instructor path guide: instructor potential

INSTRUCTOR PATH GUIDE: INSTRUCTOR POTENTIAL

SEVENTH EDITION

TNCC Instructor Path Guide: Instructor Potential • 7th Edition September 2016 i

Copyright © 2016, by the Emergency Nurses Association (ENA)

All rights reserved. Permission to reproduce or transmit in any form or by any means, electronic or mechanical, including photocopying and recording, or by an information storage and retrieval system, must be obtained by writing to the Emergency Nurses Association (ENA), 915 Lee Street, Des Plaines, IL 60016.Web site: www.ena.org E-mail: [email protected]

The official Trauma Nursing Core Course of the Emergency Nurses Association (ENA) (United States)The official Trauma Nursing Core Course of the Australian College of Emergency Nursing (Australia)The official Trauma Nursing Core Course of the National Emergency Nurses’ Affiliation, Inc. (NENA) (Canada)The official Trauma Nursing Core Course of the Trauma Nursing Committee of GreeceThe official Trauma Nursing Core Course of the Hong Kong Emergency Nurses AssociationThe official Trauma Nursing Core Course of the Emergency Nurses Association of Kenya (ENAK)The official Trauma Nursing Core Course of the Foundation of Trauma Nursing Netherlands (STNN)The official Trauma Nursing Core Course of the College of Emergency Nursing New Zealand (CENNZ)The official Trauma Nursing Core Course of the Anestesisykepleiernes Lansgruppe av Norsk Sykepleierforbund (ALNSF) (Norway)The official Trauma Nursing Core Course of the Associacao Portuguesa de Enfermeiros de Urgencia (Portugal)The official Trauma Nursing Core Course of the Trauma Committee of South AfricaThe official Trauma Nursing Core Course of the Armed Forces Nursing Academy (AFNA) (South Korea)The official Trauma Nursing Core Course of the Swedish Association of Trauma Nurses (RST)The official Trauma Nursing Core Course of the Trauma Nursing Limited (United Kingdom)The official Trauma Nursing Core Course of the Western Australia Trauma Education Committee of the Department of Health, Western Australia

ENA accepts no responsibility for course instruction by the course director or any course instructors. Because implementation of this course of instruction involves the exercise of professional judgment, ENA shall not be liable for the acts or omissions of course participants in the application of this course of instruction.

The authors, editors, and publisher have checked with reliable resources in regards to providing information that is complete and accurate. Due to continual evolution of knowledge, treatment modalities, and drug therapies, ENA cannot warranty that the information, in every aspect, is current. ENA is not responsible for any errors or omissions, or for the results obtained from use of such information. Please check with your healthcare institution regarding applicable policies.

Medication dosages are subject to change and modification. Please check with your local authority or institutional policy for the most current information.

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Instructor Path Guide: Instructor Potential

TNCC Instructor Path Guide: Instructor Potential • 7th Edition September 2016 ii

AcknowledgementThe Emergency Nurses Association would like to extend its appreciation to the TNCC/ENPC Instructor Course Revision Work Team for the development and implementation of the Instructor Path.

Lead Editor and AuthorDiane Gurney, MS, RN, CEN, FAENEducational ConsultantAthol, MA

Authors and ContributorsJames Holtvoigt, BSN, RN, MPAClinical Education Specialist II – Emergency New Hanover Regional Medical CenterWilmington, NC

Deb Horsman, MS, RN, CEN, CPENTrauma Outreach CoordinatorMayo Clinic Rochester Saint Mary’s Campus, Level 1 Trauma/Level 1 Pediatric TraumaWest Concord, MN

Jared Kutzin, DNP, MS, MPH, RN, CPPS, CPHQ, CHSOS, NEA-BCDirector of EducationNew York Presbyterian/Hudson Valley Hospital

Rebecca Steinmann, MS, APN, CPEN, CEN, TCRN, CCRN, CCNS, FAENClinical Nurse Specialist, Emergency DepartmentAnn & Robert H. Lurie Children’s Hospital of ChicagoElmhurst, IL

Sharon A. Trumbly, MS, BSN, RNOnboarding CoordinatorFreeman Health SystemJoplin, MO

Marlene L. Bokholdt, MS, RN, CPEN, TCRN, CENSenior Nurse Associate, Institute for Emergency Nursing EducationEmergency Nurses AssociationDes Plaines, IL

Peer ReviewersDaniel Andrews, MBA, RN, CENChristina Dellinger, BSN, RNSandra Waak, RN, CEN, TCRNMindy B. Yorke, MSN, ARNP, CEN, CPEN, FNP-BC

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TNCC Instructor Path Guide: Instructor Potential • 7th Edition September 2016 iii

IntroductionThe path to becoming an instructor is complex and one class does not provide sufficient time for learning, practicing, and being mentored. The path to becoming an instructor includes learning about different teaching strategies, understanding how people learn, and being familiar with various types of teaching media.

Additionally, the successful Instructor Potential (IP) with learn how to demonstrate new behaviors, competently execute skills, and function in various roles. The new and improved method for educating, teaching and mentoring new instructors is a process or path, not a single 8-hour course.

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TNCC Instructor Path Guide: Instructor Potential • 7th Edition September 2016 iv

Table of Contents

Preparation for Live Session ............................................................................................................................................1

Competency Validation/Precourse Testing ....................................................................................................................2

TNCC Instructor Path Live Session .................................................................................................................................2

Welcome, Introduction, and Presentation of Disclosure .......................................................................................2

Review of Readiness to Teach/Instructor Path Checklist ......................................................................................2

Lecture Microteach Exercise .....................................................................................................................................3

Group Discussion Exercise ........................................................................................................................................6

Psychomotor Skill Station: Trauma Nursing Process (TNP) Exercise ..................................................................8

Psychomotor Skill Station: Airway and Ventilation Exercise ...............................................................................12

Psychomotor Skill Station: Trauma Interventions Exercise .................................................................................16

Evaluating a Psychomotor Skill Station .................................................................................................................22

Mentoring ..........................................................................................................................................................................24

Monitored Session ...........................................................................................................................................................25

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TNCC Instructor Path Guide: Instructor Potential • 7th Edition September 2016 1

Preparation for Live SessionOutline of responsibilities to Prepare for the Live Session.

Instructor Path Component

Instructor Potential Responsibilities

Instructor Potential and Course Director Responsibilities

Online modules � Access and complete all online modules

IP and IFCD: • Access and complete all online modules

Readiness to Teach Needs Assessment

� Complete as part of the Online Session

� Bring a copy to the Live Session for review

IP and IFCD: • Review the results with each IP, identifying areas for focused

learning

Instructor Path Checklist

� Bring a copy to the Live Session to check off completed items

IP: • Check off completed items

Certificate of Completion of the Online Session

� Bring a copy to the Live Session to verify completion

IFCD: • Confirm each IP has completed the Online Session

TNCC Provider Manual

� Reread the TNCC Provider Manual

IP and IFCD: • Encourage preparation in all IP communications

Lecture Microteach slides

� Receive these from the IFCD � Review and prepare to teach the slides as assigned

IFCD: • Assign a set of slides• Send the assignment at least 30 days prior to the Live Session • Follow up one week prior to Live Session for questions

Vignette for group discussion

� Use the assigned TNP skill station scenario to create a short vignette to facilitate discussion around one of the teaching points

IFCD: � Assign teaching scenario � Send the assignment at least 30 days prior to the Live Session � Follow up one week prior to Live Session for questions

TNP skill station teaching scenario

� Receive this from the IFCD � Review and prepare to facilitate the scenario as assigned

IFCD: � Assign the same scenario as above � Send the assignment at least 30 days prior to the Live Session � Follow up 1 week prior to Live Session for questions

Lecture Microteach Critique Form, Group Discussion Critique Form, Psychomotor Skill Station Teaching Critique Form

� Review each form IFCD: � Distribute to each IP to review expectations for evaluation used during the Live Session

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Competency Validation/Precourse TestingAttendees with Instructor Potential status are required to revalidate their competency as TNCC Providers just prior to the Live Session of the Instructor Path. This competency validation may be scheduled the same day as the Live Session or up to four weeks before. Study is strongly recommended to attain the required 90% written examination and 90% skill station scores to be eligible to attend the Live Session.

