Head and Neck
21%of exam
Trunk and Pelvis
25%of exam
Musculoskeletal and Wound
9%of exam
FracturesCompartmentAmputationWoundsCrush
Special Populations
15%of exam
Continuum of Care
24%of exam
Professional Practice
7%of exam
MCITQIPRegistryEMTALAHandoff
Quick Facts
- Exam
- TCRN
- Body
- BCEN
- Questions
- 175 items
- Scored
- 150 items
- Pretest
- 25 items
- Time
- 3 hours
- Pass
- 96 of 150
- Vendor
- PSI
- Window
- 90 days
- Validity
- 4 years
Cushing Triad
Hypertension, bradycardia, irregular respirations.
High BPLow HRIrregular breathing
EDH vs SDH
EDH
- Arterial bleed
- Lens shaped
- Lucid interval
SDH
- Venous bleed
- Crescent shaped
- Older adults
Artery vs vein
Neuro Trauma
- Concussion
- Transient brain dysfunction
- DAI
- Shearing injury
- EDH
- Arterial lens bleed
- SDH
- Venous crescent bleed
- SAH
- Meningeal blood
- Herniation
- Cushing warning
- ICP
- Prevent secondary injury
- CPP
- MAP minus ICP
NEXUS
No pain, neuro, intoxication, alertness, distraction.
TendernessDeficitAlertnessIntoxicationDistraction
Neurogenic vs Spinal Shock
Neurogenic
- Hemodynamic shock
- Bradycardia
- Vasodilation
Spinal
- Neurologic loss
- Areflexia
- Temporary phase
Circulation vs reflexes
Face Neck Spine
- Le Fort
- Midface fracture
- Mandible
- Airway risk
- Globe injury
- Shield, no pressure
- Neck hematoma
- Airway threat
- Central cord
- Arms worse
- Neurogenic shock
- Warm brady hypotension
- Spinal shock
- Transient areflexia
- Immobilization
- Neutral alignment
Tension vs Tamponade
Tension
- Absent breath
- Chest decompression
- Obstructive shock
Tamponade
- Muffled tones
- Pericardial blood
- Surgical relief
Pleura vs pericardium
Imaging Transfer Picker
- Unstable abdomen→FAST first
- Stable abdomen→CT imaging
- Urethral signs→RUG first
- Blunt chest risk→CXR eFAST
- Higher care needed→Interfacility transfer
- Department move→Intrafacility handoff
Thoracic
- Rib fractures
- Pain impairs ventilation
- Flail chest
- Paradoxical segment
- Pulmonary contusion
- Delayed hypoxia
- Tension pneumo
- Obstructive shock
- Open pneumo
- Vented seal
- Hemothorax
- Blood in chest
- Tamponade
- Beck triad
- Aortic injury
- Deceleration clue
Solid vs Hollow Organ
Solid
- Bleeds early
- FAST positive
- Shock risk
Hollow
- Leaks contents
- Peritonitis later
- Sepsis risk
Blood vs contamination
Abdomen Pelvis
- Solid organ
- Bleeding risk
- Hollow organ
- Peritonitis risk
- Diaphragm
- Missed on left
- Retroperitoneal
- Hidden bleeding
- Open book
- Pelvic volume expands
- Binder
- Greater trochanters
- Urethral injury
- Blood at meatus
- Bladder injury
- Gross hematuria
Compartment vs Crush
Compartment
- Closed pressure
- Pain stretch
- Fasciotomy risk
Crush
- Muscle breakdown
- Hyperkalemia
- Renal injury
Pressure vs toxins
MSK Wounds
- Open fracture
- Antibiotics early
- Long-bone fracture
- Fat embolism risk
- Dislocation
- Neurovascular checks
- Compartment
- Pain with stretch
- Crush
- Rhabdo hyperkalemia
- Amputation
- Wrap cool dry
- Soft tissue
- Irrigate debride
- Vertebral injury
- Protect cord
Parkland
Four times weight times percent.
4 mLkgTBSALR
Adult vs Pediatric
Adult
- Earlier hypotension
- Fixed reserves
- Larger airway
Pediatric
- Late hypotension
- Big occiput
- More surface area
Early vs late crash
Special Pop Picker
- Pregnant hypotension→Displace uterus
- Viable arrest→Perimortem cesarean
- Child vague history→Abuse screen
- Elder anticoagulated→Early CT
- Burn circumferential→Perfusion checks
- Violence suspected→Preserve evidence
Special Populations
- Pediatric
- Compensates then crashes
- Geriatric
- Medications mask shock
- Pregnancy
- Left uterine displacement
- Bariatric
- Airway positioning
- Burns
- TBSA fluid guide
- IPV
- Screen privately
- Child abuse
- Pattern mismatch
- Trafficking
- Control red flags
Burn Fluid vs Shock Blood
Burn fluid
- LR resuscitation
- TBSA driven
- Urine titrated
Shock blood
- Balanced products
- Hemorrhage driven
- MTP titrated
Capillary leak vs hemorrhage
Burns
- Thermal
- Stop burning
- Chemical
- Brush then irrigate
- Electrical
- Deep tissue injury
- Inhalation
- Early airway concern
- Parkland
- 4 mL/kg/%
- First half
- 8 hours from burn
- Adult urine
- 0.5 mL/kg/hr
- Escharotomy
- Restore perfusion
ABCDE
Fix killers before finding everything.
