Trauma Nursing Core Course 7th Edition Chapter 5: Initial Assessment Instructor Course: Microteach Lecture Set 2 Trauma Nursing Core Course 7th Edition Chapter 5: Initial Assessment, begins on page 39 of the TNCC Provider Manual.

Objectives Recognize competence in the initial assessment process. It is the foundation of trauma nursing practice. Demonstrate the components of the initial assessment process Differentiate between goals of the primary and secondary surveys Determine actual and potential threats to life and limb using the initial assessment process Select interventions to manage life-threatening conditions identified during the initial assessment process

Across-the-room Observation Uncontrolled hemorrhage is a major cause of preventable death after injury On arrival, determine the need to reorder ABC to <C>ABC Look for uncontrolled external hemorrhage First priority is to treat the greatest threat The across-the-room observation is the trauma counterpart to the pediatric assessment triangle (PAT) used in the Emergency Nursing Pediatric Course (ENPC). As the patient arrives, this observation is used to identify any uncontrolled external hemorrhage and determine if there is a need to reorder the ABC to C<ABC>, where the priority is to control the hemorrhage before proceeding with the primary survey. During this step, look for uncontrolled external bleeding. Uncontrolled hemorrhage is a major cause of preventable death after injury. The first priority is to treat the greatest threat to life condition. Civilian trauma care has been guided by practice and evidence from the military battlefield. However, the approach to civilian trauma care often allows multiple trauma team members to address several priorities simultaneously. In some military situations, there may be the need to prioritize the life threats. The first priority is to treat the greatest threat to life condition.

A–Airway and Alertness Cervical spinal immobilization Manual stabilization Spine board primarily a transportation device After the preparation and across-the-room observation, the next step is the primary survey, which includes steps A through E. The first part of the primary survey looks at airway and alertness. Any assessment of airway includes simultaneously maintaining cervical spinal immobilization. Suspect a cervical spinal injury (CSI) in patients with multisystem trauma until it can be ruled out. While in the ED, align and protect the cervical spine by: Cervical spinal immobilization: A correctly sized, semi-rigid cervical collar securely fastened Manual stabilization: Two hands holding the patient’s head and neck in alignment Keep in mind that the rigid spine board is primarily a transportation device.

A–Airway and Alertness Is the patient alert and can the patient speak? Alert Verbal Pain Unresponsive Can the patient open and protect the airway? If patient is unable to open airway Manually open airway using jaw-thrust Two-person procedure AVPU is used to quickly assess the patient’s level of alertness. Use AVPU at the beginning of the primary survey to help determine if the patient requires airway intervention. A–the patient is alert and responsive V–the patient responds to voice P–the patient responds to painful stimuli U–the patient is unresponsive If the patient is anything but alert, he or she may not have a gag reflex and be unable to protect his or her airway If the patient is unresponsive, announce it to the team and have someone check for a pulse

A–Airway and Alertness Inspect for: Tongue obstructing, loose teeth, foreign objects, blood, vomitus, secretions, edema, burns Auscultate for: Obstructive airway sounds Palpate for: Bony deformity If a definitive airway is in place, assess for placement and continue assessment Once the airway is open: Inspect for: Tongue obstructing the airway Loose or missing teeth Foreign objects Blood, vomitus, or secretions Edema Facial burns or evidence of inhalation injury (blistering of the oral mucosa, singed nasal hairs) Listen for: Obstructive airway sounds such as snoring or gurgling Palpate for: Possible occlusive maxillofacial bony deformity If there is a definitive airway in place (endotracheal tube (ETT)), the priority is to assess for placement by: Auscultating over the epigastrium for presence of gurgling while at the same time assessing for symmetric rise and fall of the chest Auscultating for bilateral breath sounds at the midclavicular and midaxillary lines Using a carbon dioxide (CO2 ) detection device to assess for exhaled CO2

A–Airway and Alertness Patent Not patent Suction Remove debris Airway adjunct Definitive airway Is the airway patent? If so, move on to B. If the airway is not patent, there are commonly two interventions necessary: suctioning and insertion of an airway adjunct. Suction If secretions, blood or foreign objects are the cause, suction the airway while taking care to avoid stimulating a gag reflex Remove any foreign bodies, using suction, if possible, or forceps Airway adjunct If suctioning does not relieve the airway obstruction, the tongue or edema may be the cause of the obstruction Insert an airway adjunct: These are discussed further in Chapter 6, Airway and Ventilation Consider a definitive airway. If an airway adjunct is needed, it is likely a definitive airway will be necessary NOTE: Image of patient with airway compromise from multiple facial injuries