TNCC Instructor Path Live SessionObjectives

At the end of the Live Session, the IP will be able to:1. Present a lecture section using preassigned slides (microteach).2. Perform an assigned role as a learner for other IPs in the Lecture Microteach, Group Discussion, and Psychomotor

Skill Station exercises. 3. Facilitate a small Group Discussion.4. Lead a Psychomotor Skill Station teaching exercise.5. Evaluate the performance of a recorded Psychomotor Skill Station.

Welcome, Introduction, and Presentation of DisclosureDuring this introductory section, the IF will review the Live Session schedule and disclose any conflicts of interest.

Review of Readiness to Teach/Instructor Path ChecklistThe IP will review the Readiness to Teach Needs Assessments in class. For self-assessments rated 3 or lower, the IFCD and IPs will identify specific teaching and learning sessions to best provide opportunities for IPs to focus their practice and teaching skills.

Each IP will arrive with a copy of the ENA Instructor Path Checklist (available via the Resources tab in the Online Session) to monitor progress on the Instructor Path. As each teaching exercise is completed, the IP facilitating the exercise will signify completion and sign the checklist.

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Lecture Microteach Exercise

Objectives

At the end of this exercise, the IP will be able to:1. Present content accurately in a concise and logical manner in the time allotted.2. Exhibit mannerisms, behaviors, and language that complement the presentation.3. Use instructor notes and appropriate examples to illustrate major points.4. Interact with audience and confidently manage challenging learner role play.5. Perform an assigned role as a challenging learner for other IPs. 6. Participate in evaluation and complete a Lecture Microteach Critique Form for peer presentations.

Presenting a Lecture

When presenting a lecture, instructors use the ENA-provided slides. These slides include suggested speaker notes. To provide adequate delivery of content within the allotted time, instructors need to fully prepare and practice lectures in advance. Content in the speaker notes may be customized to fit the audience. It is important that all information appearing on the written examination is presented at some time during the course. However, it is equally important to teach the core content and emphasize all major concepts, not just those that are evaluated.

It is unacceptable for instructors to: � State: “You may see this again.” � Read test questions verbatim or paraphrase test questions

� Wink or joke about contentInstructors may introduce real-life applications to the lecture by using case studies, vignettes, discussions, and scenarios to enhance adult learning. Remember that

continuing education (CE) credit is based on current peer-reviewed expert content. No additional slides, video, websites or other material may be presented.

While presenting lectures, urge learners to follow along in their TNCC Provider Manuals. Identify tables or figures in individual chapters and refer learners to the page on which they are located. Many of the slides contain images. Where appropriate, images used in the lecture are described in the speaker notes. Instructors may use this information to enhance the lecture. Instructors are expected to be familiar with all images and to be prepared for questions regarding all images and content.

Before the Lecture Microteach Exercise begins, the IF will distribute Lecture Microteach Critique Forms to all IPs for them to evaluate the performance of their peers. Following each presentation, expect to share verbal feedback in a supportive and helpful manner.

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Review of the Interactive Lecture

One effective method of teaching adult learners is to use a case study or scenario approach in which the learner can relate an element of course content to practice. When incorporating a case study, scenario, or vignette into a lecture, the successful instructor will be aware that the purpose is to connect course content and theory to clinical practice. This also provides the instructor with an excellent opportunity to engage the learners with a highly interactive component within the presentation. A few key recommendations for success include:

� Be familiar with the flow and outcome of the case presentation. It can be very difficult to facilitate the discussion if you do not know how it unfolds.

� Be careful not to just lecture § Stimulate thinking with questions § Have questions prepared in advance § Allow learners a moment to silently read and review the case presentation slides before asking a question. This will give the learners time to analyze the content.

An example of a case scenario and how it may unfold is described below.

TNCC Case Scenario — breathing assessment and differentiating chest trauma (TNCC 7th edition, Chapter 11: Thoracic and Neck Trauma)

� MVC: ~ 45 mph, single vehicle struck a tree; unrestrained driver, the air bag did not deploy, steering wheel deformed

� Injuries: Possible fracture of the right femur, contusions and abrasions over the left chest

� Signs and symptoms: Patient complains of severe pain in his chest and right leg: “It’s hard to breathe”

� Treatment: Oxygen via nonrebreather mask at 15 L/min, cervical spinal motion restriction is in place, 18G IV in the right antecubital vein with normal saline at controlled rate, traction splint to the right lower extremity

Preparation is complete. The across-the-room observation reveals no external hemorrhage.

Airway and alertness: The patient is alert with a patent airway.

Breathing and ventilation assessment: Patient states: “I… can’t… catch… my… breath.” Respirations are spontaneous at 36 breaths/min. There is asymmetrical chest rise. Breath sounds are diminished on the left. There are no open wounds and no chest wall deformity. The trachea is midline with no jugular venous distention. His color is pale.

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Discussion Illustration

Instructor: “Now that you have completed your TNP breathing assessment, what do you think might be going on with this patient?”

Learner #1: “Well, it is definitely a concern that he is tachypneic with asymmetrical chest rise and diminished breath sounds on the left. But I don’t believe that it is a tension pneumothorax because his trachea is midline and there is no JVD.”

Learner #2: “I read in the Provider manual that tracheal deviation and JVD are late signs of a tension pneumothorax, so I’m not sure I would rule this out quite yet.”

Instructor: “Very astute! I would not rule out that potentially life-threatening condition just yet either. Tracheal deviation and JVD are late signs of a tension pneumothorax. Is he exhibiting any other signs or symptoms that might indicate the development of a tension pneumothorax?”

Learner #1: “He’s complaining of difficulty breathing, has an increased respiratory rate, and diminished breath sounds on the left. Can you tell me more about the asymmetrical chest rise?”

Instructor: “Yes, his chest is not rising as much on the left.”

Learner #1: “These signs and symptoms suggest a pneumothorax that could possibly develop into tension. I’d keep monitoring that.”

Instructor: “Right on the mark. What about some other life-threats? Could this possibly be a flail chest presentation?

Learner #2: “I don’t think so. There is asymmetrical chest rise, but no paradoxical moving of a section of the chest wall.”

Instructor: “Good answer. But are there some signs and symptoms that could overlap?”

Learner #1: “Yes, the difficulty breathing, tachypnea and diminished breath sounds.”

Instructor: “I agree and great job! In a few slides, we’ll discuss the different presentations of these complications.”

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Group Discussion Exercise Objectives

At the end of this exercise, the IP will be able to:1. State the objectives and development of his or her preassigned scenario.2. Conduct a group review of discussion points and identify important elements for emphasis.3. Prepare and present a short vignette based on one scenario objective or discussion point. 4. Facilitate a group discussion using query and critical thinking.5. Participate in evaluation and complete a Group Discussion Critique Form for peer facilitations.

Facilitating a group discussion may seem similar to presenting an interactive lecture in that they both are based on a case study, short scenario or vignette. However, the interactive lecture is more structured and based on clarifying or emphasizing elements of the lecture as well as engaging the learners. A group discussion is used to initiate critical thinking and assist learners in using their knowledge and experience to analyze a situation and determine an appropriate course of action. It is an exercise using reflection, synthesis of information, linking of concepts, problem-solving and decision-making.

For this exercise, go to your assigned TNP Skill Teaching Scenario and select one of the discussion points on the first page. With this discussion point as the foundation, create a short vignette with a patient background, assessment findings, and suggested interventions that will help the learner understand this content. Be prepared to present this vignette and lead the discussion with other IPs at the Live Session.

