TNCC Summary 6th Edition EdComp, Inc.

MIVT Victims of Violence Collecting Evidence

Mechanism of Injury Interview in safe private environment Place evidence in separate paper bags
Injuries sustained away from family or others who may Sealing bag with label with name, date, time, location where
Vital signs have accompanied patient to ED evidence was collected
Treatment Ask if know assailant Name and signature of person collecting
In a relationship where they have been hurt before Maintain chain of custody
Is patient pregnant Give to appropriate authorities
Was victim forced to have intercourse
Can pt explain injuries he/she has sustained History from victim of Violence - in private, no family, quiet and safe environment

Airway and Ventilation Rapid intubation

Factors contributing to ineffective airway LOAD
AMS Lidocaine - reduce risk of inc ICP
LOC Protect C-Spine while assess/treat airway problems Opioids
Neurologic injury Atropine ETT most definitive airway in unconscious patient
Spinal cord injury Defasciculating Agents
Head injury
Rib fractures, chest wall instability Steps - Table 4-2 - Seven P's Protection and positioning
Pain from chest/abdominal injuries Preparation Placement with proof
Preexisting respiratory disease Preoxygenation - 100% oxygen Most effective assessment tube placement
Increased age Pretreatment visualize tube through cords
Atropine for peds Inflate cuff
Shock - inadequate perfusion of tissues Lidocaine in head injury or inc ICP ETCO2
Decrease in supply of oxygen and nutrients required to maintain metabolic needs of body Defasciculating dose Epigastric ausculation
Sedation Bilateral Breath sounds
Effects of Sympathetic Nervous System Stimulation Benzodiazepines Postintubation management
Increase force of contraction (Positive inotropy) Opioids Secure ETT
Increase heart rate (positive chronotropy) Anesthesia/Induction Vent Settings
Vasoconstriction Etomidate, Thiopental sodium Chest X-ray
Dilation of pupils Propofol, Methohexital Pulse ox
Increased sweating (cholinergic) Paralysis with induction Medicate
Adrenals - increased cortical and medullary secretion Succinylcholine Signs of airway failure
Dilation of bronchials Depolarizing restless
Renin secretion increased, vasoconstriction, retain water, sodium retention Pancuronium, Vecuronium, Rocuronium agitation
Glycogenolysis (breakdown of stored glycogen)
Prolonged hyperventilation causes vasoconstriction in head injury pts - therefore bag with appropriate rate for pt
Hypovolemia - hemorrhage/burns Obstructive
Blood loss - tachycardia early sign 2 large bore IV's Cardiac Tamponade
S Plasma loss Rapid infusion of Crystalloids Compression of heart with obs. to atrial filling
H Monitor Urinary output for response to fluid resuscitation Tension Pneumothorax
O Monitor temp - use warmed fluids Mediastinal shift with obs to atrial filling
C Affects tissue extraction of oxygen 1st labs type and cross and H&H Tension Hemothorax
K Impaired cardiac contractility Combination of Pneumothorax and Hemothorax
Coagulopathies - due to cellular disruption ( also in hypothermic trauma pts)
S Control bleeding - elevation and direct pressure Distributive Shock
T Cardiogenic Neurogenic shock
A MI Base Deficit and Lactate Levels may need vasopressors for hypotension not responsive to IV boluses
T Arrythmias Resuscitation endpoints for Septic Shock
E Blunt Injury determining the degree of oxygen Anaphylactic Shock
S Decrease contractility debt (lack of oxygenation over Shunting microcirculation - decrease venous resistance
Decrease cardiac output resuscitation time) for shock Venous pooling -maldistribution of blood volume
Loss contractility Poor distribution of blood flow
 TNCC Summary 6th Edition EdComp, Inc.
