop-shaped left pupil is noted on exam. What type of injury is suspected? H,I - ansSecondary Survery hemoglobin does not readily release O2 for use by the tissues - ansWhat is the effect of hypothermia on the oxyhemoglobin dissociation curve? History and Head to toe MIST - prehospital report MOI Injuries sustained S s/s in the field T treatment in the field TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition - Assess extraocular movement, except when an open globe injury is known or suspected. - Limitation range of ocular motion may indicate orbital rim fx w/entrapment or paralysis of cranial nerve or ocular muscle - Perform visual acuity exam - Use Snellen or handheld chart. Check uninjured eye first - Assess for blurred or double vision with injured eye and then with both eyes open - Inspect for rhinorrhea or otorrhea - If drng present, may indicate CSF leak - Observe for impaled objects - Assess occlusion of mandible and maxilla - Malocclusion or inability to open + close mouth is highly indicative of maxillary or mandibular fx - Observe for uncontrolled bleeding PALPATION - Palpate periorbital area, face and neck for: - Tenderness - Edema - Step-off de How would you assess a patient with ocular, maxillofacial and neck trauma? - ans(Initial assessment) HISTORY - MOI? - Acceleration/Deceleration? - What was it caused by? - Pt restrained? Airbags deployed? Etc. - What are the pt's complaints? - Pt normally wear glasses or contacts? - Pt have hx of eye problems? - Pt ever have eye surgery? - Pt have visual or ocular changes associated with chronic illness? PHYSICAL INSPECTION: - Inspect eye, orbits, face and neck - Check for symmetry, edema, ecchymosis, ptosis, lacerations and hematomas - Inspect globe for lacerations, large corneal abrasions, hyphema, and extrusion or prolapse of intraocular contents - Determine whether lid lac's - Assess pupil's (PERRL) - Unilateral fixed and dilated pupil may indicate oculomotor nerve compression as a result of ICP + herniation syndrome TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition - Bilateral fixed and pinpoint pupils = pontine lesion or drugs - Mildly dilated pupil w/sluggish response may early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Assess for consensual response - Assess redness, eye watering, blepharospasm - Assess extraocular movement, except when an open globe injury is known or suspected. - Limitation range of ocular motion may indicate orbital rim fx w/entrapment or paralysis of cranial nerve or ocular muscle - Perform visual acuity exam - Use Snellen or handheld chart. Check uninjured eye first - Assess for blurred or double vision with injured eye and then with both eyes open - Inspect for rhinorrhea or otorrhea - If drng present, may indicate CSF leak - Observe for impaled objects - Assess occlusion of mandible and maxilla - Malocclusion or inability to open + close mouth is highly indicative of maxillary or mandibular fx - Observe for uncontrolled bleeding PALPATION - Palpate periorbital area, face and neck for: - Tenderness - Edema - Step-off de How would you assess a pt with a cranial injury? - ans(Initial assessment) INSPECTION: - Assess airway - RR, pattern and effort - Assess pupil size and response to light - Unilateral fixed and dilated pupil = oculomotor nerve compression from increased ICP + herniation syndrome - Bilateral fixed and pinpoint pupils indicate a pontine lesion or effects of opiates - Mildly dilated pupil w/sluggish response may be early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Determine if pt uses eye meds - Abnormal posturing? - Inspect craniofacial area for ecchymosis/contusions - Periorbital ecchymosis - Mastoid's process ecchymosis - Blood behind tympanic membrane - Inspect nose and ears for drainage TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition - Drng present w/out blood, test drng w/chemical reagant strip. Presence of glucose indicated drng of CSF - If drng present and mixed with blood, test by placing drop of fluid on linen or gauze. If a light outer ring forms around dark inner ring, drng contains CSF - Assess extraocular eye movement (Tests cranial nerves, III, IV, VI) - Performing extraocular eye movements indicates functioning brainstem - Limitation indicates orbital rim fx w/entrapment or paralysis of either a cranial nerve or ocular muscle - Determine LOC with GCS PALPATION - Palpate cranial area for: - Point tenderness - Depressions or deformities - Hematomas - Assess all 4 extremities for: - Motor function, muscle strength and abnormal motor posturing - Sensory function DIAGNOSTIC PROCEDURES - Lab Studies PLANNING AND IMPLEMENTATION - (Initial assessment) - Clear airway (stimulation of gag reflex can produce transient increase in ICP or vomiting with subsequent aspiration. - Administer O2 via NRB - Assist with early ET intubation - Administer sedative/neuromuscular blocking agent - Consider hyperventilation - PaCO2 above 45 How would you assess a pt with a cranial injury? - ans(Initial assessment) INSPECTION: - Assess airway - RR, pattern and effort - Assess pupil size and response to light - Unilateral fixed and dilated pupil = oculomotor nerve compression from increased ICP + herniation syndrome - Bilateral fixed and pinpoint pupils indicate a pontine lesion or effects of opiates - Mildly dilated pupil w/sluggish response may be early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Determine if pt uses eye meds - Abnormal posturing? - Inspect craniofacial area for ecchymosis/contusions TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition - Inspect jugular veins (Distended = increased intrathoracic pressure as result of tension pneumothorax or pericardial tamponade. Flat = external jugular veins may reflect hypovolemia) - Inspect upper abdominal region for injury Percussion: - Percuss the chest (Dullness = hemothorax, Hyperresonance = pneumothorax) Palpation: - Palpate chest wall, clavicles and neck for: - Tenderness - Swelling or hematoma - Subcutaneous emphysema - Note presence of bony crepitus - Palpate central and peripheral pulses and compare quality between: - Right and left extremities - Upper and lower extremities - Palpate the trachea (above suprasternal notch. Trach shift may indicate late sign of tension pneumothorax or massive hemothorax) - Palpate extremities for motor and sensory function (lower extremitiy paresis or paralysis may indicate aortic injury). Auscultation: - Auscultate compare BP in both UE's and LE's - Auscultate breath sounds (decreased or absent breath = pneumo or hemothorax. Diminshed BS = splinting. Shallow = b/c of pain). - Auscultate chest for presence of BS (diaphragmatic rupture) - Auscultate Heart sounds (muffled = pericardial tamponade) - Auscultate neck vessels for bruits (vascular injury) Diagnostic Procedures: - Xrays - Arteriography - Bronchoscopy and laryngoscopy - CT's - FAST - Labs (cardiac enzymes) - ECG, CVP How would you assess someone in hypovolemic shock? - ans(Use Initial Assessment) and then: Inspect: - LOC - Rate and quality of respirations - External bleeding? - Skin color and moisture TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition - Assess jugular veins and peripheral veins Auscultate: - BP - Pulse pressure - Breath sounds - Heart sounds - Bowel sounds Percuss: - Chest and abdomen Palpate: - Central pulse (carotid or femoral) - Positive inotropic effect (force of contraction) may be evidence by a bounding central pulse - Palpate peripheral pulses - Palpate skin temp and moisture Diagnostic Procedures: - Xrays and other studies - Labs Planning and Implementation - Oxygen - IV's with warmed replacement fluids - Control external bleeding with direct pressure - Elevate LE's - NGT - Foley - Monitor and pulse oximeter - Monitor for development of coagulopathies - Surgery? How would you assess someone in hypovolemic shock? - ans(Use Initial Assessment) and then: Inspect: - LOC - Rate and quality of respirations - External bleeding? - Skin color and moisture - Assess jugular veins and peripheral veins Auscultate: - BP - Pulse pressure - Breath sounds - Heart sounds TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition - Bowel sounds Percuss: - Chest and abdomen Palpate: - Central pulse (carotid or femoral) - Positive inotropic effect (force of contraction) may be evidence by a bounding central pulse - Palpate peripheral pulses - Palpate skin temp and moisture Diagnostic Procedures: - Xrays and other studies - Labs Planning and Implementation - Oxygen - IV's with warmed replacement fluids - Control external bleeding with direct pressure - Elevate LE's - NGT - Foley - Monitor and pulse oximeter - Monitor for development of coagulopathies - Surgery? ICP is a reflection of what three volumes? What happens when one increases? - ans1. Brain 2. CSF 3. Blood within the nonexpansible cranial vault As volume of one increases, the volume of another decreases to maintain ICP within normal range. As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful. Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP. ICP is a reflection of what three volumes? What happens when one increases? - ans1. Brain 2. CSF TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition Penetrating: The List the populations at higher risk for interpersonal violence. - ans MARCH - ansWhich of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage? Measurement of an OPA - ansPlace the proximal end or flange of the airway adjunct at the corner of the mouth to the tip of the mandibular angle. Mechanism of Injury - ansIs how external forces are transferred to the body, resulting in injury Mitigation - ansFollowing a review of recent drills and a real disaster event, a hospital has identified deficiencies and is taking steps to minimize the impact of a future disaster . Which phase of the disaster life cycle does this describe? Multiple requests for water - ansEMS brings a pt who fell while riding his bicycle. Using the American College of Surgeobs screening guidelines, which assessment finding would prompt the RN to prepare the pt for a radiologic spine clearance? Name the three ways to confirm ETT placement - ansPlacement of a CO2 monitoring device, Assessing for equal chest rise and fall, and listening at the epigastrium and four lung fields for equal breath sounds. narrowed - ansWhich of the following pulse pressures indicate early hypovolemic shock? nausea and vomiting - ansWhich of the following is a late sign of increased intracranial pressure? Needle pericardiocentesis, but it is a temp solution. Requires surgical evaluation. (Ultrasound guided) - ansCardiac Tamponade Intervention: Newton's First Law of Motion - ansan object in motion will remain in motion unless acted upon by another force Newton's Second Law of Motion - ansThe acceleration of an object depends on the mass of the object and the amount of force applied. TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition Newton's Third Law of Motion - ansFor every action there is an equal and opposite reaction occurs as a result of maldistribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability. Ex: Anaphylactic - release of antihistamines Septic Shock - systemic release of bacterial endotoxins, resulting in increased vascular permeability and vasodilation. Neurogenic shock - spinal cord injury results of loss in sympathetic nervous system control of vascular tone. Goal: Volume replacement and vasoconstriction - ansDistributive Shock padding the upper back while stabilizing the cervical spine - ansCaregivers carry in a 2 y/o into the ED who fell out of a second-story window. The pt is awake and crying with increased work of breathing and pale skin. Which of the following interventions has the highest priority? Pediatric Assessment Triangle 1. General appearance - muscle tone, interactiveness, consoloability, poor or gaze, speech or cry 2. Work of breathing - inadequate or excessive, accessory muscle use, retractions, tripod position, abnormal upper airway sounds 3. Circulation of the skin - color, mottling or central or peripheral cyanosis, diaphoresis - ansPAT pelvic stability - ansthe most reassuring finding for a male pt with hip pain after a fall is which of the following? pericardiocentesis - ansWhich of the following is NOT considered goal-directed therapy for cardiogenic shock? placental abruption - ansYou are caring for a pt who was involved in a MVC and is 32 weeks pregnant. Findings of your secondary survey include abd pain on palpation, fundal ht at the costal margin, and some dark bloody show. Varying accelerations and decelerations are noted on cariocgraphy. These findings are most consistent with which of the following? pressure - ansAn intubated and sedated pt in the ED has multiple extremity injuries with the potential for causing compartment syndrome. What is the most reliable indication of compartment syndrome in a patient who is unconscious? TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition Pt is at hospital in the right amount of time, right care, right trauma facility, right resources - ansSafe Care: pulse oximetry and capnography - ansWhat bedside monitoring parameters are used to assess for adequacy of O2 and effectiveness of ventilation? Reevaluation and Consider the need to Transfer - ansFinal step in primary survey reorganize care to C-ABC - ansIf uncontrolled hemorrhage .. Report your suspicion of maltreatment in accordance with local regulations - ansa 5 y/o child presents to the ED with bruises to the upper arm and buttocks in various stages of healing and multiple small, clean, round burns to the back. There are no abnormalities found based on the pediatric assessment triangle or primary survey. Which of the following is the priority survey. Which of the following is the priority nursing intervention? results from hypo perfusion to the tissue due to an obstruction in either vasculature or heart. Goal is to relieve obstruction and improve perfusion. Ex: tension pneumo or cardiac tamponade are two classic examples that may result from trauma. - ansObstructive Shock 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. Ex: MI's or dysrhythmia are common causes - ansCariogenic Shock Review the age-related anatomic and physiologic change of the older adult in relation to the components of the initial assessment. - ans Sample is part of history S symptoms associated with injury A allergies and tetanus status M meds currently on including anticoagulant therapy P past medical hx L last oral intake E Events and environment factors related to the injury - ansSAMPLE serial FAST exams - ansa 49 y/o restrained driver involved in a MVC presents to the trauma center complaining of abd, pelvic, and bilateral lower extremity pain. VS are TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition - Chest pain - Chest wall ecchymosis - Widened mediastinum on chest xray - Paraplegia What are aortic injuries S/S? - ans- Hypotension - Decreased LOC - Hypertension in UE's - Decreased quality (amplitude) of femoral pulses compared to UE pulses - Loud systolic murmur in parascapular region - Chest pain - Chest wall ecchymosis - Widened mediastinum on chest xray - Paraplegia What are contributing factors to injuries related to blunt traumas? - ansThe point of impact on the patient's body, the type of surface that is hit, the tissues ability to resist (bone versus soft tissue, air-filled versus solid organs), and the trajectory of force. What are factors that contribute to ineffective ventilation? - ans- AMS - LOC - Neurologic injury - Spinal Cord Injury - Intracranial Injury - Blunt trauma - Pain caused by rib fractures - Penetrating Trauma - Preexisting hx of respiratory diseases - Increased age What are factors that contribute to ineffective ventilation? - ans- AMS - LOC - Neurologic injury - Spinal Cord Injury - Intracranial Injury - Blunt trauma - Pain caused by rib fractures - Penetrating Trauma - Preexisting hx of respiratory diseases - Increased age TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition What are intracerebral hematoma's and its S/S? - ansOccur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration. S/S: - Progressive and often rapid decline in LOC - H/A - Signs of increasing ICP - Pupil abnormalities - Contralateral hemiplegia What are intracerebral hematoma's and its S/S? - ansOccur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration. S/S: - Progressive and often rapid decline in LOC - H/A - Signs of increasing ICP - Pupil abnormalities - Contralateral hemiplegia What are neck injury S/S? - ans- Dyspnea - Hemoptysis (coughing up blood) - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - Penetrating wounds or impaled objects - Pulsatile or expanding hematoma - Loss of normal anatomic prominence of the laryngeal region - Bruits - Active external bleeding - Neurologic deficit, such as aphasia or hemiplegia - Cranial nerve deficits - Facial sensory or motor nerve deficits - Dysphonia (hoarseness) - Dysphagia (difficulty swallowing) What are neck injury S/S? - ans- Dyspnea - Hemoptysis (coughing up blood) - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - Penetrating wounds or impaled objects TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition - Pulsatile or expanding hematoma - Loss of normal anatomic prominence of the laryngeal region - Bruits - Active external bleeding - Neurologic deficit, such as aphasia or hemiplegia - Cranial nerve deficits - Facial sensory or motor nerve deficits - Dysphonia (hoarseness) - Dysphagia (difficulty swallowing) What are S/S of a rib fracture? - ans- Dyspnea - Localized pain on movement, palpation, or inspiration - Pt assumes position intended to splint chest wall to reduce pain - Chest wall ecchymosis or sternal contusion - Bony crepitus or deformity What are S/S of a rib fracture? - ans- Dyspnea - Localized pain on movement, palpation, or inspiration - Pt assumes position intended to splint chest wall to reduce pain - Chest wall ecchymosis or sternal contusion - Bony crepitus or deformity What are S/S of a ruptured diaphragm? - ans(Anything below the nipple line and should be evaluated for potential diaphragmatic injury). - Dyspnea or orthopnea - Dysphagia - Abdominal pain - Sharp epigastric or chest pain radiating to left shoulder (Kehr's sign) - Bowel sounds heard in lower middle chest - Decreased breath