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General Guidelines � Facilitate, don’t lecture � Involve everyone in small group discussions � If a learner is not participating, ask a direct question, using his or her name to encourage involvement

� Prepare for what the group may bring to the discussion � Plan how you might handle Disengaged, Competing, Disruptive, Test-Hedge, Unprepared, and My Way Learners

� It is okay to be silent. Do not let it make you uncomfortable. Waiting will encourage the learners to participate.

� Observe behavior and clues that may indicate a challenging learner

§ Nonverbal · Learner is quiet or hangs back—Unprepared · Learner is not paying attention, talking with others—Disruptive

· Learner is not interested—Disengaged § Verbal

· Learner knows it all or thinks so—My Way · Learner is overconfident—Competing · Learner continually asks unrelated questions, delaying his or her engagement—Unprepared

� Debriefing: § Correct any stated information that was inaccurate. Do so in a positive way. If you do not correct the misinformation, the others will not learn and you may lose credibility with your learners.

§ If you are unsure of any stated information, ask the learner to identify where in the manual the information was found. Ask with an inquiring tone, not an accusatory one. Find the answer together.

� Summarize the key points at the end of the discussion � Thank the learners for a job well done

Break into assigned groups. Each IP will take a turn as facilitator using his or her assigned scenario as in the following example:

Assignment: TNP Skill Station: Teaching Scenario D – The Bariatric Trauma Patient

Selected Discussion Point: Discuss the pathophysiologic changes in the bariatric patient related to fluid administration.

Prepared Vignette and Sample Discussion

Facilitator to group: “This is a patient with a gunshot wound to the chest. Let’s discuss how you will address the C for circulation and control of hemorrhage step in the Primary survey for this unique population. If the patient’s assessment includes cool, clammy skin and tachycardia, is there anything that may cause you to think critically about automatically inserting the usual 2 large bore intravenous lines and delivering a large bolus? I would like you to discuss it as a group.”

Learner #1: “I might be worried about the bariatric patient’s lungs.”

Facilitator: “What about the lungs?”

Learner #1: “I think the bariatric patient has a greater risk for atelectasis in the lung bases, so we might be worried about fluid overload.”

Facilitator: (Wait for others to join the discussion. Silence can be a motivation for them to speak. Wait. If no one else speaks, address a different learner and ask a specific question.) “Is there anything else that might impact the delivery of a large bolus to this patient?”

Learner #2: “The weight of the chest wall adds to the work of breathing, so the respiratory rate might be increased normally. If we give a large bolus of fluid, we could be adding to the work of breathing.”

Facilitator: “What is this called?” (If no one offers the name, ask the question, again by addressing a different learner.)

Learner #3: “Oh, I know………..it is called obesity hypoventilation syndrome.”

Facilitator: “Exactly. What may be the result or outcome of overloading this trauma patient?”

Learner #1: “They might develop right-sided heart failure and/or pulmonary hypertension.”

Facilitator: “Correct. So, in this special population, delivering a fluid bolus may not be as straightforward as one might think. Good discussion. Do you have any questions? If not, let’s begin with the scenario and go through Teaching Skill Station D….”

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Psychomotor Skill Station: Trauma Nursing Process (TNP) Exercise Ojectives

At the end of this exercise, the IP will be able to:1. Function in the role of instructor.2. Set up the skill station to reflect the assigned Psychomotor Teaching Scenario.3. Demonstrate competence in facilitating a Psychomotor Skill Teaching Scenario.4. Facilitate a group debriefing of the teaching of a Psychomotor Skill Teaching Scenario. 5. Participate in evaluation and complete a Psychomotor Skill Station Teaching Critique Form for peer teaching.

Preparation � Each IP will function in the role of instructor for his or her assigned skill station teaching scenario � Two IPs will be assigned a challenging learner role for each skill station teaching scenario � Each IP will be assigned to observe one skill station teaching scenario and prepare to lead the debriefing after the scenario

� Each IP will complete the TNCC Psychomotor Skill Station Teaching Critique Form for each of his or her colleagues

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Guidelines for Psychomotor Skill Station Teaching

� When preparing to teach the Psychomotor Skill Teaching Station, it is essential to know where to find information in the scenario. Learners often ask for information out of sequence, making it difficult for unprepared instructors to locate the responses.

� Prepare posters/flip charts of teaching tools, such as the A through I mnemonic and components of airway, breathing, and circulation assessments

� The skills and principles are to be taught consistently in every course, regardless of regional, national, or international differences

� Identify a method for keeping the skill teaching on schedule. It is important to manage time wisely to provide everyone with the opportunity to practice and emphasize the important information.

� Begin the skill station by asking learners to open their TNCC Provider Manuals and follow along with the skill station template

� Ask for a volunteer to go first § Human nature is to mimic the behavior previously demonstrated, so if possible, select someone who will do well

§ Sometimes a person may volunteer to get it over with when they have not read the TNCC Provider Manual

§ Try to determine who has taken the class before, who has studied, and who is familiar with the material

� If the learner asks for information that is not included in the instructor responses, inform the learner that the information is not available

§ Do NOT alter or make up assessment findings or other information. Deviation from the script can alter a carefully constructed scenario, making it difficult to remember and reconcile added information.

§ An effective strategy is to redirect the learner back to the point of deviation

� The IP assigned to the role of instructor during the TNP Psychomotor Skill Teaching Station will prepare the learner by reviewing the following skill station teaching points:

§ Remember to smile and be encouraging. Create a learning environment that is safe and enjoyable.

§ It is important to memorize the Initial Assessment Process Points and the A through I and LMNOP mnemonics

§ The Primary survey includes A, B, C, D, and E § F and G may be initiated during the Primary survey. They are used as adjuncts to care and monitoring the effectiveness of interventions and resuscitation.

§ Emphasize: · A is for airway AND alertness · B is for breathing AND ventilation · C is for circulation AND control of hemorrhage · The AVPU mnemonic is used at Airway and Alertness; the Glasgow Coma Scale is used at Disability

§ It is essential not only to demonstrate selected skills but also to describe what is being demonstrated. A step that is only demonstrated may inadvertently be missed if the action is not stated.

§ The learner is expected to handle and use the manikin and equipment

· Learners are expected to palpate and auscultate during the assessment, as indicated in the teaching scenarios and evaluation form. If the learner states “I would palpate the abdomen” but does not touch the manikin, ask the learner to demonstrate palpation.

· Similarly, if the learner states “I would auscultate the chest” but does not demonstrate the skill, ask the learner to demonstrate chest auscultation

Primary Survey � The sequence of the Primary Survey is critical � The steps with double-asterisks (**) are to be performed in order during the Primary survey

� Double-asterisk (**) steps are either an assessment or an intervention related to an identified problem within the Primary survey

� Single-asterisk (*) criteria are required for successful completion. They may be addressed in any order.

� Learners are expected to evaluate the effectiveness of interventions intended to have an immediate effect on the patient. These reassessments are often double-asterisk (**) steps. Examples include:

§ Patency of the airway after suctioning or insertion of a nasopharyngeal or oropharyngeal airway

§ Effectiveness of bag-mask ventilation § Status of circulation after a fluid bolus

� During the Primary survey, each abnormal assessment parameter will be addressed before moving on to the next one

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� Intubation § Preparation for intubation is indicated if the patient has ineffective ventilatory effort or has no spontaneous respirations and is receiving bag-mask ventilation

§ The scenarios are designed so that the learner will identify the need for intubation and proceed with the assessment while other members of the team prepare for and perform the intubation

§ Verification of proper endotracheal tube placement is essential

§ Inform the learner that all steps in the verification of proper ETT placement must be stated and performed in order

§ The steps are as follows: · Attach a carbon dioxide (CO2) detection device · Observe for rise and fall of the chest with assisted ventilation AND auscultate over the epigastrium

· Auscultate for bilateral breath sounds · After 5 or 6 breaths, observe the CO2 detection device for evidence of CO2 in the exhaled air

· Assess for improvement in the patient’s skin color.

