The Secondary Survey
- ABCDE completed
- resuscitation / definitive treatment of emergency issues
- vital functions normalising.
- Head to toe evaluation
- Complete history and physical
- Reassessment of vitals
- Complete neuro including GCS
- Indicated XRs
- Special / lab procedures.
Obtain from wherever possible.
Consider event, mechanism and implications.
Past Hx / Pregnancy
Events / Environment of trauma
Eg seat belt use, steering wheel deformation, impact, damage,
Frontal impact --> Neck,
chest and upper abdo injuries, posterior #dislocation of
Side impact --> Neck,
chest, diaphragm rupture, upper abdo on side of impact,, # pelvis.
Rear impact --> Neck.
Ejection --> Great risk
virtually anything / everything.
Hit pedestrian --> Head
injury, aortic disruption, abdo viscera, # legs / pelvis.
Type, region affected, velocity, proximity.
May be coupled with other injury.
Inhalation / CO poising.
Environment - open/closed, substances consumed.
Hypothermia / wet clothes.
Drugs / ETOH causing vasodilation.
Exposure to chemicals, toxins, radiation.
- hazard to both the pt and doctors.
Entire scalp and head
- inspect / palpate for #s, lacs, contusions, burns.
- eyes and nose for CSF leakage
Reassess GCS and pupils
Eyes (swelling may make it
- acuity, haemorrhage, penetrating injury, contact lenses (remove),
lens dislocation, ocular entrapment.
- #s may be initially difficult to identify so reevaluate.
- midface #s raise suspicion of cribriform plate # (use oral route
- bleeding, CSF, lacerations, foreign bodies / teeth.
Inspect, palpate and auscultate.
- tenderness of c-spine
- subcutaneous emphysema, tracheal deviation, accessory muscle use,
Carotids may lose pulse or develop a bruit.
- occlusion of dissection may occur late, angiography or USS may be
needed if suspected.
- traction injury from neck/shoulder may cause intimal disruption,
Do not explore wounds through the platysma.
Active bleeding, expanding haematoma, bruit or airway compromise
indicates rapid surgical consult.
Cervical nerve root injury.
Beware decubitus ulcers from
CTA if blunt cerebrovascular injury suspected
- look everywhere for penetrating injury.
- open pneumothorax, flail segments
- pain, dyspnoea, hypoxia should be noted.
- distended neck veins in tamponade or tension pneumothorax
- subcutaneous emphysema
- clavicle, ribs, sternum for contusions, haematomas (suspect occult
injury) or clear #s.
- hyper-resonance, shock and decreased breath sounds may be only
of tension pneumothorax.
- high anteriorly for pneumothorax
- low posteriorly for haemothorax
- distant heart sounds and narrow pulse pressure in cardiac
- haemo, pneumothorax.
- widened mediastinum in aortic disruption.
- needle decompression, tube thoracostomy, pericardiocentesis as
- attach chest tube to underwater seal drainage
- dress open chest wounds
- transfer to theatre if required
Children can have
intrathoracic damage without clear chest damage
Elderly can be compromised
minor chest injury.
Specific diagnosis not as important as recognising
need for surgery.
Close observation and frequent reevaluation is required.
- everywhere for signs of injury
- tenderness, guarding, rebound, gravid uterus.
- for peritonism.
- presence of bowel sounds
Lavage - if unexplained hypotension, neurological injury /
impaired sensorium and equivocal abdo findings, equivocal fast
- or CT if haemodynamically stable.
Pelvic / rib #s may hinder abdo examination.
Retroperitoneal organ damage is difficult to detect and must be
Contusion, haematoma, lacs, urethral bleeding.
Blood in bowel, prostate position, rectal wall integrity and
Blood in vault, lacerations.
- female urethral injury is uncommon (does happen in straddle injury
pelvic #) but difficult to detect.
Inspect for penetrating
/ lacerations / contusion / deformity.
Palpate for tenderness /
crepitations, test for movement & sensation.
- ligament / muscle-tendon injuries are often picked up later as are
hand/foot injuries (reassess)
Palpate all peripheral
- consider nerve damage, ischaemia and compartment syndrome in an
- suspected if ecchymosis over iliac wings, pubis, labia or scrotum,
pain on palpation, mobility.
--> greet these with a sense of urgency, can be difficult to
- Do not manipulate the
pelvis; leave that to orthopods if they want.
--> may provoke dangerous bleeding.
- just get the XR.
Pelvic binder centered over trochanters
Thoracic and lumbar
Palpate entire spine, assessing for deformity, swelling, crepitus,
Identify lacs, gaps between spinous processes, haematomas or
pupil size & response and GCS.
- consult a neurosurgeon early.
- monitor for deterioration: signifies ongoing intracranial injury.
- reassess ABCDEs first.
Consider pain, paralysis and
paraesthesia as markers of spinal injury.
Motor and sensory
- and deep tendon reflexes
- Many diagnostic/therapeutic interventions increase ICP, which can
reduce cerebral perfusion further in the head-injured patient.
- Any evidence of neuro deficit due to spinal column damage demands entire patient
immobilisation; and early consultation with orthopedic /
XRs - spine and extremities.
CT head, chest, abdo, spine.
TOE, bronchoscopy, esophagoscopy.
As one problem is managed another may become apparent.
Underlying medical problems may become clear.
Vitals / urinary output monitoring is required.
- 0.5ml/kg/hr is desirable.
ABG, cardiac monitoring, pulse oximetry and end-tidal CO2 (if
intubated) should be considered.
Relieve severe pain in small doses that do not cause respiratory
depression or mask injury.
There are criteria for this.
- physiologic, injury, mechanisms, concurrent disease and prognostic
factors are considered.
Move to closest appropriate local facility.
Meticulous record keeping with
is very important.
- flowsheets can help.
Consent is sought if possible but treat first if life-threats exist.
Preserve any forensic evidence such as clothing and bullets and
of blood alcohol.