Scalp - five layers Meninges - 3 layers - PAD Cerebral perfusion pressure = Mean arterial pressure (MAP) - Intracranial pressure (ICP)
Skin Pia Mater Reflects brain, cerebrospinal fluid, blood in the fixed space vault
Connective Tissues Arachnoid Adequate perfusion of oxygen and nutrients to the brain is dependent on this pressure
Aponeurotic galea Dura mater Primary determinant of cerebral blood flow
Loose areolar tissue Should be maintained at 60 mm Hg in absence of ischemia
Pericranium Augmented systolic BP may be necessary to increase CPP
Less than 70 can cause increased risk of ischemia
Less than 60 associated with poor outcomes
Early signs of Increased ICP Late Signs on increased ICP CUSHING's Reflex (Phenomemon) or Response - sign of ischemia
Headache Dilated nonreactive pupil Increase in systolic BP
Nausea/vomiting Unresponsive to verbal/painful stimuli Widening Pulse Pressure
Amnesia Abnormal Posturing Reflex Bradycardia
Altered level of consciousness Elevated Systolic Blood Pressure Diminished Respitory Effort
Restlessness Widening pulse pressure
Drowsiness Decreased pulse rate Skull Fracture - linear and nondisplaced Depressed Skull Fracture
Changes in speech Changes in respiratory rate and pattern Headache Headache
Loss of Judgement Osmotic diuretic reduces ICP - Possible decreased LOC Possible decreased LOC
assessed benefit - resolution symptoms Open Fracture Possible
Hypotension and hypoxia Concussion - diffuse brain injury Palpable depression
Less than 90 mm Hg Transient Loss of consciousness
Apnea/cyanosis Headache Basilar Skull Fracture Mandible Fracture
PaO2 less than 60 mm Hg Confusion/Disorientation Headache No Nasal Intubation Malocclusion
Dizziness Decreased LOC Trismus - can't open mouth
Herniation of brainstem Nausea/vomiting Raccoon's eyes Pain/movement
Unilateral or bilateral pupillary dilation Loss of Memory Battle's signs Facial asymmetry
Asymmetric pupilary reactivity Difficulty with Concentration Hemotympanium Step off deformity
Abnormal posturing Irritability Facial nerve palsy Edema, hematoma
Fatigue CSF rhinorrhea, otorrhea Hemotympanium
Anesthesia lower lip
Supratentorial herniation Post Concussive Syndrome Facial Trauma
Uncal most - posterior Persistant headache
Central or transtentorial herniation Dizziness Lefort I Lefort II
- Dicephalon and midbrain Nausea Separate teeth from rest of maxilla Fracture nasal, orbits, medial pyramid
Memory impairment slight swelling Massive edema
CSF leakage Attention Deficit Lip lac/fractured teeth nasal swelling
Rhinorrhea - nose Irritability independently move maxilla Malocclusion
Otorrhea - ear Insomnia mal occlusion CSF Rhinorrhea
High potential for infections Loss of libido
Anxiety Lefort III - complete break maxilla, Orbital Fracture
Depression zygoma, orbits, bones Diplopia
Early sign of changes in neuro Massive edema Loss of vision
Diffuse Axonal Injury Altered level of consciousness Mobility zygoma bones Altered EOMs
Acceleration/Deceleration Immediate coma - few weeks to 3 mos Ecchymosis Enopthalmos
Diffuse, microscopic, Hemorragic lesions Hypertension Anesthesia cheek Subconjunctval Hemorrhage
Brain Stem, Reticular Activation System Elevated Temp Diplopia Infra orbital pain or loss sensation
Prolonged coma Excessive sweating autonomic dysfunction Open bite, malocclusion Orbital bony deformity
Shaken baby this kind of injury Abnormal Posturing CSF Rhinorrhea Tapping of muscle/nerve
Elevated ICP
Mild to severe memory impairment, cognitive Do Not intubate Nasally with Facial Trauma
behavioral, and intellectual deficits Aggressive airway management of secretions/ intubation is indicated
Focal Brain Injury
Raising Head of Bed - head higher than feet Neuro assessment
Contusion - Intracranial hemorrhage - 48 hours to 2 weeks Decreases ICP C-5 - Top of shoulder
Altered level of consciousness Decreases Intraocular pressures T-4 - Nipple line
Unusual behavior May improve breathing in a COPD trauma patient T-10 - Umbilicus
Abnormal Posturing (flexion, extension, or flaccidity) Simple, doesn't require much effort or equipment L-4 - Great toe
Signs of increasing ICP May be lifesaving.