sounds on injured side What are S/S of a ruptured diaphragm? - ans(Anything below the nipple line and should be evaluated for potential diaphragmatic injury). - Dyspnea or orthopnea - Dysphagia - Abdominal pain - Sharp epigastric or chest pain radiating to left shoulder (Kehr's sign) - Bowel sounds heard in lower middle chest - Decreased breath sounds on injured side What are s/s of chemical burns to the eye? - ansChemical injuries require immediate intervention if it is to be preserved. TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition - Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing - Sucking chest wounds - Absent or diminished breath sounds - Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated - Anticipate definitive airway management to support ventilation. What are signs of ineffective circulation? - ans- Tachycardia - AMS - Uncontrolled external bleeding - Pale, cool, moist skin - Distended or abnormally flattened external jugular veins - Distant heart sounds What are signs of ineffective circulation? - ans- Tachycardia - AMS - Uncontrolled external bleeding - Pale, cool, moist skin - Distended or abnormally flattened external jugular veins - Distant heart sounds What are the early signs and symptoms of increased ICP? - ans- Headache - N/V - Amnesia regarding events around the injury - Altered LOC - Restlessness, drowsiness, changes in speech, or loss of judgement What are the early signs and symptoms of increased ICP? - ans- Headache - N/V - Amnesia regarding events around the injury - Altered LOC - Restlessness, drowsiness, changes in speech, or loss of judgement What are the early signs of increased Intracranial pressure - ansheadache, vomiting, behavioral changes that begin with restlessness and may progress to confusion, drowsiness, or impaired judgment What are the five forms in which energy exist? - ans1. Mechanical 2. Thermal 3. Chemical 4. Electrical 5. Radiant TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition What are the four types of shock? - ansHypovolemic, Cardiogenic, Obstructive, & Distributive What are the four types of trauma related injuries? - ansBlunt, penetrating, thermal, or blast. What are the greatest risks for transport? - ansLoss of airway patency, displaced obstructive tubes lines or catheters, dislodge splinting devices, need to replace or reinforce dressings, deterioration in patient status change in vital signs or level of consciousness, injury to the patient and/or team members What are the interventions for Disability? - ans- If assessment indicates a decreased LOC, conduct further investigation during secondary focused assessments - If pt is not alert or verbal, continue to monitor for any compromise to ABC's - If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation. What are the interventions for Disability? - ans- If assessment indicates a decreased LOC, conduct further investigation during secondary focused assessments - If pt is not alert or verbal, continue to monitor for any compromise to ABC's - If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation. What are the interventions for Effective/Ineffective Circulation? - ans- Control any uncontrolled external bleeding by: - Applying direct pressure over bleeding site - Elevating bleeding extremity - Applying pressure over arterial pressure points - Using tourniquet (last resort). - Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution - Use warmed solution - Use pressure bags to increase speed of IVF infusion - Use blood administration tubing for possible administration of blood - Use rapid infusion device based on protocol - Use NS 0.9% in same tubing as blood product - IV = surgical cut-down, central line, or both. - Blood sample to determine ABO and Rh group - IO in sternum, legs, arms or pelvis - Administer blood products - PASG (without interfering with fluid resuscitation) TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition What are the interventions for Effective/Ineffective Circulation? - ans- Control any uncontrolled external bleeding by: - Applying direct pressure over bleeding site - Elevating bleeding extremity - Applying pressure over arterial pressure points - Using tourniquet (last resort). - Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution - Use warmed solution - Use pressure bags to increase speed of IVF infusion - Use blood administration tubing for possible administration of blood - Use rapid infusion device based on protocol - Use NS 0.9% in same tubing as blood product - IV = surgical cut-down, central line, or both. - Blood sample to determine ABO and Rh group - IO in sternum, legs, arms or pelvis - Administer blood products - PASG (without interfering with fluid resuscitation) What are the late observable signs of symptoms of increased ICP? - ans- Dilated, nonreactive pupil - Unresponsiveness to verbal or painful stimuli - Abnormal motor posturing patterns - Widening pulse pressure - Increased systolic blood pressure - Changes in RR and pattern - Bradycardia What are the late observable signs of symptoms of increased ICP? - ans- Dilated, nonreactive pupil - Unresponsiveness to verbal or painful stimuli - Abnormal motor posturing patterns - Widening pulse pressure - Increased systolic blood pressure - Changes in RR and pattern - Bradycardia What are the late signs of breathing compromise? - ans- Tracheal deviation - JVD What are the late signs of breathing compromise? - ans- Tracheal deviation - JVD TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition What are the nursing interventions for a pt with an ocular injury? - ans- Assess visual acuity & reassess - Elevate HOB to minimize intraocular pressure - Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise intraocular pressure - Assist w/removal of foreign bodies as indicated; stabilize impaled objects - Apply cool packs to decrease pain + periorbital swelling - Admin medications - Instill prescribed topical anesthetic drops for pain - Instill NS drops or artificial tears to keep corneas moist. Cover eyelids w/sterile, moist saline dsg to prevent drying and ulceration - Antibiotics topically or systemically - Admin tetanus prophylactically - Use an eye patch to affected eye - Patch or shield both eyes to reduce movement + photophobia in pt's w/retinal injuries - Patch, shield or cover w/cool pack - Do NOT patch injured eye of pt w/suspected open or ruptured globe or impaled object, patch unaffected eye. Use metal or plastic and do not put pressure on the globe. - Provide psychosocial support - Obtain an ophthalmology consultation - Provide d/c instructions: - Importance of protective eyewear - No driving w/eye patch on - Wear sunglasses to prevent tearing, aid photophobia - Prepare for admission, OR or transfer What are the Rapid Sequence Intubation Steps? - ansPREPARATION: - gather equipment, staffing, etc. PREOXYGENATION: - Use 100% O2 (prevent risk of aspiration). PRETREATMENT: - Decrease S/E's of intubation PARALYSIS WITH INDUCTION: - Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING: - Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration PLACEMENT WITH PROOF - Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between attempts. - After intubation, inflate the cuff - Confirm tube placement w/exhaled CO2 detector. TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition POSTINTUBATION MANAGEMENT: - Secure ET tube - Set ventilator settings - Obtain Chest x-ray - Continue to medicate - Recheck VS and pulse oxtimetry What are the Rapid Sequence Intubation Steps? - ansPREPARATION: - gather equipment, staffing, etc. PREOXYGENATION: - Use 100% O2 (prevent risk of aspiration). PRETREATMENT: - Decrease S/E's of intubation PARALYSIS WITH INDUCTION: - Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING: - Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration PLACEMENT WITH PROOF - Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between attempts. - After intubation, inflate the cuff - Confirm tube placement w/exhaled CO2 detector. POSTINTUBATION MANAGEMENT: - Secure ET tube - Set ventilator settings - Obtain Chest x-ray - Continue to medicate - Recheck VS and pulse oxtimetry What are the S/S of a basilar skull fx? - ans- H/A - Altered LOC - Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic membrane (hemotympanum) - Facial nerve (VII) palsy - CSF rhinorrhea or otorrhea What are the S/S of a basilar skull fx? - ans- H/A - Altered LOC - Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic membrane (hemotympanum) - Facial nerve (VII) palsy - CSF rhinorrhea or otorrhea TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition What are the S/S of a depressed skull fx? - ans- H/A - Possible decreased LOC - Possible open fx - Palpable depression of skull over the fx site What are the S/S of a depressed skull fx? - ans- H/A - Possible decreased LOC - Possible open fx - Palpable depression of skull over the fx site What are the S/S of a linear skull fx? - ans- H/A - Possible decreased LOC What are the S/S of a linear skull fx? - ans- H/A - Possible decreased LOC What are the S/S of a pneumothorax? - ans- Dyspnea, tachypnea - Tachycardia - Hyerresonance (increased echo produced