AirwayBreathingCirculationDisabilityExposure
Intrafacility vs Interfacility
Intrafacility
- Within hospital
- Department handoff
- Same organization
Interfacility
- Another hospital
- EMTALA applies
- Transport planning
Inside vs outside
Primary Survey Picker
- Airway threatened→Protect airway(C-spine)
- Breathing impaired→Ventilate oxygenate
- Tension suspected→Decompress chest
- External bleeding→Direct pressure
- Shock present→Blood products
- Neuro change→GCS pupils
Assessment
- MOI
- Predict injury pattern
- Primary survey
- ABCDE threats
- Secondary survey
- Head-to-toe exam
- Tertiary exam
- Find missed injuries
- GCS
- Neuro trend
- POCUS
- Bedside imaging
- FAST
- Free fluid screen
- Pain
- Assess and treat
Trauma Diamond
Cold, acid, coagulopathic, hypocalcemic.
HypothermiaAcidosisCoagulopathyHypocalcemia
Shock Picker
- Cold tachy hypotension→Hemorrhagic shock
- Warm brady hypotension→Neurogenic shock
- JVD tracheal shift→Tension pneumo
- JVD muffled tones→Tamponade
- Fever vasodilation→Septic shock
- Pump failure→Cardiogenic shock
Resuscitation
- MTP
- Balanced blood products
- TXA
- Within 3 hours
- TEG/ROTEM
- Goal-directed coagulation
- Hypocalcemia
- Citrate complication
- Permissive BP
- Bleeding control bridge
- Damage control
- Stop bleeding first
- Diamond death
- Cold acid coagulopathic
- Warming
- Prevent coagulopathy
Bleeding Picker
- Major hemorrhage→Activate MTP
- Compressible extremity→Tourniquet
- Pelvic instability→Pelvic binder
- Positive FAST→Surgical team
- Early trauma bleed→TXA
- Coagulopathy unclear→TEG/ROTEM
Shock
- Hypovolemic
- Volume loss
- Obstructive
- Flow blocked
- Neurogenic
- Sympathetic loss
- Septic
- Distributive infection
- Cardiogenic
- Pump failure
- Lactate
- Perfusion marker
- Base deficit
- Shock burden
- Urine output
- Perfusion endpoint
SBAR
Situation before background before ask.
SituationBackgroundAssessmentRecommendation
Undertriage vs Overtriage
Undertriage
- Too low level
- Missed resources
- Higher risk
Overtriage
- Too high level
- Resource strain
- Safer bias
Risk miss vs resource use
Exam Blueprint
- Head/neck
- 31 scored items
- Trunk/pelvis
- 38 scored items
- MSK/wound
- 13 scored items
- Special
- 22 scored items
- Continuum
- 36 scored items
- Professional
- 10 scored items
Professional Systems
- MCI
- Greatest good
- Decontamination
- Protect team
- Registry
- Trauma data
- TQIP
- Risk-adjusted benchmarking
- PI
- Close care loops
- SBAR
- Structured handoff
- EMTALA
- Stabilize or transfer
- HIPAA
- Privacy standard
Common Traps
Pelvic Binder
Greater trochanters ≠ Not iliac crests
Burn Clock
From injury time ≠ Not arrival time
TXA Window
Within 3 hours ≠ Not late hemorrhage
Pediatric Shock
Late hypotension ≠ Not early sign
Open Pneumothorax
Vented occlusive seal ≠ Not fully sealed
Globe Injury
Rigid shield ≠ Not pressure patch
Urethral Injury
RUG before catheter ≠ Not forced Foley
Hypothermia
Coagulation failure ≠ Not comfort issue
Last Minute
- 1.150 scored, 96 pass
- 2.Largest domain: trunk pelvis
- 3.ABCDE before diagnostics
- 4.GCS trend beats snapshot
- 5.CPP equals MAP minus ICP
- 6.Binder on greater trochanters
- 7.TXA within 3 hours
- 8.Parkland starts at burn
- 9.Pediatric hypotension is late
- 10.Pregnancy: displace uterus left
- 11.Tertiary exam finds misses
- 12.TQIP uses risk-adjusted benchmarking
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