 TNCC Summary 6th Edition EdComp, Inc.
Epidural Hematoma - Arterial Facts about the eye
Initial decreased LOC - Lucid period - rapid deterioration Pupil dilation occurs with sympathetic stimulation Penetrating Trauma
Persistant decreased LOC Severe Headache Intraocular pressures keep the globe rounded Visual impairment
Hemiparesis/Hemiplegia, opposite side - posturing Sleepiness Normal Intraocular pressures - 15 mm Hg Contents leaking out
Unilateral fixed and dilated pupil same side Dizziness range 10-20 Odd shaped globe
Nausea, vomiting greater than 30 may have glaucoma hyphema
Subdural Hematoma - venous - more in elderly, those on anticoagulants, and etoh abuse low may have penetration of globe decreased IOP
More lethal Signs increased ICP restricted extraocular movements
Steady decline in LOC Ataxia Hyphema
Hemiparesis or hemiplegia opposite side Incontinence blood in the anterior chamber - direct impact to eye
Unilateral fixed and dilated pupil same side Seizures deep, aching pain
mild to severe decrease in visual acuity
Intercranial Hematomas increased intraocular pressure
Progressive and often rapid decline in LOC Pupil abnormalities restricted EOMs
Headache Contralateral hemiplegia
Signs of increased ICP Neck Injuries
Dyspnea, tachypnea Hematoma
Flail Chest Hemoptysis Loss of layrngeal prominence
Free floating sternum Sub Q Emphysema Bruits
Decreased to absent breath sounds Active bleeding
Pneumothorax Penetrating trauma Cranial nerve, facial sensory or motor nerve deficits
Air in pleural space with loss of negative intrapleural pressure Hoarseness Difficulty swallowing
Dyspnea
Tachycardia Blunt Trauma may cause Hemothorax - 1500 or more - mediastinal shift, low venous return, low BP
Hyperresonnance injured side Increased intrathoracic pressure Dyspnea, Tachypnea
Decreased or absent BS injured side Respiratory distress Chest pain Associated Injuries
Chest Pain Hypotension Signs shock Sternal Fractures
Possible open pneumo sucking wound on insp. Unilateral absent breath sounds Tracheal Deviation - in Tension Hemothorax Blunt Cardiac injury
Assess for chest tube insertion Decreased Breath sounds on injured side First and second rib fracture
Tension pneumothorax Assess for needle thoracentesis Dullness to percussion on injured side. Great Vessel injuries
Life threatening - needle decompression immediately Brachial plexus injuries
Severe respiratory distress Chest tube troubleshooting Ruptured Diaphragm head and spinal cord injuries
Absent sounds on injured side F fluctuation in water seal Dyspnea/orthopnea Rib fractures and flail chest
Hypotension O output Dysphagia Pulmonary contusions
Low BP C color of drainage Abdominal pain Pneumothorax
Distended Neck veins - head and upper extremities A air leak Sharp epigastric or chest pain radiating Hemothorax
Trachael deviation Left shoulder - (KEHR's Sign) Fractures of lower ribs (7th-12th)
Cyanosis - late sign 2nd ICS mid clavicular line - needle decomp. Bowel sounds in lower to middle chest Liver and spleen injuries
Decreased Breath sounds injured side.