by percussion over the lung field) on the injured side - Decreased or absent breath sounds on the injured side - Chest pain - Open, sucking wound on inspiration (open pneumothorax) What are the S/S of a pneumothorax? - ans- Dyspnea, tachypnea - Tachycardia - Hyerresonance (increased echo produced by percussion over the lung field) on the injured side - Decreased or absent breath sounds on the injured side - Chest pain - Open, sucking wound on inspiration (open pneumothorax) What are the S/S of a tension pneumothorax? - ans- Severe respiratory distress - Markedly diminished or absent breath sounds on affected side - hypotension - Distended neck, head and upper extremity veins-may not be clinically appreciated if significant blood loss present - Tracheal deviation - shift toward uninjured side (LATE sign) - Cyanosis (LATE sign) What are the S/S of a tension pneumothorax? - ans- Severe respiratory distress TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition What are the signs and symptoms of decompensated shock? - ansDecreased level of consciousness, hypertension, narrow pulse pressure, tachycardia with weak pulses, tachypnea, skin that is cool clammy and cyanotic, base access outside the normal range, and serum lactate levels greater than two to 4MMOL/L. What are the signs and symptoms of irreversible shock? - ansObtunded stuporous or comatose state, marked hypertension and heart failure, bradycardia with possible dysrhythmias, decreased and shallow respiratory rate, pale cool and clammy skin, kidney liver and other organ failure, severe acidosis, elevated lactic acid levels, worsening base access on ABGs, coagulopathies with petechiae purpura or bleeding. What are the signs and symptoms of postconcussive syndrome? - ans- Persistent H/A - Dizziness - Nausea - Memory impairment - Attention deficit - Irritability - Insomnia - Impaired judgement - Loss of libido - Anxiety - Depression What are the signs and symptoms of postconcussive syndrome? - ans- Persistent H/A - Dizziness - Nausea - Memory impairment - Attention deficit - Irritability - Insomnia - Impaired judgement - Loss of libido - Anxiety - Depression What are the signs of compensated shock? - ansAnxiety, confusion, restlessness, increased respiratory rate, narrowing pulse pressure were diastolic increases yet systolic remains unchanged, tachycardia with bounding pulses, and decreased urinary output What are the symptoms of a subdural hematoma? - ansDecreased LOC, nausea vomiting headache and ipsilateral pupillary changes TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition What are the three factors that contribute to the damage caused by penetrating trauma's? - ansThe point of impact, the velocity and speed of impact, and the proximity to the object. What are the three processes that transfer oxygen from the air to the lungs and blood stream - ansVentilation: the active mechanical movement of air into and out of the lungs; diffusion: the passive movement of gases from an area of higher concentration to an area of lower concentration; and perfusion: the movement of blood to and from the lungs as a delivery medium of oxygen to the entire body. What are the three stages of shock - ansCompensated, decompensated or progressive, and irreversible. What are the treatment goals for a TBI? - ansO2 saturation > or equal to 95%, systolic blood pressure > or equal to 100 MMHG, ICP < 15 MMHG, CPP > or equal to 60 MMHG, normal glycemia, hemoglobin > or equal to 7 g/DL, sodium 135-145, osmotic diuretics, anti-emetics, sedatives, anticonvulsants, head of bed at 30°, and neck at midline What are the two types of herniation that occurs with ICP? - ans1. Uncal herniation 2. Central or transtentorial herniation What are the two types of herniation that occurs with ICP? - ans1. Uncal herniation 2. Central or transtentorial herniation What are you looking for when auscultating lung sounds? - ansAbsence of BS: - Pneumothorax - Hemothorax - Airway Obstruction Diminished BS: - Splinting or shallow BS may be a result of pain What are you looking for when auscultating lung sounds? - ansAbsence of BS: - Pneumothorax - Hemothorax - Airway Obstruction Diminished BS: - Splinting or shallow BS may be a result of pain What are you looking for when palpating the chest wall, clavicles and neck? - ans- Tenderness TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition - Swelling - subcutaneous emphysema - step-off deformities = These may indicate: esophageal, pleural, tracheal or bronchial injuries. Palpate trachea above suprasternal notch. Tracheal deviation may indicate a tension pneumothorax or massive hemothorax. What are you looking for when palpating the chest wall, clavicles and neck? - ans- Tenderness - Swelling - subcutaneous emphysema - step-off deformities = These may indicate: esophageal, pleural, tracheal or bronchial injuries. Palpate trachea above suprasternal notch. Tracheal deviation may indicate a tension pneumothorax or massive hemothorax. What are you looking for when percussing the chest? - ansDullness: - hemothorax Hyperresonance - Pneumothorax What are you looking for when percussing the chest? - ansDullness: - hemothorax Hyperresonance - Pneumothorax What assessment findings differentiate a placental abruption from a uterine rupture? - ans What causes quarternary effects of blast traumas? - ansAll explosion related injuries, illnesses, or diseases not due to the first three mechanisms. Injuries include external and internal burns, crush injuries, closed and open brain injuries, asthmatic or breathing problems from dust smoke or toxic fumes, angina, or hyper glycemia and hypertension. What causes quinary effects of blasts traumas? - ansThose associated with exposure to hazardous materials from radioactive, biologic, or chemical components of a blast. Injuries include a variety of health effects depending on agent. What causes the primary effects of blast traumas? - ansThe direct blast effects. Types of injuries include last long, tympanic membrane rupture and middle ear damage, abdominal hemorrhage and perforation, global rupture, mild Trumatic brain injury. TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition - Difficulty with concentration - Irritability - Fatigue What is a concussion and its signs and symptoms? - ansA temporary change in neurologic function that may occur as a result of minor head trauma. S/S: - Transient LOC - H/A - Confusion and disorientation - Dizziness - N/V - Loss of memory - Difficulty with concentration - Irritability - Fatigue What is a flail chest? - ansA fracture of two or more sites on two or more adjacent ribs, or when rib fractures produce a free-floating sternum. Flail segments may not be clinically evident in the first several hours after injury b/c of muscle spasms that cause splinting. After positive pressure intiated, paradoxical chest wall movement ceases. What is a flail chest? - ansA fracture of two or more sites on two or more adjacent ribs, or when rib fractures produce a free-floating sternum. Flail segments may not be clinically evident in the first several hours after injury b/c of muscle spasms that cause splinting. After positive pressure intiated, paradoxical chest wall movement ceases. What is a Laryngeal Mask Airway? - ansLooks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area. ILMA, does not require laryngoscopy and visualization of the chords. What is a Laryngeal Mask Airway? - ansLooks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area. ILMA, does not require laryngoscopy and visualization of the chords. TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition What is a pulmonary contusion? - ansThey occur as a result of direct impact, deceleration or high-velocity bullet wounds. It develops when blood leaks into lung parenchyma, causing edema + hemorrhage. This usually develops overtime and not immediately. What is a pulmonary contusion? - ansThey occur as a result of direct impact, deceleration or high-velocity bullet wounds. It develops when blood leaks into lung parenchyma, causing edema + hemorrhage. This usually develops overtime and not immediately. What is a subdural hematoma and its S/S? - ansA focal brain injury beneath the dura mater that results from acceleration/deceleration. Usually venous, and not necessarily from a fx. Formation may be acute or chronic. Acute pt's hematoma manifest 48 hrs post injury S/S: - Altered LOC or steady decline in LOC - S/S of increased ICP - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma Chronic pt's " " up to 2 wks post injury - H/A - Progressive decrease in LOC - Ataxia - Incontinence - Sz's What is a subdural hematoma and its S/S? - ansA focal brain injury beneath the dura mater that results from acceleration/deceleration. Usually venous, and not necessarily from a fx. Formation may be acute or chronic. Acute pt's hematoma manifest 48 hrs post injury S/S: - Altered LOC or steady decline in LOC - S/S of increased ICP - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma Chronic pt's " " up to 2 wks post injury - H/A TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition - Progressive decrease in LOC - Ataxia - Incontinence - Sz's What