§ If the patient is intubated, a gastric tube is indicated. If it is not stated at the time of ETT insertion, during the head-to-toe assessment, the abdomen will be distended to clue the learner regarding the need for insertion

� Circulation § Fluid administration rate is determined by the patient’s condition in the scenario

§ Use a controlled rate for those patients who do not show signs of shock or may be at risk for fluid overload

§ Use a fluid bolus for those patients who require immediate fluid resuscitation

� Spinal motion restriction § For those scenarios in which the patient arrives stabilized on a spineboard with a rigid cervical collar, the learner is awarded credit for maintaining spinal motion restriction if none of the stabilization devices are removed completely

§ It is essential to open the anterior portion of the collar during the assessment and state that manual stabilization is maintained

§ To perform the posterior assessment, the learner will state “I will logroll the patient to inspect the back.” Note: At this time, there is no alternative to logrolling for inspection of the posterior surfaces. It is still taught. As research continues, this practice may change. Notification will be done via Course Vitals, the ENA electronic newsletter for Course Directors and Instructors, with updates on this and any other practice change.

§ For some scenarios in which the patient arrives by private vehicle, the learner may need to initiate spinal motion restriction while simultaneously assessing the airway and asking another learner to maintain the cervical spine in a neutral position

Secondary Survey � The Secondary Survey does not begin until the Primary Survey (ABCDE) is complete, resuscitative interventions are in progress, and the vital signs have been stabilized

� Appropriate interventions to manage potential life threats are initiated during the Primary Survey; interventions for abnormal, but non-life threatening findings are addressed within the Secondary Survey

� It is acceptable for the learner to use adjuncts (F and G steps of the A through I mnemonic) such as placing the cardiac monitor or pulse oximeter, bedside glucose measurement, inserting a gastric tube or an indwelling urinary catheter, or diagnostic studies during the Primary survey

§ This does not constitute leaving the Primary Survey § Note: Encourage the use of caution with this as it may be easy to get off track by using these adjuncts during ABCDE. They are adjuncts to the Primary Survey and are implemented directly following E.

� If at any time the patient’s condition deteriorates during the assessment, the learner is expected to immediately reassess the components of the Primary Survey to determine the cause and initiate interventions

Note: Spinal motion restriction is now accepted terminology replacing spinal immobilization and stabilization. This will be updated in the Provider Course with the next revision.

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General points � When learners ask for vital signs all parameters will be given: blood pressure, pulse, respirations, temperature, and pulse oximetry

� Temperature is obtained using the most appropriate method for age and patient condition

� Some scenarios do not require the insertion of a gastric tube or an indwelling urinary catheter

§ To obtain credit for these steps, the learner is expected to state the need to consider whether an indication or contraindication exists

§ If the patient is intubated, a gastric tube is indicated. If it is not stated at the time of ETT insertion, during the head-to-toe assessment, the abdomen will be distended to clue the learner regarding the need for insertion.

� The history of the event and prehospital treatment is obtained using the MIST mnemonic

� If a learner states the need for any additional diagnostic studies or interventions during the Primary or Secondary survey, they will be counted towards the total needed at the completion of the initial assessment as long as they are not part of another required step

� Any time “AND” is emboldened and capitalized, the learner must request or demonstrate both components to successfully complete the step. Important examples include:

§ When assessing circulation, assess both the central AND peripheral pulse rate

§ When assessing circulation, evaluate skin color AND temperature

§ During the Secondary Survey inspect AND palpate is used in multiple instances

§ Assess for lung sounds AND heart sounds § Inspect AND palpate the head AND face when beginning the Secondary survey

� When multiple elements are required for assessment of airway patency, breathing effectiveness, or circulatory status, and the learner does not identify the required number of elements, the instructor may ask for additional elements. For example, if the learner states two out of the three required methods for evaluating airway patency, it is acceptable for the instructor to state “You’ve assessed the airway using two elements. You need to assess one more.”

Completion � At the end of the skill station, ask the learner if there is anything he or she would like to add

§ This allows the opportunity to add any missed steps, excluding the double-asterisk criteria

§ Use of this phrase during teaching can help to increase the learner comfort level when it is used during the evaluation station

� A debriefing is held after the skill station teaching session

§ An IP is assigned to observe and lead the debriefing; it is to review the teaching of the scenario

§ The debriefing facilitator may use the following questions to stimulate IP self-reflection and group interaction:

· How do you feel the teaching experience went? · What about the experience did you like? · What would you change about your teaching performance?

· What did you learn from this teaching exercise?

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Psychomotor Skill Station: Airway and Ventilation ExerciseOverview

After assessing for and controlling any external uncontrolled hemorrhage in the trauma patient, the next priority is the establishment and maintenance of a patent airway.

� Management and care of the airway in the trauma patient includes cervical spinal motion restriction to prevent further injury

� Thoroughly review the TNCC Provider Manual Chapters 5 (Initial Assessment), 6 (Airway and Ventilation), and 11 (Thoracic and Neck Trauma) before teaching this station to become familiar with their contents

� This section describes the skill steps specific to common airway and ventilation assessment and interventions for the trauma patient, along with guidelines for teaching these Psychomotor Skills Stations

Teaching Points

During the station, the instructor will discuss and/or demonstrate: � Jaw-thrust maneuver with a second person maintaining manual cervical spinal motion restriction � Oropharyngeal suctioning � Insertion of oropharyngeal and nasopharyngeal airways � Various oxygen delivery devices � Bag-mask ventilation � Indications for and types of definitive airways � Review of rapid sequence intubation � Difficult airways � Endotracheal intubation � Assessment of endotracheal tube placement � Surgical airways � Rescue airways � Insertion of a multilumen esophageal airway (King tube), with indications and contraindications for use � Insertion of a laryngeal mask airway with indications and contraindications for use � Chest trauma interventions of needle decompression, chest tube insertion and management, and autotransfusion

Learner Skill Objectives

The learners will describe and/or demonstrate: � Jaw-thrust with a second person maintaining manual cervical stabilization � Insertion of an oropharyngeal and a nasopharyngeal airway � Bag-mask ventilation � Principles of rapid sequence intubation � Assessment of endotracheal tube placement � Landmarks and procedure for needle thoracentesis � Management of chest tube malfunction � Insertion of and ventilation with a multilumen esophageal airway (King tube) (optional) � Insertion of and ventilation with a laryngeal mask airway (optional)

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Methods to open and clear the airway

Alertness � The first step in the airway assessment of a trauma patient is to determine if the patient is alert

� Use the AVPU mnemonic � If the patient is alert and follows commands, ask him or her to open his or her mouth

Jaw-thrust maneuver � If the patient is not alert or is unable to follow commands, manually open the airway using a jaw-thrust maneuver and a second person to maintain manual cervical spinal motion restriction

� With the patient lying flat, stand at the head and grasp the jaw with both hands

� The fingers are placed along the bottom of the lower jaw on bone, not soft tissue, and the thumbs alongside the corners of the mouth at the top of the jawline

� Using the heel of the hand on the cheek bone for stabilization, thrust the jaw up toward the ceiling to open the airway

� Alternatively, keep the fingers along the jaw as above, but place the thumbs on the cheek bone for stabilization

� The second person stands at the side of the bed and leans over facing the patient, aligning his or her shoulders parallel to the patient

� Place the wrists and palms on the shoulders for stability and place the index fingers under the occiput, curling the remaining fingers around the back of the neck, with the thumbs along each side of the neck just below the angle of the jaw

� AVOID pressure over the carotid arteries � With the airway open, complete the assessment as described in the TNCC Provider Manual, Chapter 5: Initial Assessment

Airway adjuncts � An airway opened with a jaw-thrust maneuver may require an adjunct to maintain patency; snoring may be an indication for this adjunct