Pulmonary Contusion Tracheobronchial injury Type of impact and thoracic injuries
Dyspnea, tachypnea Dyspnea, tachypnea Pericardial Tamponade Frontal Impact
Ineffective cough Hemoptysis Beck's Triad Anterior flail chest
Hemoptysis Potential airway obstruction Distended neck veins Blunt cardiac injury - tamponade
Hypoxia Sub Q emphysema neck, face, suprasternal Low blood pressure Pneumothorax
Chest Pain Decreased or absent breath sounds Muffled heart sounds Transection of aorta
Chest wall contusion or abrasions EKG abnormalities - tachycardia, PEA Side impact
Chest drainage systems Dyspnea Lateral flail chest
Blunt Cardiac Injury Tape down and secure to prevent dislodging Cyanosis Pneumothorax
EKG abnormalities - tach, PVC, AV blocks Maintain chest system below level of chest Traumatic aortic rupture
Chest Pain Keep water seal chambers upright Diaphragmatic rupture
Chest wall ecchymosis No dependent loops to kinks Motor vehicle vs pedestrian
Never clamp Transection of aorta
Notify MD if output greater than 1000 or Abdominal visceral injuries
200ml/hr for 3-4 hours'
 TNCC Summary 6th Edition EdComp, Inc.
Hepatic Injuries Splenic Injuries Hollow Organ Injuries - lap belt injuries - suspect with bruising of abdomen
RUQ pain Kehr's sign - left shoulder referred pain Small bowel most common
Abdominal rigidity, spasm, guarding Tender LUQ Peritoneal irritation muscle rigidity, spasm, guarding
Rebound tenderness Signs hemorrhagic shock Eviseration of small bowel or stomach - cover with moist gauze
Decreased or absent Bowel Sounds Abdominal rigidity, spasm, guarding CT/DPL - bile, feces, food fibers
Signs hemorrhage or hypovolemic shock
DOPA - ETT troubleshooting
Burns Rate of infusion - crystalloids Renal Injuries Dislodgement
Zone of Coagulation - tissue not viable Age Deceleration forces - vascular damage Obstruction
Zone of Stasis - capillary occlusion, Burn size, depth Ecchymosis ove flank Pneumothorax
decreased perfusion and edema Intravascular pressures Flank tenerness ilicitied during palpation Equipment
Zone of hyperemia - increased blood flow Time elapsed since the burn Hematuria
CT best diagnostic FOCA - chest drainage troubleshooting
Plasma loss and other vascular responses % burn*kg*rate = amount in 24 hours Fluctuation
Loss of permeability of the capillary 1/2 in the first 8 hours Urethral Trauma Output
Electrical burns 1/2 over next 16 hours Female - almost always with pelvic fractures Color
Myoglobinuria - flush kidneys well Male - straddle trauma Air leak
1st intervention - STOP the BURN Inhalation burn - listen for hoarseness Supra Pubic pain
Provide airway support Urge but can't pee Suspecting Compartment Syndrome
Helmeted Riders Hematuria Elevate only to level of the heart, NOT above
Must remove helmet to adequately assess airway and protect C-Spine Blood at meatus Reassess Neurovascular status often
See Helmet removal and traction section in the back of the book. Rebound tenderness Pulses
Rigidity, spasm, guarding Sensation
A. Airway 1st five A-E in order Displaced prostate Edema
B. Breathing If you stop at one point, fix it before going on
C. Circulation You will be tested on this material Urinary output Assessing Pelvis - DO NOT Rock
D. Disability TNP stations, look at expectations in the back of infants - 2 ml/kg/hr Apply gentle pressure to bilateral iliac crests
E. Exposure book. Children - 1 ml/kg/hr toward the midline to test for instability
F. Five Adjuncts, Family, Five Vital signs Adults - 0.5 ml/kg/hr Greatest risk, large vessels in pelvis may bleed
G. Give Comfort Zones of Decontamination
H. History, MIVT, Pt information Hot zone Cold Zone
I. Inspect Posterior Highest contamination Safe and free from contamination
Minimal medical care Full Medical Treatment
Basic airway
Pregnant Women Hemorrhage control
Hypervolemic and hyperdynamic state Antidotes
Normal fetal tones 120-160 Take to warm zone Always protect yourself and team first
ABC's always first can't help others is you are incapacitated
Turning to left lateral position when if unstable, Warm Zone
removes pressure from Vena Cava Position uphill and upwind of Hot zone