is a trademark symptom of an epidural hematoma - ansLoss of consciousness then awake and alert then loss of consciousness What is an epidural hematoma and its S/S? - ansResults when a collection of blood forms between the skull and the dura mater. Bleeding is arterial=blood accumulates rapidly: - Compression of underlying brain - rapid increase in ICP - Decreased CBF - Secondary brain injury * Usually requires surgical intervention S/S: - Transient LOC - Lucid period lasting a few minutes to several hours - Rapid deterioration in neurologic status - Severe H/A - Sleepiness - Dizziness - N/V - Hemiparesis or hemiplegia on opposite side of hematoma - Unilateral fixed and dilated pupil on same side of hematoma What is an epidural hematoma and its S/S? - ansResults when a collection of blood forms between the skull and the dura mater. Bleeding is arterial=blood accumulates rapidly: - Compression of underlying brain - rapid increase in ICP - Decreased CBF - Secondary brain injury * Usually requires surgical intervention S/S: - Transient LOC - Lucid period lasting a few minutes to several hours - Rapid deterioration in neurologic status - Severe H/A - Sleepiness - Dizziness TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition stresses from rotational or accerleration/deceleration forces resulting in microscopic damage primarily to axons within the brain. S/S: - Immediate unconsciousness - mild DAI, coma = 6-24 hrs - severe DAI, coma = weeks/months or persistent vegetative state - Elevated ICP - Abnormal posturing - HTN - Hyperthermia - Excessive sweating because of autonomic dysfunction - Mild to severe memory impairment, cognitive, behavioral, and intellectual deficits What is hyphema and its S/S? - ansAccumulation of blood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV). S/S: - Blood in anterior chamber - Deep, aching pain - Mild to severe diminished visual acuity - Increased intraocular pressure What is hyphema and its S/S? - ansAccumulation of blood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV). S/S: - Blood in anterior chamber - Deep, aching pain - Mild to severe diminished visual acuity - Increased intraocular pressure What is kinematics? - ansA branch of mechanics (energy transfer) that refers to motion and does not consider the concepts of force and mass of the object or body. What is kinematics? - ansA branch of mechanics (energy transfer) that refers to motion and does not consider the concepts of force and mass of the object or body. What is kinetic energy (KE)? - ansKE equals 1/2 the mass (M) multiplied by the velocity squared. TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition What is kinetic energy (KE)? - ansKE equals 1/2 the mass (M) multiplied by the velocity squared. What is LeFort I fracture and its S/S? - ansTransverse maxillary fx that occurs above level of teeth and results in separation of teeth from rest of maxilla. S/S: - Slight swelling of maxillary area - Possible lip lac's or fractured teeth - Independent movement of the maxilla from rest of face - Malocclusion What is LeFort I fracture and its S/S? - ansTransverse maxillary fx that occurs above level of teeth and results in separation of teeth from rest of maxilla. S/S: - Slight swelling of maxillary area - Possible lip lac's or fractured teeth - Independent movement of the maxilla from rest of face - Malocclusion What is LeFort II fracture and its S/S? - ansPyramidal maxillary fx=middle facial area. Apex of fx transverses bridge of nose. Two lateral fx's of pyramid extend through the lacrimal bone of the face and ethmoid bone of skull into the median portion of both orbits. Base of the fx extends above level of the upper teeth into maxilla. CSF leak is possible. S/S: - Massive facial edema - Nasal swelling w/obvious fx of nasal bones - Malocclusion - CSF rhinorrhea What is LeFort II fracture and its S/S? - ansPyramidal maxillary fx=middle facial area. Apex of fx transverses bridge of nose. Two lateral fx's of pyramid extend through the lacrimal bone of the face and ethmoid bone of skull into the median portion of both orbits. Base of the fx extends above level of the upper teeth into maxilla. CSF leak is possible. S/S: - Massive facial edema - Nasal swelling w/obvious fx of nasal bones - Malocclusion - CSF rhinorrhea TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition What is LeFort III fracture and its S/S? - ansComplete craniofacial separation involving maxilla, zygoma and bones of cranial base. This fx is frequently associated w/leakage of CSF and fx mandible. S/S: - Massive facial edema - Mobility and depression of zygomatic bones - Ecchymosis - Anesthesia of the cheek - Diplopia - Open bite or malocclusion - CSF rhinorrhea What is LeFort III fracture and its S/S? - ansComplete craniofacial separation involving maxilla, zygoma and bones of cranial base. This fx is frequently associated w/leakage of CSF and fx mandible. S/S: - Massive facial edema - Mobility and depression of zygomatic bones - Ecchymosis - Anesthesia of the cheek - Diplopia - Open bite or malocclusion - CSF rhinorrhea What is Needle Cricothyrotomy - ansPercutaneous transtracheal ventilation. (temporary) Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation - aspiration - thyroid perforation - subcutaneous emphysema What is Needle Cricothyrotomy - ansPercutaneous transtracheal ventilation. (temporary) Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition P - Pneumothorax: Condition may occur from original trauma or barotrauma from ventilator E - Equipment failure: pt may have become detached from equipment or there's a kink in the tubing What is the DOPE mnemonic? - ansD - Displaced tube O - Obstruction: Check secretions or pt biting tube P - Pneumothorax: Condition may occur from original trauma or barotrauma from ventilator E - Equipment failure: pt may have become detached from equipment or there's a kink in the tubing What is the first thing assessed under the Secondary Assessment? - ansFULL SET VS / FOCUSED ADJUNCTS / FAMILY PRESENCE - ABCDE should be completed - Labs, X-rays, CT, Foley, - Family Presence What is the first thing assessed under the Secondary Assessment? - ansFULL SET VS / FOCUSED ADJUNCTS / FAMILY PRESENCE - ABCDE should be completed - Labs, X-rays, CT, Foley, - Family Presence What is the Law of Conservation of Energy? - ansEnergy can neither be created nor destroyed. It is only changed from one form to another. What is the Law of Conservation of Energy? - ansEnergy can neither be created nor destroyed. It is only changed from one form to another. What is the minimum permissive hypertension and a trauma patient? - ansA systolic of greater than or equal to 90 MMHG What is the minimum permissive oxygenation level of a trauma patient? - ansGreater than or equal to 94% What is the Mnemonic for the Initial Assessment? - ansA = Airway with simultaneous cervical spine protection B = Breathing C = Circulation D = Disability (neurologic status) E = Expose/Environmental controls (remove clothing and keep the patient warm) TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition What is the Mnemonic for the Initial Assessment? - ansA = Airway with simultaneous cervical spine protection B = Breathing C = Circulation D = Disability (neurologic status) E = Expose/Environmental controls (remove clothing and keep the patient warm) What is the Mnemonic for the Secondary Assessment? - ansF = Full set of VS/Focused adjuncts (includes cardiac monitor, urinary catheter, and gastric tube)/Family presence G = Give comfort measures (verbal reassurance, touch, and pharmacologic and nonpharmacologic management of pain). H = Hx and Head-to-toe assessment I = Inspect posterior surfaces What is the Mnemonic for the Secondary Assessment? - ansF = Full set of VS/Focused adjuncts (includes cardiac monitor, urinary catheter, and gastric tube)/Family presence G = Give comfort measures (verbal reassurance, touch, and pharmacologic and nonpharmacologic management of pain). H = Hx and Head-to-toe assessment I = Inspect posterior surfaces What is the Munro-Kellie doctrine? - ansWithin the skull 80% his brain, 10% is blood, and 10% is CSF. Any increase of any of the products results in increased intracranial pressure. What is the planning and implementation for thoracic injury? - ansp. 142 What is the planning and implementation for thoracic injury? - ansp. 142 What is the recommended fluid bolus for a trauma? - ans500 ML's of warmed isotonic crystalloid. Ongoing fluid boluses of 500 ML's should be given judiciously with constant reassessments after administration. What is the relationship between mass and velocity to kinetic energy? - ansKinetic energy is equal to 1/2 the mass multiplied the square of its velocity therefore when mass is doubled so is the net energy, however, when velocity is doubled energy is quadrupled. What is the second thing assessed under the Secondary Assessment? - ansGIVE COMFORT MEASURES - Talking to pt TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition - Pharmacologic/Nonpharmacologic pain management - Observe for physical signs of pain What is the second thing assessed under the Secondary Assessment? - ansGIVE COMFORT