� Nasopharyngeal airway (NPA) § Use in responsive or unresponsive patients § Contraindicated in patients with facial trauma or suspected basilar skull fracture

§ Use the largest diameter NPA that fits easily into the patient’s naris

§ Select the correct length by measuring from the corner of the naris to the tip of the earlobe

§ Apply a water-soluble lubricant to the NPA § Insert the NPA with the bevel facing the nasal septum

§ Most NPAs are manufactured to be inserted into the right naris; if using the left, turn it upside down to keep the bevel toward the septum

§ Direct the NPA posteriorly and rotate slightly toward the ear until the flange rests against the naris

§ Avoid inserting the NPA if the naris is obstructed by septal deviation or polyps

§ Reassess airway patency � Oropharyngeal airway (OPA)

§ Use in an unresponsive patient or a patient without a gag or cough reflex

§ Measure the length from the corner of the mouth to the tip of the earlobe

§ Use a tongue depressor to hold the tongue down and insert the OPA along the normal curvature of the mouth until the flange rests against the lips (for both adult and pediatric patients)

§ Reassess airway patencyNonrebreather mask

� If indicated after assessment of breathing effectiveness, apply oxygen using a tight-fitting nonrebreather mask to deliver the highest concentration of oxygen to a spontaneously breathing, nonintubated patient

� A patient with inadequate or absent respirations will require manually assisted ventilations with a bag-mask device before definitive airway control

Bag-mask ventilation � Connect the bag-mask device to an oxygen reservoir system and to an oxygen source

� To achieve effective bag-mask ventilation, a tight seal is necessary; this may require two people

� Use an oral airway with bag-mask ventilation to maintain a patent airway

� Maintain oxygen flow at 12 to 15 L/minute � Compress the bag to produce a noticeable rise in the patient’s chest; avoid overinflation

� Assess for effective ventilation � Two-person technique

§ The first person stands at the patient’s head and places the narrow end of the mask over the bridge of the patient’s nose

§ As the mask is brought down onto the lower chin, bring the soft tissue of the face up into the mask

§ Hold the mask firmly against the face, making a tight seal

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§ Place the thumbs across the nose piece and bring the index fingers up around the lower portion of the face mask

§ The remaining three fingers perform a modified jaw-thrust maneuver

§ The second person stands at the patient’s side and delivers assisted ventilations

� One-person method § The one-person method hand position uses the EC technique

§ Stand at the patient’s head and place a thumb over the top of the mask with the index finger reaching around to hold the bottom portion of the mask, forming the letter C

§ Use the remaining three fingers along the mandible forming the letter E; use caution to avoid lifting the mandible, which may compromise cervical spinal alignment

Definitive airways � A definitive airway is a tube securely placed in the trachea with the cuff inflated, if applicable

� In the trauma patient there are three indications for definitive airway management:

§ Failure to maintain or protect the airway § Failure to maintain oxygenation or ventilation § A specific anticipated clinical course

� Types of definitive airways include: § Endotracheal tube (ETT) § Surgical cricothyrotomy

Principles of rapid sequence intubation � Rapid sequence intubation (RSI) is used to provide the patient with a definitive airway in a controlled setting, using medications to facilitate the process

� RSI is not recommended for crash intubations or difficult airways

§ A crash intubation is indicated in the patient who is unresponsive or close to death; medication is not necessary to facilitate the process

§ A difficult airway is one where more than one attempt may be likely and when assisted ventilations with a bag-mask device will be necessary; there is a risk if neuromuscular blocking agents are used in this patient population

§ If neither of these situations exists, RSI is the standard of care

Assessment of endotracheal tube placementAfter intubation, verify placement. Remind the learner that, for this step, a thorough and systematic approach is necessary. The learner must state and demonstrate ALL of the steps in the correct order. Point out these steps to the learner on the applicable skill teaching station scenarios.

Use the following approach (required steps are underlined below):

� Attach the carbon dioxide (CO2) detection device to the ETT; this may be a colorimetric device or capnography

� Assesses for symmetric rise and fall of the chest AND auscultate for the absence of gurgling over the epigastrium

§ Gurgling may be an indication of an improperly placed ETT

§ The determination to remove the ETT is ideally based on the complete assessment, but there may be times when the gurgling is significant enough to warrant immediate ETT removal

� Auscultate bilaterally for breath sounds § If breath sounds are heard only on the right side, the tube may have been inserted into the right mainstem bronchus; pull back on the tube until breath sounds are equal bilaterally

� If breath sounds are heard bilaterally, deliver 5 to 6 breaths

� Assess the color of the colorimetric CO2 (qualitative) device or the capnography reading

� Assess the patient’s color for signs of improvement � Inflate the cuff, noting the number at the teeth or gums, and secure the ETT

� Prepare for mechanical ventilation � Reevaluate the effectiveness of breathing

Rescue airwaysExtraglottic devices can be used for airway management in trauma patients with failed intubation and/or in situations when unsuccessful intubation is a possibility.

� Laryngeal mask airway (LMA): § Advantages

· Better seal than bag-mask device · Can be inserted without the use of a laryngoscope

· Can be placed quickly and simply · Less gastric distention compared with bag-mask assisted ventilations

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§ Disadvantages · Limited protection against aspiration

§ Contraindications · Complete upper airway obstruction or the inability to open the patient’s mouth

� King Airway LTS-D § Contraindications

· Patients who have an intact gag reflex · Patients with past medical history of an esophageal condition

· Patients who may have ingested caustic substances

· Patients under 35 inches (90 cm) tall

Principles of Chest Trauma Interventions

Chest tube (Thoracotomy)Chest thoracotomy is indicated after a needle decompression for a tension pneumothorax, a simple pneumothorax, a hemothorax, or as initial treatment for an open pneumothorax. The goal is to evacuate air or blood from the pleural cavity.

� Prepare the patient § Ensure the patient has at least one large-caliber intravenous catheter infusing an isotonic crystalloid solution

§ Administer analgesic and antibiotic medications as prescribed

§ Monitor and document the patient’s cardiorespiratory status, including breath sounds auscultated prior to, during, and after the procedure

§ Follow institutional and manufacturer’s guidelines for the procedure and setup of the chest tube and drainage system

� Manage the chest drainage system § Assess and document using the FOCA mnemonic - Fluctuation, Output, Color of drainage, and presence of Air leak

§ Troubleshoot for problems with chest tube drainage following the DOPE mnemonic — dislodgement, obstruction, pneumothorax, and equipment

� Assess for an air leak § The water level in the water-seal chamber normally rises and falls with each patient breath

§ Constant bubbling in the water-seal chamber indicates an air leak somewhere in the chest drainage system or in the lung

§ Some bubbling with respirations may signal a pleural space air leak. Expect it to subside as the lung re-expands.

§ An air leak is an expected finding in an unexpanded lung

§ Leaks that occur after lung re-expansion may originate from:

· A displaced tube · Injury to the bronchus or esophagus · A hole in the drainage tubing or tubing that has become partially disconnected

§ If an air leak is suspected: · Assess that all connections are tight · Turn off suction and reassess after 1 minute · To find the location of the leak, while the suction is on, intermittently occlude the chest tube or drainage tubing, beginning at the dressing site and progressing toward the chest drainage unit

· If the bubbling in the water-seal chamber immediately stops when the chest tube is occluded at the dressing site, the air leak is inside the patient’s chest or under the dressing. In this case, reinforce the occlusive dressing and notify the physician.

· If the bubbling does not stop when the chest tube is occluded at the dressing site, continue to intermittently occlude the tubing at various positions until the bubbling stops

· When the bubbling stops, the air leak is between the occlusion and the patient’s chest

· If the bubbling does not stop with occlusion, replace the chest drainage unit

� Clamping the chest tube § Clamping the chest tube may lead to the development of a tension pneumothorax

§ Avoid clamping the chest tube unless you are assessing for an air leak

§ When transporting the patient, remove the distal tubing from the wall suction and leave open to water seal

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Psychomotor Skill Station: Trauma Interventions ExerciseOverview

A variety of interventions are performed during the care of the trauma patient. An essential element in providing these interventions is the availability of equipment in sizes appropriate for all trauma patients.

