TNCC 2021, 8th edition manual

• communication
• cooperation
• coordination

• Brief
• huddle
• debrief

A body at rest will remain at rest (potential energy) and a body in motion will remain in motion (kinetic energy) unless acted upon by an object

Acceleration is dependent upon 2 variables :   net force and mass of object

F=mass X acceleration

For every action there is an equal and opposite reaction

Law of Conservation of Energy

Energy cannot be created or destroyed, only changed from one form to another or transferred from one object to another

the energy of a body in motion

• KE  = 1/2 mass X square of velocity
• KE=1/2mv^2

sudden and rapid onset of motion

Ex:  struck in the head:  stationary brain is struck by cranium that has been set in motion

sudden stop

the more distance involved = less likely a severe injury will occur

Ex:  falls

internal force that resists applied external force

• 1. amount of energy involved
• 2. structure of organs and proximity to the impact

Bones:  vary and augmented by adjacent muscle systems

Muscle density:  absorbs energy

solid organs - tolerate pressure-wave energy better than air-filled organs

air filled organs:  resist shear forces better than solid organs

• blunt
• penetrating
• thermal
• blast

focused

may not have many outward signs of injury

frequent reassement

Point of impact determines major point of energy transfer

Type of surface hit:  softer will absorb more energy

Tissue's ability to resist:  bone less flexible, air filled organs rupture and solid organs may fracture

Trajectory of force:  being pushed increases acceleration

1. Vehicle collides with another object --> occupants accelerate when vehicle comes to abrupt stop

2. Occupants cont. to move until they collide with interior of vehicle/seat belt/airbags etc

3. Internal structures collide within body cavity

velocity and stopping distance

corneal abrasions and minor skin burns r/t chem in airbags

head and chest lead way over dash/steering wheel

head, neck, chest, and/or abd

under dash

LE and pelvis Fx's

misplaced seatbelt placed above pelvis

injuries depend on placement in vehicle in relation to impact- closest to impact = more likely increased injury

shear injuries to aorta/other organs, clavicle, lateral pelvic and abd, lateral head/neck

may have frontal or lateral injuries

similar to frontal injuries, extention/flexion of neck

any/all injuries, head injuries from roof intrusion

increased risk of ejection

Increased risk with rollovers/not wearing seatbelt appropriately

laying the bike down with tires leading in direction of travel

abrasions, shoulder/clavicle injuries, lateral head injuries, and LE injuries are common

begins to fall to side but regains traction resulting in unbalanced position - may vault motorcycle and catapult rider

Injuries:  low side crash injuries and speed and impact of rider landing on surface

rider ejected with head and torso leading - LE may collide with handlebars resulting in femur and pelvis Fx's and hip dislocations

other injuries depend on subsequent collisions but likely involve head, neck, chest, and extremities

significant LE injuries, UE, lateral head/neck

LE crush injury followed by shoulder/head/neck lateral injuries from striking hood

Crusing LE injuries, may be catapulted onto hood then have another collision with ground

adults may turn to escape - potential for lateral or posterior injuires

may turn toward vehicle - anterior impact injuries

may go onto hood or slide under vehicle

• 90% are male
• black male 2-7 X more likely

• small bowel 50%
• large bowe 40%
• liver 30%
• intra-abd vascular system 25%

point of impact - speed/length of penetrating object and density of area of body impacted:  more dense = more energy absorbed = less damage

velocity of impact - speed creates high energy - bullets may ricochet or deform

Proximity:  how close object is to projectile

KE increases with velicity- KE causes damage by transferring energy to tissue

when projectile passes through tissue it transfers KE and creates a cavity that may be temporary or permanent

air-filled organs:  lungs, stomach

tolerate better than denser tissues

more likely to shear or tear:  liver

energy in form of light, heat and sound is released rapidly

blast pressure expands outward in all directions at a rate greater than speed of sound

Energy contained and transferred to person - increased injuries

direct blast effects:  direct tissue damage from blast pressure

gas-filled structures are at high risk

complex stress and shear waves produce injury or body dismemberment and dissemination

