1. Trauma Nursing Core Course 7th Edition
Chapter 5: Initial Assessment Instructor Course: Microteach Lecture Set 4
Trauma Nursing Core Course 7th Edition
Chapter 5: Initial Assessment, begins on page 39 of the TNCC Provider Manual.

2. 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

3. C–Circulation and Control of Hemorrhage
Hemorrhage: Leading cause of preventable death after injury
Continued assessments and high index of suspicion during:
Across-the-room observation
Primary survey at C
Reevaluation directly following the primary survey
Reevaluation following the secondary survey
C assesses circulation as well as control of hemorrhage. Remember that the most preventable cause of death after injury is hemorrhage.
There is continued emphasis on discovering potential hemorrhage during initial assessment at the following steps of the process:
During the across-the-room observation
During the C portion of the primary survey
During the first reevaluation step after the primary survey
The assessment of circulation during the primary survey now includes early reevaluation for the possibility of occult internal hemorrhage in the abdomen and pelvis
In suspected cases, an emergent abdominal or pelvic assessment is performed
FAST examination
Radiograph of the pelvis
During reevaluation following the secondary survey
For delayed or slow bleeding, continual reevaluation and trending of assessment parameters will help with timely identification of ongoing bleeding

4. C–Circulation and Control of Hemorrhage
Inspect for:
Uncontrolled external hemorrhage
Skin color
Palpate for:
Presence of central pulse
Skin temperature and moisture
Inspect for:
For any obvious, uncontrolled, external bleeding
Skin color: Is the skin of normal color or is it pale, cyanotic, or flushed?
Palpate for:
Presence of central pulses (carotid and/or femoral) for general rate (normal, fast, slow), rhythm, and strength
Skin temperature and moisture: Is the skin cool and diaphoretic or warm and dry?

5. C–Circulation and Control of Hemorrhage
Pulses absent
Initiate basic life support
Assess for cause related to injury
Uncontrolled internal hemorrhage
Assess for potential cause
If pulses are absent, begin basic life support or cardiopulmonary resuscitation (CPR) and assess for signs of uncontrolled internal hemorrhage that may be the cause.
Consider the following as a potential cause for the absent pulses:
Pericardial tamponade
Rupture of great vessels
A penetrating wound to the heart
Abdominal or pelvic hemorrhage

6. C–Circulation and Control of Hemorrhage
If pulses are present, is circulation effective?
Inspect for external hemorrhage, skin color
Palpate for central pulses, rate/rhythm, temperature, and moisture
If circulation is ineffective
Assess for signs of uncontrolled internal hemorrhage
Consider such common sites as the chest, abdomen, and pelvis
If is not enough to know that there is a pulse; it is important to determine if that pulse is supporting effective circulation and perfusion.
Inspect for:
Any external bleeding
Skin color
Palpate for:
Central pulses
Pulses that are strong, regular, and at a normal rate may indicate normovolemia
A rapid, thready pulse may indicate hypovolemia, and an irregular pulse may warn of potential cardiac dysfunction
Skin temperature and moisture
If pulses are present, but circulation is ineffective:
Immediately assess for signs of uncontrolled internal hemorrhage
If the patient has ineffective circulation, consider common sites for hemorrhage such as the chest, abdomen, and pelvis

7. C–Circulation and Control of Hemorrhage
Apply direct pressure
Elevate hemorrhage extremity
Apply pressure over arterial sites
Consider a tourniquet
Control and treat uncontrolled external bleeding by the following:
Apply direct pressure over hemorrhage sites
Elevate a hemorrhage extremity
Apply pressure over arterial sites
Consider the use of a tourniquet (see Chapter 7, Shock, for more information).
If the patient has signs of hemorrhage, another team member may be directed to obtain a baseline blood pressure for trending as the primary survey continues uninterrupted.

8. C–Circulation and Control of Hemorrhage
Cannulate two veins
Initiate infusion of warmed isotonic crystalloid solution
Use blood administration tubing
Obtain sample for type and cross match
Consider balanced resuscitation needs
Consider a rapid infusion device
Intervene in life-threatening situations
Additional interventions for circulation include:
Cannulate two veins with large-caliber intravenous (IV) catheters:
If unable to gain venous access quickly, consider intraosseous or central venous access
A blood sample for blood typing may be obtained at this time
Use warmed isotonic crystalloid solution
If blood transfusion is anticipated, set up one line with blood administration tubing and normal saline (0.9%)
Consider balanced resuscitation needs
A rapid infusion device may be indicated. Follow organizational protocol.