� Thoroughly review the TNCC Provider Manual Chapters 7 (Shock), 13 (Spinal Cord and Vertebral Column Trauma) and 14 (Musculoskeletal Trauma) before teaching this station to be familiar with the content

� This section describes the skill steps specific to selected procedures and interventions in the trauma patient � During the Trauma Interventions Psychomotor Skill Station, the learners are presented with specific patient scenarios � The instructor will guide the learners through the scenario, clarify questions, and assist them in demonstrating the skills

� It is expected that all Trauma Interventions will be reviewed regardless of the number of learners � In some cases, steps may vary based on manufacturer’s product guidelines. Review these for any pieces of equipment that need to be demonstrated before teaching.

Teaching Points

During the station, the instructor will discuss and/or demonstrate: � Principles of spinal motion restriction � Helmet removal � Measurement and application of rigid cervical collar � Logrolling and removal of the patient from the spine board � Removal of an infant from a car seat onto a stretcher � Tourniquet application for uncontrolled hemorrhage � Strategies for stabilizing the pelvis with control of hemorrhage � Insertion of an IO catheter in the adult patient

Learner Skill Objectives

The learners will describe and/or demonstrate: � Principles of spinal motion restriction � Helmet removal � Sizing and application of a rigid cervical collar � Logrolling to remove the spine board, acting as team leader, and directing the team � The indications for tourniquet use � Application of a tourniquet � Assessment findings of uncontrolled pelvic hemorrhage � Technique for stabilization of pelvis � Indications for insertion of an intraosseous catheter in the adult patient � Insertion technique for adult intraosseous devices

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Case 1a. Spinal Protection

Scenario background and instructions � A 22-year-old male is brought to the ED after laying down his motorcycle while traveling around a corner at a high speed

� He was alert at the scene and complaining of leg pain � He has arrived in your trauma room on a spine board with a motorcycle helmet in place

� Please remove the helmet, apply a rigid cervical collar, and remove the spine board in preparation for initial assessment

General principles � Until proven otherwise, if there is a history of a high risk mechanism, or patients with distracting injuries such as significant blood loss or open fractures, or who behave as if intoxicated or experiencing an altered mental state, they may be presumed to have sustained a vertebral injury

� Patients who may benefit from spinal motion restriction on a spine board include those with an anatomic deformity of the spine or spinal tenderness, those with neurologic complaints, and those who were injured in an event involving high energy transfer

� Spine boards can lead to breathing difficulties, discomfort, pain, and skin breakdown; removal of the spine board in a timely manner will minimize these complications

� Assessment and care related to the potentially injured spine requires a team approach

� A leader is responsible for verbally directing the procedure and instructing the team to assure proper timing and coordination of any movement of the patient

� The leader stabilizes the head and cervical spine during helmet removal, directs the measurement and application of the cervical collar, and coordinates the logroll process to remove the patient from the spine board

� Removal of spinal protection devices is directed by a qualified provider who conducts an assessment appropriate to the individual patient, following accepted guidelines

� Two clinical decision tools are available to assess the patient’s need for cervical spinal imaging following trauma

� Apply manual stabilization throughout the initial assessment as necessary, such as when removing the cervical collar to examine the neck

Helmet removal skill performance procedure � The leader introduces himself or herself, instructs the patient not to move, and explains the procedure

� The leader stands behind the patient and applies manual cervical spinal motion restriction by placing hands on both sides of the patient’s helmet with fingers on the mandible

� The leader directs a team member to assess the patient’s extremities for circulation and motor and sensory function before beginning the procedure

� Team member #1 will cut or remove the helmet strap � Team member #1 will then assume manual cervical spinal motion restriction by cradling the angle of the mandible between the fingers on one side and the thumb on the other side, and simultaneously using the other hand to support under the head at the occipital ridge

§ Brace the arm or elbow of the hand used to support the occiput on a flat surface

§ Prepare a towel or sheet to place under the head once the helmet is removed to fill the space formerly occupied by the helmet and maintain inline alignment

� When team member #1 is in position, he or she will inform the leader and assume control of manual cervical spinal motion restriction

� The leader will remove the helmet in a longitudinal direction (straight back) by positioning his or her hands on each side of the helmet and pulling outward with firm, gentle pressure to move the helmet laterally

§ A full-face helmet will require tipping the helmet up to clear the nose and then down to slide it off the back of the head

� The leader then assumes manual cervical spinal motion restriction control by placing hands along the side of the patient’s head with palms over the ears and fingers under the mandible. Care is taken to not lift the mandible.

� Reassessment of circulation and motor and sensory function is performed

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Measurement for and application of a rigid cervical collar

� Specifications differ slightly, so follow the manufacturer’s guidelines

� The leader applies or maintains manual cervical spinal motion restriction

� Team member #1 determines the appropriate size by measuring the distance from the plane of the patient’s chin to the plane of the patient’s shoulder

§ The measured distance is from where the collar rests on top of the shoulder to where the chin fits into the top of the collar

§ Use a number of fingers to measure § If there is foam or soft padding on the collar, make the measurement from the rigid plastic edge, not from the padding

� Depending on the type of collar used, adjust the size to fit the patient and adjust or preform the collar, following the manufacturer’s guidelines

� Slide the rear portion of the collar under the patient’s neck and position centrally at the back of the head

� Position the front of the collar, assuring that the chin fits snugly into the chin piece

§ Do not lift the chin to fit it into the collar § If it does not fit, remove, resize, and try again

� Secure and fasten the straps � The leader maintains manual cervical spinal motion restriction throughout procedure

Logrolling the patient and removal from the spine board skill performance procedure

� The leader directs team members #1 and #2 to position themselves on the same side of the patient

� Team member #1 places one hand on the patient’s opposite shoulder and one hand on the patient’s opposite hip

� Team member #2 places one hand on the patient’s opposite hip, crossing arms with team member #1, and one arm just above the knees to support the legs

� The leader holds the head so that the patient’s nose and umbilicus remain in alignment throughout the procedure

� The patient’s arms are crossed at the front of the body � On the leader’s count, the patient is rolled in a straight line without twisting

� Team member #3 removes the board � On the leader’s count, the team maintains alignment, logrolling the patient back to a supine position

� A reassessment of circulation and motor and sensory function is performed

Case 1b. Spinal Protection of the Infant

Scenario background and instructions � An infant arrives following a motor vehicle collision (MVC)

� The infant was ejected from the vehicle, but remains secure in the child safety seat

Removal from the car seat skill performance procedure � To perform the initial assessment, the infant needs to be placed on the stretcher while maintaining cervical spinal motion restriction

� The safety seat is placed on the stretcher � Unbuckle or cut the straps � The leader stands behind the head of the stretcher with the infant still in the safety seat, and applies manual cervical spinal motion restriction

� Team member #1 is in position at the foot of the stretcher (or side if unable to reach), and grasps the infant around the waist, supporting the torso

� Team member #2 tips the seat back to bring the head of the infant down to the stretcher and slides the seat out from under the infant while the leader and team member #1 lift and lower the infant and onto the stretcher

� Apply the cervical collar � Note: When providing discharge teaching to the family, remind them that any car safety seat that has been involved in a moderate or severe MVC must be replaced. If your institution does not have a program to replace the seat, consider that cutting the straps may result in the infant having no seat for the trip home. Make provisions in advance for this situation.