MEASURES - Talking to pt - Pharmacologic/Nonpharmacologic pain management - Observe for physical signs of pain What is the trauma triad of death? - anshypothermia, acidosis, coagulopathy What is torsion? - ansTorsion forces twist ends in opposite directions. What is vascular response? - ansAs blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors. Arterioles constrict to increase TPR and BP. What is vascular response? - ansAs blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors. Arterioles constrict to increase TPR and BP. What medications are used during intubation? - ansLOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents What medications are used during intubation? - ansLOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents What she be done after the Secondary Assessment? - ansReassess: - Primary survey, - VS - Pain - Any injuries What she be done after the Secondary Assessment? - ansReassess: - Primary survey, - VS TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition The patient has been in the ED for 24 hours awaiting an inpatient bed. The night shift nurse reports the patient has been anxious, restless, shaky, and vomited twice during the night. The patient states they couldn't sleep because a young child kept coming into the room. What is the most likely cause for these signs and symptoms? a. increase intracranial pressure b. alcohol withdrawal c. rhabdomyolysis d. pulmonary embolus - ansb. alcohol withdrawal A patient involved in a MVC has sustained a fracture to the second rib of the anterior left chest. Which concurrent injury is most commonly associated with this fracture? a. Blunt cardiac injury b. Brachial plexus injury c. Pneumothorax d. Hemothorax - ansb. Brachial plexus injury A patient with a spinal cord injury at C5 is being cared for in the emergency department while awaiting transport to a trauma center. Which of the following represents the highest priority for ongoing assessment and management for this patient? a. maintain adequate respiratory status. b. administer balanced resuscitation fluid c. perform serial assessments of neurologic function d. maintain core temperature - ansa. maintain adequate respiratory status A trauma nurse cared for a child with devastating burns two weeks ago. The nurse called in sick for a couple of days and is now back working on the team. Which of the following behaviors would indicate this nurse is coping well? a. They are talking about taking the emergency nursing certification examination. b. They keep requesting to be assigned to the walk-in/ambulatory area c. They are impatient and snap at their coworkers. d. They are thinking about transferring out of the emergency department. - ansa. They are talking about taking the emergency nursing certification examination. Following a bomb explosion, fragmentation injuries from the bomb or objects in the environment are examples of which phase of injury? a. primary b. secondary c. tertiary d. quaternary - ansb. secondary In a patient with severe traumatic brain injury, hypocapnia causes which condition? a. Respiratory acidosis TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition b. Metabolic acidosis c. Neurogenic shock d. Cerebral vasoconstriction - ansd. Cerebral vasoconstriction The general impression step in the initial assessment provides the opportunity to do which of the following? a. Assess for uncontrolled internal hemorrhage b. Accurately triage the patient c. Reprioritize circulation before airway or breathing. d. Activate the trauma team - ansc. Reprioritize circulation before airway or breathing. The nurse is obtaining a history for a patient who presents following sexual assault. This history is completed using which of the following techniques? a. Bring the family in to the interview room. b. Use direct quotes to record information. c. Obtain information specific only to the assault. d. Provide food and drink to help create rapport. - ansb. Use direct quotes to record information. The vital signs of a pregnant trauma patient at 30 weeks include a blood pressure of 94/62 mm Hg and a heart rate of 108 beats/minute. Fetal heart tones are 124 beats/minute. The emergency nurse interprets the patient's hemodynamic findings as an indication of which of the following? a. Decompensated shock b. Normal vital signs in pregnancy c. Compensated shock d. Supine hypotension syndrome - ansb. Normal vital signs in pregnancy Treatment for frostbite can include which of the following interventions? a. warm the affected part over 30-60 minutes b. use gentle friction to improve circulation c. administer tissue plasminogen activator d. leave all of the blisters intact - ansc. administer tissue plasminogen activator Understanding the kinematic concepts associated with the mechanism of injury and energy transfer can initially assist the trauma care provider in which of the following? a. Anticipating the types of injuries that may be present b. Deciding whether law enforcement should be notified c. Determining needed laboratory tests d. Predicting the need for a surgical procedure - ansa. Anticipating the types of injuries that may be present TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition What is the appropriate technique for palpating the pelvis for stability? a. Apply gentle pressure over the iliac crests, downward and laterally. b. Apply gentle pressure over the iliac crests, downward and medially. c. Apply firm pressure over the iliac crests, downward and laterally. d. Apply firm pressure over the iliac crests, downward and medially. - ansb. Apply gentle pressure over the iliac crests, downward and medially. What is the best measure of the adequacy of cellular perfusion and can help to predict the outcome of resuscitation? a. End-tidal carbon dioxide b. Hematocrit level c. Base deficit d. Oxygen saturation - ansc. Base deficit What is the best position for maintaining an open airway in the obese patient? a. Prone b. Supine c. Reverse Trendelenburg d. Right lateral recumbent - ansc. Reverse Trendelenburg What is the leading cause of preventable death for the trauma patient in the prehospital environment? a. Airway compromise b. Ineffective ventilation c. Secondary head injury d. Uncontrolled external hemorrhage - ansd. Uncontrolled external hemorrhage Which of the following accurately describes ventilation principles associated with use of a bag-mask device for an adult? a. Compress the bag-mask device at a rate of one breath every 6 seconds. b. Delivers 100% oxygen. c. Squeeze the bag-mask device completely for each breath. d. Maintain the oxygen saturation levels between 92% and 94%. - ansa. Compress the bag-mask device at a rate of one breath every 6 seconds. Which of the following is considered a cornerstone of a high-performance trauma team? a. Individual goals b. Use of TeamSTEPPS c. Identification of a single decision maker d. Effective communication - ansd. Effective communication TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition 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. Classifications of Shock - ansHypovolemic - decrease in the amount of circulating blood volume Obstructive - obstruction in either the vasculature or heart Cardiogenic - pump failure in the presence of adequate intravascular volume Distributive - maldistribution of an adequate circulating blood volume (septic, anaphylactic, neurogenic) Corneal Abrasion - ansDamage to the corneal epithelium. Easy to evaluate with fluorescein. Findings: photophobia, tearing, pain, injected conjunctiva (redness), lid swelling, irritation Treatment: Ophthalmic ABX, Cycloplegic agent to decrease spasms and pain, ophthalmic NSAIDS to decrease swelling, oral analgesics, Ophthalmic f/u in 24 hours. (Do NOT patch - increases infection) Corneal Foreign Body - ansRoutinely metal, plastic or wood. Findings: photophobia, pain, injected conjunctiva (redness), lid swelling Treatment: topical anesthetic, removal of foreign body, ophthalmic ABX, cycloplegics, oral analgesia Corneal Laceration - ansInvolves one or more layers of the cornea. Visualized with a slit lamp. Findings: similar to abrasion, pain out of proportion to findings, decreased vision Treatment: treat small lacerations similar to an abrasion, larger lacerations need ophthalmology referral and possible surgery TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition Cycloplegic agent - ansCycloplegia is paralysis of the ciliary muscle of the eye, resulting in a loss of accommodation. Because of the paralysis of the ciliary muscle, the curvature of the lens can no longer be adjusted to focus on nearby objects. D (Primary Survey) - ansDisability (Neurologic Status) Disability Assessment - ansAssess GCS on arrival and repeat per policy. Assess pupils for equality, shape and reactivity (PERRL) Disability interventions - ansEvaluate for need for CT. Assume AMS to be the result of CNS injury until proven otherwise. Consider ABGs - AMS may be indicator of decreased cerebral perfusion, hypoventilation or acid-base imbalance. Consider bedside glucose. Distributive Shock - ansOccurs as a result of maldistribution of an adequate circulating volume with a loss of vascular tone