TNCC Notes for Written Exam

Terms in this set (104)

(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
- 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 mm Hg may cause increased cerebral vasodilation, increased CBF, increased ICP.
- Prolonged hyperventilation NOT RECOMMENDED.
- Hypocarbia occurs as result of hyperventilation causes cerebral vasoconstriction, decreased CBF, decreased ICP. And ischemia secondary to severe vasoconstriction.
- Hyperoxygenate pt with 100% O2 via bag-mask
- Apply direct pressure to bleeding sites except depressed skull fractures
- Cannulate 2 large IV's
- Hypotension doubles pt's death rate (w/severe head trauma)
- Vasopressors used to maintain CPP.
- Insert OG or NGT. OG should be used with severe facial trauma.
- Position pt, elevate head to decrease ICP (but may also reduce CPP).
- Position head midline to facilitate venous drng. Rotate head to compress veins in neck and result in both venous engorgement and decreased drng from brain
- Prepare for ICP monitoring device
- Administer mannitol as prescribed.
- Mannitol, hyperosmolar, volume-depleting diuretic, decreases cerebral edema + ICP by pulling interstitial fluid into intravascular space for eventual excretion by kidneys.
- Administer anticonvulsant
- Sx should be avoided b/c increases cerebral metabolic rate + ICP. Indications for sz prophylaxis:
- Depressed skull fx
- Sz at time of injury
- Sz on arrival to ED
- Hx of sz's
- Penetrating brain injury
- Acute subdural/epidural hematoma

- Administer antipyretic med/Cooling blanket
- Hyperthermia may increase cerebral metabolic rate + ICP. Avoid causing shivering during cooling process; increases cerebral metabolic rate + may precipitate rise in ICP
- Do not pack ears/nose if CSF leak suspected
- Admin tetanus prophylaxis
- Wound repair for facial/scalp Lac's
- Admin other meds
- Analgesics, sedatives, narcan, romazicon, etc.
- Admin antibiotics
- Pt's w/basilar skull fx need prophylaxis against meningitis
- Prepare pt for OR, hospital admin or transfer.
(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
- 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 defects or depressions
- Subcutaneous emphysema (esophageal or tracheal tear)
- Palpate trachea above suprasternal notch
- Trach deviation = late indication of tension pneumothorax or massive hemothorax
- Assess sensory fx of perioribital areas, face and neck
- Facial fx's can impinge on infraorbital nerve, causing numbness of inferior eyelid, lateral nose, cheek, or upper lip on affected side.
- Check position of trachea
DIAGNOSTIC STUDIES:
- Xrays, CT scans, MRI's
- Fluorescein staining
- Slit-lamp exam
- tonometry (measures intraocular pressure)
- Bronchoscopy or esophagoscopy
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