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Case 2. Tourniquet Application for Uncontrolled Hemorrhage

Scenario background and instructions � A 49-year-old male was working on a gas pipe when it exploded

� Prehospital providers found him conscious, bleeding profusely with a partially severed left leg

� Oxygen is being administered via a nonrebreather mask at 15 L/min, and a large-caliber intravenous (IV) catheter is in place with isotonic crystalloid solution infusing at a rapid rate

� The patient is in complete cervical spinal motion restriction and has just arrived in your ED

� Please begin your initial assessment � The learner begins the initial assessment

§ Across-the-room observation: Determine if there is an uncontrolled hemorrhage and if ABC needs to be reordered to <C>ABC

§ Inspect and palpate for: · Uncontrolled bleeding · Central pulse · Skin color, temperature, and moisture

§ Assess the patency of the prehospital IV catheter � Scenario information continues with assessment findings

§ The patient has uncontrolled hemorrhage from his left lower extremity

§ The dressing is soaked through; skin is pale, diaphoretic, and cool

§ Central pulse is rapid and weak § The prehospital IV line is patent and infusing at a rapid rate

General principles � The use of a tourniquet has for some time been thought to be an unsafe intervention resulting in ischemic complications. However, a life-over-limb viewpoint is the basis for considering tourniquet use, and recent evidence shows tourniquets can be lifesaving.

� Indications include: § Life-threatening extremity hemorrhage § Hemorrhage that cannot be controlled by elevation, direct pressure, or use of a pressure dressing

� Contraindications: § None in the presence of life-threatening hemorrhage

� Types of tourniquets: § Tactical ratchet-style tourniquets used by the military and emergency medical services (EMS)

§ Improvised tourniquets

§ Blood pressure cuffs (may be ineffective because they can lose pressure)

§ Pneumatic tourniquets used during orthopedic surgery

� Complications include § Neuromuscular injury and function loss after 2 hours (cooling may increase the ability to salvage the limb in some cases)

§ Inflamed tissue under the tourniquet blocking functional nerve transmission, causing a cascade of events leading to anaerobic metabolism and ultimately to microvascular injury after 2–6 hours

§ Additional systemic pathophysiologic changes, referred to as post-tourniquet syndrome, which generally resolve between 1 and 6 weeks; tourniquet paralysis can last up to 6 months

Tourniquet skill performance procedure � Follow the manufacturer’s guidelines � Use an adjustable constricting-band tourniquet at least 2 inches wide

� Avoid placing the tourniquet over a joint or impaled object

� Consider padding the skin under the tourniquet � Tie or secure the tourniquet � Place a rigid object inside the knot and tighten until all visible bleeding stops and secure the knot

� Assure that the extremity and tourniquet are exposed and easy to see; a brightly colored tag can be used for this purpose

� Document the application time clearly on the device. � Insert a second, large-caliber IV catheter, initiate massive transfusion protocol, and send blood for typing

� Complete the Primary survey, resuscitation adjuncts, and reevaluation to determine the need for immediate transfer to surgery

� Assess and manage pain as a priority because tourniquets, as well as the original injury, can be painful

� Continually monitor the tourniquet and readjust tightness to control bleeding

� Maintain the tourniquet until definitive intervention is available

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Case 3. Stabilization of the Pelvis with Control of Hemorrhage

Scenario background and instructions � A 67-year-old male was crossing the street when he was struck by a motor vehicle

� He arrives alert and asking questions, but confused � He has oxygen via a nonrebreather mask at 15 L/min, is in full spinal motion restriction with a cervical collar and spine board, and has one large-caliber intravenous (IV) catheter infusing at a moderate rate

� Please begin with your assessment of pelvic injury and hemorrhage

General principles � Pelvic fractures are classified as either stable or unstable

§ Unstable fractures are two or more fractures of the pelvic ring resulting in outward rotational displacement

§ Unstable fractures increase the volume of the pelvic cavity and the potential to sequester large amounts of blood from a traumatic hemorrhage, requiring a massive blood transfusion

� Begin to raise awareness of the risk for pelvic fracture based on the mechanism of injury—for example, ejection from a vehicle; a pedestrian hit by a car

� Assessment findings include: § Unexplained signs and symptoms of shock, such as tachycardia, hypotension, pale, cool, and clammy skin

§ Shortening of the leg with external rotation—bilateral external rotation of the legs or hips can indicate an open-book fracture

§ Pelvic instability and/or pain § Concurrent urethral trauma, with findings such as the urge to urinate with an inability to void, blood at the urinary meatus, hematuria, or displacement of the prostate gland

� If pelvic instability is suspected, defer the assessment of the pelvis to avoid causing additional bleeding and expedite a portable pelvic radiograph during reevaluation

� Interventions aimed at stabilizing or internally rotating the lower limbs improve pelvic alignment, reduce pelvic volume, control venous bleeding, and aid in patient comfort. Methods include:

§ Internal rotation of the legs to bring them back to midline; pad over bony surfaces and secure them in place with a sheet

§ Use of commercial stabilization and reduction devices such as binders, slings, wraps

§ Application of an external pelvic fixator § Application of pelvic sheeting as a stabilization maneuver

� Full stabilization includes securing the ankles together � Once immobilized, expedite the patient to angiography to embolize arterial bleeding sites as needed

Pelvic stabilization skill performance procedure � The sheet wrap method is used specifically for an open-book fracture

� Assess distal pulses, sensory, and motor function � Fold the sheet two or three times lengthwise until it is approximately 4 to 5 inches wide

� Place under the patient with the ends to the sides, positioned so that when the ends are brought up around patient, they meet over the area of the femoral trochanters and the pubic symphysis

� Remove any debris, sharp objects, or wrinkles in the sheet that might result in injury to the skin

� Avoid movement of the pelvis � Crosswrap the sheet around the pelvis � With one team member at each end, pull the sheet tight and gradually squeeze the pelvis until legs are internally rotated

� Use towel clamps to fasten the sheet in place � Reassess distal pulses, sensory, and motor function � Treat shock following a massive transfusion protocol as needed

� Consider the need for urgent surgical intervention or transfer to a trauma center

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Case 4. Insertion of an IO Catheter in the Adult Patient

Scenario background and instructions Technology is advancing quickly in this area, and improved next-generation devices are being developed based on feedback from the military, ED trauma, and Emergency Medical Services. Be familiar with the manufacturer and model you are demonstrating and follow all manufacturers’ guidelines.

General principles � Devices are developed for quick, easy, and safe access for resuscitation

� Devices are indicated for emergency use, and recommendations suggest that they should be replaced within 24 hours

� Contraindications § Fractures or injuries at the insertion site § Previous attempts at an IO at the same site § Cellulitis at the insertion site § Bone disorders or abnormalities such as osteoporosis

§ Inability to recognize anatomy at the insertion site � Be familiar with the age, weight, or site limitations of the device being demonstrated

� Complications § Extravasation into the surrounding tissue § Possible fractures § Infection of the bone and surrounding tissue

Intraosseous insertion skill performance procedure � Follow the manufacturer’s guidelines � Select the appropriate-size needle � Prepare the site with an antiseptic cleanser � Support the site with towels, as needed � Sites

§ Proximal tibia: 1 to 3 cm below and slightly medial to the tibial tuberosity

§ Distal tibia: Flat area of tibia, proximal to medial malleolus

§ Distal femur: 1 to 3 cm above the distal epicondyle, midline (pediatric only)

§ Humerus: Adduct the arm, placing the hand over the umbilicus; the greater tuberosity of the humoral head is 1 cm above the surgical neck or palpable notch, midline

§ Sternum: The upper one-third of the sternum � Insert the device following manufacturer’s instructions � Remove the trocar and attempt to aspirate bone marrow; it may be correctly placed despite lack of return of bone marrow

� Flush with normal saline solution and observe for extravasation

� Administer 1% lidocaine before beginning the fluid to reduce pain

� Attach to IV tubing and secure in place; an IV pump or pressure bag may be needed as it may not flow freely

� Continually assess the site for extravasation of fluid into the tissues

� Monitor for signs of compartment syndrome

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Evaluating a Psychomotor Skill Station Objective

At the end of this exercise, the IP will be able to:1. Evaluate a learner’s demonstration of the TNP Psychomotor Skill Evaluation Station.2. Use the Psychomotor Skill Station Evaluation Form while viewing a recorded scenario performance.3. Accurately calculate and score the evaluation form.

