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

 

 

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

• examine for distension (sign of tension pneumothorax, massive haemothorax or cardiac tamponade)

Arteries

• auscultate for carotid bruits 

Oesophagus

• ask patient to swallow – is this painful?

 

 

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

 

 

Abdomen

 Look

• examine abdomen for contusions/abrasions, lacerations

Palpate

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

Auscultate

• bowel sounds

 

 

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

 

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

 

 

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)