Secondary survey

After the primary survey is completed and life threats addressed, a systematic secondary survey should be undertaken. This is a complete examination of the patient from top to toe, both front and back. All findings are documented, usually on a standard trauma form.

 

Head and face

Scalp

  • Examine and palpate entire scalp for lacerations, abrasions or depressions
  • Look for signs of base of skull fracture – haemotympanum, posterior auricular or periorbital bruising, CSF leak from nose or ears

Eyes

  • Perform visual acuity if alert and cooperative
  • Check pupil size and reactivity, eye movements
  • Examine for: hyphaema, penetrating injury, subconjunctival haemorrhage, contact lenses, foreign bodies
    • note – patient may need formal slit lamp examination performed when mobile later on

Nose

  • examine for deformities, epistaxis, septal haematomas

Mouth

  • examine teeth, look for lacerations of lips, cheeks, palate, gums

Facial bones

  • palpate for bony tenderness (orbits, zygoma, jaw), check mouth opening
  • if infraorbital fracture suspected, check again for eye movements and infraorbital nerve sensation

Cranial nerve exam

  • eye exam as above
  • assess facial sensation and power, and other cranial nerves as indicated
    • Horner’s syndrome (miosis, ptosis, anhydrosis) can indicate a vertebral or carotid artery injury

 

Pitfalls

  • Posterior scalp lacs or compound fractures not appreciated as patient supine
  • Ocular injuries
  • Changes in pupil reactivity since primary survey
  • If teeth are missing – consider that they may have been aspirated

 

Neck

 If cervical spine collar in place, will need to open collar and have inline stabilisation applied

Cervical spine

  • Palpate for midline cervical spine tenderness or deformity

Trachea

  • confirm is midline

Neck

  • examine for abrasions/contusions, lacerations, palpate for subcutaneous emphysema (from pneumothorax, tracheal laceration)

Larynx

  • gently palpate checking for crepitus or pain, assess voice if talking

Veins

Arteries

Oesophagus

  • ask patient to swallow – is this painful?

 

Pitfalls

  • Not removing collar and missing hidden injuries
  • Blunt neck vascular injuries can present with subtle findings. A high index of suspicion should be maintained if there is an appropriate mechanism

 

Chest

 Look

  • examine chest for wall movement, abrasions/contusions, lacerations

Palpate

  • assess for tenderness/crepitus over ribs/sternum, subcutaneous emphysema

Auscultate

  • breath sounds bilaterally, heart sounds

 

Pitfalls

  • Rib and sternal fractures might not be seen on CXR and can be missed
  • Don’t forget to examine the axilla

 

Abdomen

 Look

  • examine abdomen for contusions/abrasions, lacerations

Palpate

  • for tenderness especially over solid organs (liver, kidneys, spleen)

Auscultate

  • bowel sounds

 

Pitfalls

  • The abdomen that is not assessable (eg: patients with altered GCS or intubated patients) with an appropriate mechanism needs further investigations (CT)

 

Pelvis

Do not “spring” pelvis – this can cause more damage

  • Gently palpate pelvis for areas of pain
  • Inspect groin, perineum and genitals
  • Vaginal examination may be indicated in women with significant pelvis injuries or new vaginal bleeding since the onset of trauma

 

Pitfalls

  • The groin and perineum can hide significant injuries and need to be examined

 

Log roll

Perform logroll (with spinal precautions if indicated)

5 people required – 1 for head/neck, 3 for the body, 1 to examine patient

Look

  • at back for abrasions/contusions, lacerations
  • between buttocks for penetrating injury

Palpate

  • down spine for tenderness, deformity, crepitations

Rectal examination

  • is only indicated if there is a suspicion of significant spinal injury, perineal injuries or if there is a penetrating injury that might traverse the rectum. A “high riding prostate” is an unreliable sign of significant urethral injury.

 

Limbs

Look

  • examine limbs systematically checking for contusions/abrasions/lacerations.

Palpate

  • all bones/soft tissues for pain and assess joints for pain and stability, assess tendon function if indicated

Vascular

  • Assess capillary refill, warmth, and all pulses

Limb neurology

  • Assess sensation, motor function and reflexes

 

Pitfalls

  • Missing a limb/hand/foot injury in a multitrauma patient can lead to significant morbidity and loss of function when the life threats have been treated

 

ADJUNCTS TO PRIMARY SURVEY

 

Radiology

As indicated by the mechanism of injury and injury patterns

Many severely injured patients will undergo a screening “pan scan” – CT head, neck, chest, abdo, pelvis

 

Plain radiology

  • CXR and PXR as indicated
  • Limb and joint injuries
  • Can consider screening cervical, thoracolumbar films – though many major trauma patients will have CT imaging of these areas
  • Cysto-urethrogram if suspected urethral injury

Note: there is little/no role for plain abdominal xrays in trauma

 

CT (as indicated)

  • Non-contrast head
  • Non-contrast cervical spine
  • CTA neck vessels (blunt and penetrating neck trauma)
  • CT chest with contrast (will also examine thoracic spine)
  • CT aorta
  • CT abdomen and pelvis with contrast (will also examine thoraco/lumbar spine)
    • Multiphase protocols may be required to further define solid organ injury
  • CTA of peripheral vascular injuries

 

Angiography

Treatment of bleeding from pelvis, spleen, kidneys etc….

 

MRI

Further define spinal cord injuries

 

Ultrasound

Bedside ultrasound (eFAST)

Note: there is limited role for ultrasound in defining solid organ injuries. These are best assessed by CT

 

Additional imaging/investigations

Echocardiography

Oesophagoscopy

Bronchoscopy for suspect tracheo-bronchial injuries

 

 

Supportive care

  • Analgesia
    • Titrated morphine or fentanyl
    • Consider adding small doses of ketamine if the patient has ongoing severe pain despite opiates
  • Antiemetic
  • Prophylactic antibiotics if indicated
    • Cephazolin 1g IV, can add gentamicin for heavily contaminated wounds
  • Update tetanus immunisation if required
  • Reduce fractures or dislocations, splint injured limbs
  • Explore and repair lacerations
  • IDC if indicated
    • Note: IDC is contraindicated if there is suspicion of a urethral injury – blood at the meatus, perineal bruising, high riding prostate on PR exam, anterior pelvis fractures
  • NG tube if intubated
    • Note: an NG tube is contraindicated in patients with facial or suspect base of skull fractures (place orogastric tube instead)

Related Guidelines

NEXT SECTION >>

Life Threats – Guideline: Open Pneumothorax

About this guideline

First published: February 2018 (Author: Emma Batistich)
Updated April 2021 (Jonathan McMillan )
Approved by: Northern Region Trauma Network, ADHB, WDHB, CMDHB, NDHB, NRHL, St John
Review due: 2 years