Mother's life is critical to fetus life, protect fetus, but treat the mother Some contamination, but less than Hot
Limited Medical Care
Pediatric Trauma Stabilize
Order of frequent injury Blood volume dependent on size of pt Decontaminate
Head Infant approx 90 ml/kg Move to cold zone
Musculoskeletal Child approx 80 ml/kg
Abdomen Can compensate 25% blood loss by inc. HR and Inc PVR Chemical agents Table 14-2 page 253 Vesicants
Thorax Heart Rate categorized by physiological effects Exposure
Tachycardia first sign of shock Chemical makeup Inhalation
Bradycardia ominous sign No antidotes Topical
IV Bolus 20ml/kg Skin Decontamination Most common
Blood Admin 10 ml/kg Cap refill > 3 seconds best indicator for poor perfusion Nerve Agents mustard
Pallor/mottled skin Sarin most well known lewisite
Spinal Immobilization Cyanosis late sign V-Series Treatment
Make sure pad shoulders for Hypotension - late sign of shock G-Series airway management
children - large heads Urine output for peds Exposure oxygen
Keep spine neutral position Infants - 2 ml/kg/hr Dermal remove clothing
Child - 1 ml/kg/hr Inhalation Decontaminate
Action - inhibit acetylcholinesterase Soap and water and 10%
SLUDGE/BBB and DUMBELS bleach
 TNCC Summary 6th Edition EdComp, Inc.
Nerve Agents (con't)
S Salivation D Diaphoresis and Diarrhea
SCIWORA L Lacrimation U Urinary incontinence
Suspected spinal cord injury without radiographic abnormality U Urination M Myosis
D Diarrhea B Bradycardia, Bronchorrhea, Bronchospasm
Peds G Gastrointestinal Distress E Emesis
22 gauge catheter E Emesis L Lacrimation
20 ml/kg bolus for pediatrics - consider blood after 2 bolus B Bronchorrhea S Salivation and Secretion
PRBC - rate of infusion 10mlkg B Bronchospasm
If no peripheral access after 90 seconds - intraossesous B Bradycardia
16 - 18 gauge bone marrow Antidotes
Aspirate bone marrow Atropine
pralindoxime - minutes to few hours to administer

Blood Administration in Trauma - untyped and crossed Pulmonary Agents Anthrax

O-Negative - childbearing females - due to Rh compatiblility issues Chlorine and Phosgene Woolsorter's disease
Causes pulmonary edema similar to inhalation burn Black Bane
Transporting patients - Stabilize, Transfer - Transport Treatment Fifth Plague
Table 16-2 on page 288 - Criteria for transfer Move to fresh air, higher ground Modes
Must have accepting MD Possible Mechanical ventilation cutaneous
Must have available resources - increased level of care - and the appropriate hospital Oxygen inhalational
Risks do not outweigh benefits of transfer Antibiotics for pneumonia gastrointestinal
MD of transferring hospital initiates transfer
Type of transfer must be appropriate - critical care transport, ALS - minimum RN and Paramedic usu. Blood Agents Ricin - Castor Beans
Type of Transport - ground, helicopter, fixed wing Carbon Monoxide and Cyanide ( bitter almonds) Ingested - NVD, dehydration, GI hemorrhage
What to send Hallmark of Cyanide toxicity is Metabolic Acidosis Inhaled - pulmonary and systemic
MIVT report Cells in anaerobic metabolism fever, tachypnea, tachycardia, hypotension
Patient assessments Alert to key things hepatitis, pancreatitis, myocardial damage
Diagnostic procedure results Bitter almond smell bone marrow suppression
Vital Signs Surroundings 8-24 hours after exposure
Planned interventions and procedures Dead animals death in several days
Copies of all medical records/xrays etc. Multiple casualities
Family Time, route and nature of exposure
Allow family to see patient prior to transport
Suggest stay at sending hospital until pt leaves Biological Agents Clues to exposure
Provide written directions, maps to receiveing hospital Bacterial A number of patients present with
Reinforce - not to follow too closely, open laws Viral same signs and symptoms
Provide psychological support - have someone stay with family until leaves Toxins Unusual age distribution for a common
If death occurs, have someone else on your team with you to help support family Types A,B,C disease
Virulence
Whenever you move a patient - reassess ETT Ability to spread from person to person