Tips for Completing the Skill Station Evaluation Forms

� Review guidelines for the Psychomotor Skill Evaluation Station

§ Use check marks to indicate which assessment elements are used by the learner when there is more than one element to be stated or assessed

§ Use a check mark in the YES column to indicate each demonstrated skill step

§ Circle any skill step that is not demonstrated in order to return and check it if the learner consequently demonstrates or mentions it. The exceptions are double-asterisk criteria, which must be demonstrated in the correct order during the Primary survey. At the end of the station, review all steps, and if a circled skill is not checked, place a check in the NO column.

§ To total the skill steps, count those NOT demonstrated and subtract that from the total number of skill steps in the station. Use the grid to find the final percentage corresponding to that number.

Guidelines for the Evaluation of the TNP Skill Station

� During the evaluation portion of the TNCC Provider Course, all flip charts and posters—such as the A through I mnemonic and components of airway, breathing, and circulation assessments— can be placed in a study or waiting area, but are not allowed in the evaluation area

� During the Psychomotor Skill Evaluation Station, the instructor may respond to the learner’s questions related to the scenario

� The case progression may need to be adapted in response to the learner’s questions, interventions, or lack of interventions. Reminding the learner of the most recent assessment data given may get him or her back on track.

� Do NOT alter or make up assessment findings or other information. Deviation from the script can alter a carefully constructed scenario, making it difficult to remember and reconcile added information. This also makes accurate evaluation of the steps impossible as the additional or altered information is not part of the scenario. If the learner asks for information that is not part of the script, simply state that the requested data are not available at this time.

� If the learner inadvertently skips an element that may contribute to failure, a simple redirect or review of where they are may be appropriate. For example, the learner has completed A and B, intubated and reassessed, and begins assessment for D. Simply say, “You have just finished B.” This may quickly prompt the learner to realize where she or he is in the scenario. If not, no additional prompting is allowed.

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Acceptable Cues:

Problem: Multiple elements are required for a skill step (e.g. “List at least THREE…”), but the learner does not identify the required number.

Instructor cue: “You have identified two elements; please state one more.”

Problem: The learner does not state the need to position the patient and demonstrate manually opening the airway.

Instructor cue: “What do you need to do to assess the airway in this patient?”

Problem: Learner states an intention to perform an assessment (e.g., “I’m going to assess the airway for patency.”)

Instructor cue: “Tell me what assessment parameters (or what you are looking for) that will help you determine if the airway is patent.” (Use similar cues for breathing and circulation.)

Problem: The learner demonstrates bag-mask ventilation but does not assess its effectiveness.

Instructor cue: “How can you tell if the ventilations are effective?”

Problem: Learner identifies the need for intubation but does not initiate bag-mask ventilation.

Instructor cue: “What can you do for the patient while the team prepares for intubation?”

Problem: Learner states the need for IV access.

Instructor cue: “There is one IV catheter in place from the prehospital provider.” Or “One IV catheter has been inserted.”

Problem: Learner does not identify rate of infusion of IV solution.

Instructor cue: “How fast do you want to infuse the fluid?”

Problem: The learner states “I would assess level of consciousness.”

Instructor cue: “Which tool will you use?” (i.e., AVPU, GCV, FOUR score)

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Mentoring

TNCC Instructor Mentor/Mentee ProcessAfter completing the TNCC Instructor Path Live Session, finding a mentor can be valuable in your progress towards becoming an independent instructor. Some challenges you may face in teaching the TNCC Provider Course include how to prepare for a specific lecture, how to teach a skill station, how to manage a challenging student, how to advise a student that they did not successfully complete a testing station, or how to remediate a learner who has been unsuccessful in the written examination. While the Instructor Path will help prepare you for some of these situations, having the support and guidance of an experienced instructor may also assist you in becoming a competent and confident instructor.

TNCC Instructor Mentor/Mentee GuidelinesAsk yourself the right questions to help clarify your needs and focus on the right fit.

� Consider these questions about the mentor: § Who would be a good fit for me, my needs, my style, and my schedule?

§ What do I hope to gain from the relationship? § What specific qualities should the person possess? § What type of assistance can this mentor provide? § Is this someone who is patient and has the time? § Is this someone who will be generous and honest with advice?

� Consider these questions about yourself: § What is it I want to learn? § What do I need help with to improve? § How much time do I have or want to devote to this? § What is my preferred learning style? § What are the steps to be followed? § What resources do I need? § What is my time frame? § How will I monitor my progress?

Follow these guidelines to select and work with a mentor successfully.

� Take the initiative § Identify someone whose success and teaching style you admire

§ Approach him or her and explain that you would enjoy finding out more about the skills and techniques that have helped this person excel

� Address any concerns § If someone is hesitant, find out why and suggest ways to make it easier for him or her to provide assistance

§ If, for example, the person seems pressed for time, you might reduce the frequency of meetings or ask him or her to refer you to someone else who might have a more flexible schedule

� Take an active role § Once you’ve found someone you think would be a great mentor, it’s important for you to take responsibility for the process

§ When you meet with your mentor, bring a list of questions, but don’t expect your mentor to have all the answers

§ As you begin to think about your relationship with your mentor, create a list of objectives and target dates, the tasks and processes you would implement to meet those objectives, and the resources you would need

� Be appreciative § Respect your mentor’s time, arrive on time for meetings, and keep in mind that while it’s acceptable to reach out to your mentor between formal meetings, don’t take advantage by constantly calling or emailing him or her

§ Show your appreciation by sending your mentor a thank-you note after a particularly helpful coaching session and always offer to provide any assistance you can

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Monitored Session

The Monitored Session is the next step after successful completion of the Live Session and selection of a mentor. You will have 12 months from the Live Session to complete this monitoring.

Remember to use the TNCC Instructor Path Checklist as your guide. It will help you keep track of what you’ve accomplished and what steps remain to be completed. It will also help any TNCC Provider Course Director who may invite you to teach a course to identify the steps you’ve taken and your progress on the path.

To find a course in which to be monitored: � Contact the State Trauma Chair or a Course Director

§ He or she will assist in finding TNCC Provider Courses where you can be monitored

§ Contact information can be found in the Letter of Acceptance for Instructor Potential

� Provider Course Monitoring Requirements § Be evaluated teaching one or two lectures (no more than one lecture per class day)

§ Be evaluated teaching at least one rotation of the TNP skill station (a minimum of four learners)

§ Be evaluated conducting Psychomotor Skill Station evaluations (a minimum of 4 learners)

You will be evaluated by an Instructor Candidate Monitor who will critique your performance, discuss strengths and areas for improvement, and help determine if you are ready for full instructor status or if another monitored course might be helpful. Three opportunities in a monitored TNCC Provider Course environment are not only allowed, but encouraged, to assure proper preparation of the new instructor. Take advantage of these experiences to become an expert instructor. The first one must include the requirements as described above. Subsequent monitored teaching may be only lecture or skill station depending on which one requires additional monitoring.

Upon final completion of monitoring, the Course Director will submit documentation to ENA and you will receive your Instructor Card in the mail.

As a TNCC Course Instructor you are responsible for knowing your role and responsibilities as outlined in the Course Administrative Procedures (https://www.ena.org/education/ENPC-TNCC/enpc/Documents/TNCCENPCAdminProcedures.pdf). These Procedures include all rules associated with holding and teaching all ENA courses and define the process for obtaining and maintaining your instructor status.

Look for updates and announcements in Course Vitals and on the ENA Website.

7th Edition



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