or increased permeability. Diffuse vasodilation lowers the systemic pressure, creating a relative hypovolemia or reduction of the mean systemic volume and venous return to the heart or drop in preload, resulting in distributive shock. Anaphylactic: release of inflammatory mediators, such as histamine, which contracts bronchial smooth muscle and increases vascular permeability and vasodilation. Septic Shock: systemic release of bacterial endotoxins, resulting in an increased vascular permeability and vasodilation Neurogenic shock: loss of sympathetic nervous system control of vascular tone, which produces venous and arterial vasodilation. With the loss of sympathetic nervous system input in spinal cord injury, unopposed vagal activity may result in decreased cardiac output through bradycardia. TREATMENT: increase systemic resistance, controlled volume replacement. Vasoconstriction and in some cases (neurogenic) Atropine to counteract bradycardia. E (Primary Survey) - ansExposure and Environmental Control TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition Exposure and Environmental Control - ansCarefully and completely undress the patient. Inspect for uncontrolled bleeding and note any obvious injuries. Prevent heat loss. Hypothermia combined with hypotension and acidosis is a potentially lethal combination in the injured patient. Consider: warm blankets, keep ambient temperature warm, warm IVF, forced air warmers, radiant warming lights. F (Primary Survey) - ansFull Set of VS & Family Presence G (Primary Survey) - ansGet Resuscitation Adjuncts: (LMNOP) L: Labs M: Monitor cardiac rate and rhythm N: Naso or orogastric tube consideration O: Oxygenation - SpO2 and/or etCO2 monitor P: Pain assessment and management GCS - ansGCS EYES 1: Does not open eyes 2: Opens eyes in response to pain 3: Opens eyes in response to voice 4: Opens eyes spontaneously VERBAL 1. Makes no sounds 2. Makes sounds 3. Words 4. Confused, disoriented 5. Oriented, converses normally MOTOR 1. Makes no movements 2. Extension to painful stimuli (decerebrate) 3. Abnormal flexion to painful stimuli (decorticate) 4. Withdrawal to painful stimuli 5. Localizes painful stimuli 6. Obeys commands H (Secondary Survey) - ansHistory Prehospital Report (MIST) TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition The liver filters out toxins, takes the nutrients and returns the blood to the heart via the hepatic veins. Hepatocyte cells are capable of regeneration allowing the liver to repair its own tissue. Functions: Store and metabolize lipids, transport nutrients, produce glucose and bilirubin, convert ammonia to urea, secrete electrolytes, lipids, lecithin, cholesterol and bile. Metabolizes vitamin K and produces thrombin and fibrinogen (all necessary for clotting). Obstructive Shock - ansResults from hypo perfusion of the tissue due to an obstruction in either the vasculature or heart. Tension pneumothorax - increased thoracic pressure leads to displacement of the vena cava, obstruction to atrial filling, decreased preload and decreased cardiac output. Cardiac tamponade - impedes diastolic expansion and filling leads to decreased preload, strokes volume and cardiac output and ultimately end organ perfusion. P (AVPU) - ansPainful. Responds only to painful stimuli. (Airway adjunct may be needed while determining need for intubation) Reevaluation - ansPortable radiograph - AP chest, pelvis. Can quickly identify potentially life-threatening injuries such as pneumothorax or pelvic fracture with uncontrolled internal hemorrhage. Can also confirm placement of ET tubes, chest tubes and gastric tubes. Consider need for transfer. shock - ansInadequate tissue perfusion. Spleen - ansEncapsulated organ LUQ level of 9th-11th ribs and curves around a portion of the stomach. Minimal elasticity and flexibility - most frequent injured organ in blunt trauma. Secondary lymph organ that filters and cleanses the blood. Removes old RBCs and holds a reserve of blood. It recycles iron. It removes antibody-coated bacteria. Supplies lymphocytes to stimulate an immune response to blood borne microorganisms. Stores 200-300ml of blood and leads to hemodynamic instability quickly if damaged. Splenic Injuries - ansIn blunt trauma the spleen may lacerate from increased abdominal pressure. TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition Graded I-V, I = minor trauma Assessment findings: signs of trauma LUQ, abdominal distention, asymmetry, abnormal contour, tenderness, guarding, rigidity, pain left shoulder when supine. CT: Hemoperitoneum. Hypodensity - represents parenchymal disruption, intraparenchymal hematoma or subcapsular hematoma. Contrast blush or extravasation - hyperdense area that represent traumatic disruption. Active extravasation implies ongoing bleeding. Nonoperative management is preferred if hemodynamically stable, stable H/H x 12-24 hours, minimal transfusion requirements (<2units), grade I or II without blush, age <55, alert able to assist in assessment of abdomen. Surgical options: total splenectomy for severe injury, for less severe - direct pressure packing, embolization, splenorrhaphy (suturing spleen), partial removal. Asplenic patients have difficulty destroying encapsulated bacteria - Streptococcus pneumonia, Neisseria meningitides and Haemophilus influenza. At risk for pneumococcal sepsis. Need annual flu shot and q5yr meningococcal and pneumococcal vaccines. U (AVPU) - ansUnresponsive. Does not respond to any stimuli. V (AVPU) - ansVerbal. Needs verbal stimuli to respond. (Airway adjunct may be needed to prevent tongue obstruction) A (AVPU) - ansAlert. Will be able to maintain airway once clear. A (Primary Survey) - ansAirway and alertness with simultaneous cervical spinal stabilization. Airway Assessment - ansInspect: 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: - ansSuction TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition Remove foreign body if noted Jaw thrust maneuver (maintain cspine) Nasopharyngeal airway (can be conscious) Oropharyngeal airway (no gag) Consider definitive airway Alertness Assessment - ansA-Alert V-Verbal P-Painful U-Unresponsive B (Primary Survey) - ansBreathing and Ventilation Breathing and Ventilation Assessment - ansInspect: 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 - ansBreathing 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) - ansCirculation and Control of Hemorrhage Cardiogenic Shock - ansResults 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. TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition Diffuse vasodilation lowers the systemic pressure, creating a relative hypovolemia or reduction of the mean systemic volume and venous return to the heart or drop in preload, resulting in distributive shock. Anaphylactic: release of inflammatory mediators, such as histamine, which contracts bronchial smooth muscle and increases vascular permeability and vasodilation. Septic Shock: systemic release of bacterial endotoxins, resulting in an increased vascular permeability and vasodilation Neurogenic shock: loss of sympathetic nervous system control of vascular tone, which produces venous and arterial vasodilation. With the loss of sympathetic nervous system input in spinal cord injury, unopposed vagal activity may result in decreased cardiac output through bradycardia. TREATMENT: increase systemic resistance, controlled volume replacement. Vasoconstriction and in some cases (neurogenic) Atropine to counteract bradycardia. E (Primary Survey) - ansExposure and Environmental Control Exposure and Environmental Control - ansCarefully and completely undress the patient. Inspect for uncontrolled bleeding and note any obvious injuries. Prevent heat loss. Hypothermia combined with hypotension and acidosis is a potentially lethal combination in the injured patient. Consider: warm blankets, keep ambient temperature warm, warm IVF, forced air warmers, radiant warming lights. F (Primary Survey) - ansFull Set of VS & Family Presence G (Primary Survey) - ansGet Resuscitation Adjuncts: (LMNOP) L: Labs M: Monitor cardiac rate and rhythm N: Naso or orogastric tube consideration O: Oxygenation - SpO2 and/or etCO2 monitor P: Pain assessment and management GCS - ansGCS EYES 1: Does not open eyes 2: Opens eyes in response to pain TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition 3: Opens eyes in response to voice 4: Opens eyes spontaneously VERBAL 1. Makes no sounds 2. Makes sounds 3. Words 4. Confused, disoriented 5. Oriented, converses normally MOTOR 1. Makes no movements 2. Extension to painful stimuli (decerebrate) 3. Abnormal flexion to painful stimuli (decorticate) 4. Withdrawal to painful stimuli 5. Localizes painful stimuli 6. Obeys commands H (Secondary Survey) - ansHistory Prehospital Report (MIST) M: MOI I: Injuries sustained S: Signs and symptoms in the field T: Treatment in field Patient History (SAMPLE): S: Symptoms A: Allergies and tetanus status M: Medications P: Past medical history L: Last oral intake E: Events and Environmental factors related to injury. H: Head and Face Head to Toe Assessment (secondary survey) - ansSOFT TISSUE: Inspect: lacerations, puncture