Transporting patient - may dislodge and airway not effective Availability
Whenever you treat a person, reassess neurovascular status i.e. splinting Small Pox
Plague Viral Prodrome
Unmanaged Pain Gram negative Bacillus Yersinia pestis Malaise, fever, cephalgia,
Increased heart rate Bubonic - most common Gastrointestinal upset
Peripheral vasocontriction and pallor septicemic, pneumonic Red Rash - 2-3 days after exposed
Tachypnea Patient to patient common and highly fatal progress to vesicles and pustules
Muscle tension leading to guarding or splinting as a reflex to reduce pain Contact and Droplet Precautions begins on face, to extremities and
Loss of parasympathetic tone - anorexia, nausea/vomiting then to torso
Release of catecholamines resulting in increase BP, Cardiac afterload, and myocardial oxygen Contact and airborne precautions
consumption
Assess Botulinum Radiation
Subjective - pain is what is it to the patient, you can't assess level most lethal substance known Survival probable - Less and 100 rads
Objective signs - see above poorly canned or preserved food Survival possible - dose 200-800 rads
Side effects from medication - re - assessment critical for pt safety and pain control Hallmark symptoms - descending flaccid paralysis Survival Improbable - more than 800 rads
Resp depression facial nerved, chewing muscles, swallowing, resp. Treatment
Hypotension Action - prevents release of acetylcholine Stabilization, assessment, ABCs
N/V prohibits muscle contraction Decontamination
Bradycardia Dirty and clean areas
Hallucinations See Zones above
 TNCC Summary 6th Edition EdComp, Inc.
Wound management CISM - why
Primary intention prepare staff to manage their job-related stress
Sutures, staples, skin tape, glue Provide assistance for staff members who are experiencing the negative effects of stress
6-8 hours after injury provide education and prevention programs
well approximated and noncontaminated injuries Interventions
Delayed primary intention Irrigation essential to infection prevention promote ventilation of feelings
Bite wounds and lacerations provide support and reassurance
cleansing, irrigation, debridement and antibiotic administration mobilize resources for additional support
to promote wound preparation for 3-5 days before primary closure do not criticize anyone's performance
Secondary Intention - dirty wounds Conduct the debriefing with specially trained facilitators
not closed and allowed to heal gradually by granulation and re-epithelialization See table 15-1 for symptoms of Stress in critical incidents - pg 280
ulcerations, human bites, full or partial thickness abrasions, punctures Disaster Management
grossly contaminated wounds D - detect Triage - utilitarian approach to provide the greatest good to the
Older Adults differences I - Incident command greatest number
Aging related changes can increase comorbities and modify response to meds S - Scene security and safety
Limited ability to respond to stress of injury - decreased physiological reserves A - Assess hazards
Decreased cerebral blood flow S - Support required
loss of pulmonary reserve T - Triage and Treatment
loss of pulmonary muscle tone E - Evacuation
reduced cough reflex R - Recovery
hypoxia from pre-existing conditions Family intervention
Atherosclerosis Be truthful, don't give false hope
cardiac output and stoke volume decrease with age If a death occurs, have another team member go with you to help support family
medications impair myocardial response to shock - may not increase heart rate
preexisting anemia
preexisting malnutrition - decreased peristalsis, and gastric mobility
decreased fat stores, slowed metabolic rate This material is copyrighted by EdComp, Inc. Any reproduction or use without
impaired ability to concentrate urine written consent is prohibited.
urine output not best indication of hydration status
loss of ability to buffer acids and bases,
reduced glomerular filtration rate
may need to reduce doses of medication
many take anticoagulants - increasing risk to bleed
have thinner vessel walls as well.