• blast lung - pulmonary barotrauma
• tympanic membrane rupture and middle ear damage
• abd hemorrhage and perforation
• globe eye rupture
• mild TBI without physical signs of head injury

projectiles propelled by explosion

fragments from shrapnel, projectiles from environment

• penetrating or blunt injuries
• eye penetriation
• closed and open brain injury

individual being thrown by blast

displacement of body and structural collapse

• blunt/penetrating trauma
• Fx's
• amputations
• closed/open brain injury

all explosion-related injuries, illnesses, or diseases not due to primary, secondary, or tertiary mechanisms (heat/combustion)

burns and toxic injuries, metals, septic syndromes from soil and environmental contamination

• external and internal burns
• crush injuries
• asthma, COPD, etc exacerbations from smoke etc
• hyperglycemia, HTN

associated with exposure to hazardous materials

tissues contaminated with bacteria, radiation, chemicals, tissue from bystander/assailant

• prep and triage
• primary survey (ABCDE) with interventions as needed
• Reevaluation - consider Tx/need for higher level of care
• Secondary assessment
• Reevaluation and post-resuscitation care
• definitive care of Tx

A- Across room assessment for uncontrolled hemorrhage then Airway and Alertness with simultaneous C-spine immobilization

B- Breathing and ventilation

C- Circulation and Control of hemorrhage

D- Disability (neuro status)

E- Expose and keep warm

F- Full set of VS and family presence

G - Get monitoring devices and Give comfort:  LMNOP - labs, monitor, naso/orogastric tube, oxygenation/ventilation analysis, Pain assessment and mgmt

H History and Head to toe assessment

I Inspect posterior surfaces

J Juse keep reevaluating ABCDEFGHI

First step of initial assessment

• Call trauma team and consider safety
• - PPE
• - decon needed prior to trauma room?
• - prep trauma room and gather needed supplies based on report

accross-the-room observation

rapid determination of stability and ID uncontrolled external hemorrhage

uncontrolled hemorrhage

whole blood or 1:1:1 ratio RBC, plasma, and platelets to achieve systolic BP 80-90 ASAP

treat most life-threatening condition first

• Alertness and Airway:  Assess alertness and airway while having second person stabilize C-spine
• Alertness:  AVPU - then address any issues
• A- no airway, V may need adjunct, P may need adjunct while considering need for definitive airway,
• U- report to team loudly and get someone to check for pulse - consider CABC - needs ETT
• Airway:
• Inspect for obstruction due to:
• - tongue
• - foreign bodies
• - loose/missing teeth
• - blood vomit secretions
• - edema
• - burns/inhalation injury evidence
• - use jaw thrust if patient cannot open mouth
• Auscultate for:  snoring, gurgling, or stridor
• Palpate for:  possible occlusive maxillofacial bony deformity and SQ emphysema
• - If has definitive airway:  assess for proper placement:  CO2 detector after 5-6 breaths, chest rise/fall, auscultation of epigastrium (no gurgling) and bilat breath sounds

need 2 providers - one holds c-spine while the other does jaw-thrust

Patent airway:  interventions are to maintain

• - Suction liquids, removed FB with forcepts - don't stimulate gag reflex
• - adjunct airway to alleviate tongue obstruction
• - ETT for:  apnea, GCS 8 or less, severe maxillofacial Fx's, evidence of inhalation injury, laryngeal/tracheal injury or neck hematoma, high risk of aspiration/ability to maintain airway, compromised/ineffective ventilation, anticipation of deterioration of neuro status

* Reassess interventions

conscious or unconscious patients

DO NOT USE if evidence of mid-face Fx's

not for pt with gag reflex

• facial burns
• singed nose hairs
• hoarse voice
• carbonaceous sputm

cont to ventilate with BVM 10-15L/min O2 until airway is established

Breathing and ventilation

• Inspect chest for:
• spontaneous breathing
• equal chest rise/fall
• RR depth, and pattern
• skin color
• contusions, abrasions, or deformities
• open pneumothorax
• JVD and tracheal deviation that may indicate tension pneumo
• s/s of inhalation injury

• Auscultate for:
• bilat breath sounds

• Palpate for:
• bony injuries
• subcutaneous emphysema
• soft tissue injury
• jugular venous pulsations at suprasternal notch or in supraclavicular area

pneumothorax