wounds, abrasions, contusions, edema, ecchymosis, impaled objects. Palpate: areas of tenderness, step-offs, crepitus BONY DEFORMITIES: TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition Inspect: asymmetry of facial expressions, exposed tissue or bone for brain matter Palpate: depressions, angulations, tenderness Hepatic Injuries - ansIn blunt trauma the liver may lacerate from increased abdominal pressure. Hematoma - bleeding contained within the capsule Laceration - the capsule is disrupted Findings: Cullen sign (ecchymosis around the umbilicus or RUQ), tenderness, guarding or rigidity RUQ, 9-12 rib FXs, elevated LFT Graded I-VI, I = minor trauma Nonoperative management is standard of care in hemodynamically stable patient. Observed with serial abdominal exams. Findings of contrast extravasation may be embolized by IR. For surgical patients - fluid resuscitation is essential. Risks of surgery include disruption of the natural tamponade process due to the evacuation of large amounts of blood resulting in hypovolemia. Hypovolemic Shock - ansCaused by a decrease in the amount of circulating blood volume. In trauma typically results from hemorrhage, but can result in a precipitous loss of volume, ie vomiting or diarrhea. Burn trauma can result in hypovolemic shock from damage to the cell membranes leading to plasma and protein leakage. of body water, results in inadequate perfusion. Hyperventilation can cause increased intrathoracic pressure resulting in compression of the heart and decreased cardiac output. Initial Assessment - ans1. Preparation and Triage 2. Primary Survey 3. Reevaluation 4. Secondary Survey TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition U (AVPU) - ansUnresponsive. Does not respond to any stimuli. V (AVPU) - ansVerbal. Needs verbal stimuli to respond. (Airway adjunct may be needed to prevent tongue obstruction) A (AVPU) - ansAlert. Will be able to maintain airway once clear. A (Primary Survey) - ansAirway and alertness with simultaneous cervical spinal stabilization. Airway Assessment - ansInspect: 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: - ansSuction Remove foreign body if noted Jaw thrust maneuver (maintain cspine) Nasopharyngeal airway (can be conscious) Oropharyngeal airway (no gag) Consider definitive airway Alertness Assessment - ansA-Alert V-Verbal P-Painful U-Unresponsive B (Primary Survey) - ansBreathing and Ventilation Breathing and Ventilation Assessment - ansInspect: 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 TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition 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 - ansBreathing 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) - ansCirculation and Control of Hemorrhage Cardiogenic Shock - ansResults 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 - ansInspect: 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 - ansControl 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. TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition **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. Classifications of Shock - ansHypovolemic - decrease in the amount of circulating blood volume Obstructive - obstruction in either the vasculature or heart Cardiogenic - pump failure in the presence of adequate intravascular volume Distributive - maldistribution of an adequate circulating blood volume (septic, anaphylactic, neurogenic) Corneal Abrasion - ansDamage to the corneal epithelium. Easy to evaluate with fluorescein. Findings: photophobia, tearing, pain, injected conjunctiva (redness), lid swelling, irritation Treatment: Ophthalmic ABX, Cycloplegic agent to decrease spasms and pain, ophthalmic NSAIDS to decrease swelling, oral analgesics, Ophthalmic f/u in 24 hours. (Do NOT patch - increases infection) Corneal Foreign Body - ansRoutinely metal, plastic or wood. Findings: photophobia, pain, injected conjunctiva (redness), lid swelling Treatment: topical anesthetic, removal of foreign body, ophthalmic ABX, cycloplegics, oral analgesia Corneal Laceration - ansInvolves one or more layers of the cornea. Visualized with a slit lamp. Findings: similar to abrasion, pain out of proportion to findings, decreased vision Treatment: treat small lacerations similar to an abrasion, larger lacerations need ophthalmology referral and possible surgery TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition M: MOI I: Injuries sustained S: Signs and symptoms in the field T: Treatment in field Patient History (SAMPLE): S: Symptoms A: Allergies and tetanus status M: Medications P: Past medical history L: Last oral intake E: Events and Environmental factors related to injury. H: Head and Face Head to Toe Assessment (secondary survey) - ansSOFT TISSUE: Inspect: lacerations, puncture wounds, abrasions, contusions, edema, ecchymosis, impaled objects. Palpate: areas of tenderness, step-offs, crepitus BONY DEFORMITIES: Inspect: asymmetry of facial expressions, exposed tissue or bone for brain matter Palpate: depressions, angulations, tenderness Hepatic Injuries - ansIn blunt trauma the liver may lacerate from increased abdominal pressure. Hematoma - bleeding contained within the capsule Laceration - the capsule is disrupted Findings: Cullen sign (ecchymosis around the umbilicus or RUQ), tenderness, guarding or rigidity RUQ, 9-12 rib FXs, elevated LFT Graded I-VI, I = minor trauma Nonoperative management is standard of care in hemodynamically stable patient. Observed with serial abdominal exams. TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition Findings of contrast extravasation may be embolized by IR. For surgical patients - fluid resuscitation is essential. Risks of surgery include disruption of the natural tamponade process due to the evacuation of large amounts of blood resulting in hypovolemia. Hypovolemic Shock - ansCaused by a decrease in the amount of circulating blood volume. In trauma typically results from hemorrhage, but can result in a precipitous loss of volume, ie vomiting or diarrhea. Burn trauma can result in hypovolemic shock from damage to the cell membranes leading to plasma and protein leakage. of body water, results in inadequate perfusion. Hyperventilation can cause increased intrathoracic pressure resulting in compression of the heart and decreased cardiac output. Initial Assessment - ans1. Preparation and Triage 2. Primary Survey 3. Reevaluation 4. Secondary Survey 5. Reevaluation Adjuncts 6. Reevaluation and Post Resuscitation Care 7. Definitive Care or Transport Intraocular Foreign Body - ans*TRUE EMERGENCY AND EARLY INTERVENTION IS ESSENTIAL. Findings: compromised visual acuity, misshapen pupils, pain Treatment: elevate HOB, ophthalmology, immobilize foreign body, patch UNAFFECTED eye to limit concomitant eye movement, globe closure ASAP, systemic and ophthalmic ABX, analgesics. Postop infection, retinal detachment and vision loss are common complications. lid injury - ans Liver - ansLargest solid organ of the body. RUQ, 6th to 10th ribs. Encased by Glisson capsule with blood vessels, lymphatics and nerves. Filters 1.7L of blood per minute. TNCC test prepA, TNCC Notes for Written Exam, TNCC Notes for Written Exam, TNCC Prep, TNCC EXAM, TNCC 8th Edition The liver filters out toxins, takes the nutrients and returns the blood to the heart via the hepatic veins. Hepatocyte cells are capable of regeneration allowing the liver to repair its own tissue. Functions: Store and metabolize lipids, transport nutrients, produce glucose and bilirubin, convert ammonia to urea, secrete electrolytes, lipids, lecithin, cholesterol and bile. Metabolizes vitamin K and produces thrombin and fibrinogen (all necessary for clotting). Obstructive Shock - ansResults from hypo perfusion of the tissue due to an obstruction in either the vasculature or heart. Tension pneumothorax - increased thoracic pressure leads to displacement of the vena cava, obstruction to atrial filling, decreased preload and decreased cardiac output. Cardiac tamponade - impedes diastolic expansion and filling leads to decreased preload, strokes volume and cardiac output and ultimately end organ perfusion. P (AVPU) - ansPainful. Responds only to painful stimuli. (Airway adjunct may be needed while determining need for intubation) Reevaluation - ansPortable radiograph - AP chest, pelvis. Can quickly identify potentially life-threatening injuries such as pneumothorax or pelvic fracture with uncontrolled internal hemorrhage. Can also confirm placement of ET tubes, chest tubes and gastric tubes. Consider need for transfer. shock - ansInadequate tissue perfusion. Spleen - ansEncapsulated organ LUQ level of 9th-11th ribs and curves around a portion of the stomach. Minimal elasticity and flexibility - most frequent injured organ in blunt trauma. Secondary lymph organ that filters and cleanses the blood. Removes old RBCs and holds a reserve of blood. It recycles iron. It removes antibody-coated bacteria. Supplies lymphocytes to stimulate an immune response to blood borne microorganisms. Stores 200-300ml of blood and leads to hemodynamic instability quickly if damaged. Splenic Injuries - ansIn blunt trauma the spleen may lacerate from increased abdominal pressure.