Secondary Survey

The Secondary Survey
History
Physical Exam
Adjuncts
Reevaluation
Definitive Care
Record Keeping

The Secondary Survey

Begins once:
- ABCDE completed
- resuscitation / definitive treatment of emergency issues established
- vital functions normalising.

Consists of:
- Head to toe evaluation
- Complete history and physical
- Reassessment of vitals
- Complete neuro including GCS
- Indicated XRs
- Special / lab procedures.


History
Obtain from wherever possible.
Consider event, mechanism and implications.

Allergies
Medications
Past Hx / Pregnancy
Last meal
Events / Environment of trauma

Blunt trauma
Eg seat belt use, steering wheel deformation, impact, damage, ejection.
Frontal impact --> Neck, chest and upper abdo injuries, posterior #dislocation of hip&knee.
Side impact --> Neck, chest, diaphragm rupture, upper abdo on side of impact,, # pelvis.
Rear impact --> Neck.
Ejection --> Great risk of virtually anything / everything.
Hit pedestrian --> Head injury, aortic disruption, abdo viscera, # legs / pelvis.

Penetrating trauma
Type, region affected, velocity, proximity.

Burns / Cold
May be coupled with other injury.
Inhalation / CO poising.
Environment - open/closed, substances consumed.
Hypothermia / wet clothes.
Drugs / ETOH causing vasodilation.

Hazardous environments
Exposure to chemicals, toxins, radiation.
- hazard to both the pt and doctors.


Physical Exam

Head
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 difficult later).
- acuity, haemorrhage, penetrating injury, contact lenses (remove), lens dislocation, ocular entrapment.
Maxillofacial
- #s may be initially difficult to identify so reevaluate.
- midface #s raise suspicion of cribriform plate # (use oral route for tubes).
Mouth
- bleeding, CSF, lacerations, foreign bodies / teeth.

Neck
Inspect, palpate and auscultate.
- tenderness of c-spine
- subcutaneous emphysema, tracheal deviation, accessory muscle use, laryngeal #s.
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, dissection, thrombosis.
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 prolonged immobilisation.
CTA if blunt cerebrovascular injury suspected

Chest
Inspect
- look everywhere for penetrating injury.
- open pneumothorax, flail segments
- pain, dyspnoea, hypoxia should be noted.
- distended neck veins in tamponade or tension pneumothorax (decrease in hypovolaemia)
Palpate
- subcutaneous emphysema
- clavicle, ribs, sternum for contusions, haematomas (suspect occult injury) or clear #s.
Percuss
- hyper-resonance, shock and decreased breath sounds may be only signs of tension pneumothorax.
Auscultate
- high anteriorly for pneumothorax
- low posteriorly for haemothorax
- distant heart sounds and narrow pulse pressure in cardiac tamponade.
CXR
- haemo, pneumothorax.
- widened mediastinum in aortic disruption.
Manage
- needle decompression, tube thoracostomy, pericardiocentesis as indicated
- attach chest tube to underwater seal drainage
- dress open chest wounds
- transfer to theatre if required
Note
Children can have significant intrathoracic damage without clear chest damage
Elderly can be compromised from minor chest injury.

Abdo
Specific diagnosis not as important as recognising need for surgery.
Close observation and frequent reevaluation is required.
Inspect
- everywhere for signs of injury
Palpate
- tenderness, guarding, rebound, gravid uterus.
Percuss
- for peritonism.
Auscultate
- presence of bowel sounds
Investigations
FAST
Lavage - if unexplained hypotension, neurological injury / impaired sensorium and equivocal abdo findings, equivocal fast
- or CT if haemodynamically stable.
Note
Pelvic / rib #s may hinder abdo examination.
Retroperitoneal organ damage is difficult to detect and must be suspected.

Perineum/rectum/vagina
Perineum
Contusion, haematoma, lacs, urethral bleeding.
Rectum
Blood in bowel, prostate position, rectal wall integrity and sphincter tone.
Vaginal (essential)
Blood in vault, lacerations.
- female urethral injury is uncommon (does happen in straddle injury / pelvic #) but difficult to detect.

Musculoskeletal
Inspect for penetrating injury / 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 pulses.
- consider nerve damage, ischaemia and compartment syndrome in an impaired limb.
Pelvic #:
- 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 control.
- 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 spine

Palpate entire spine, assessing for deformity, swelling, crepitus, tenderness, contusions/lacs.
Identify lacs, gaps between spinous processes, haematomas or posterior pelvic defects.

Neurology
Reevaluate consciousness, 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 evaluation in extremities
- and deep tendon reflexes
Note:
- 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 / neurosurgeon.


Adjuncts
When stable.

As indicated:
XRs - spine and extremities.
CT head, chest, abdo, spine.
Contrast urography
Angiography
TOE, bronchoscopy, esophagoscopy.


Reevaluation

Reevaluate constantly.
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.


Definitive Care

There are criteria for this.
- physiologic, injury, mechanisms, concurrent disease and prognostic factors are considered.
Move to closest appropriate local facility.


Record Keeping

Meticulous record keeping with times 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 think of blood alcohol.