Secondary Survey

The secondary survey:

• Aims to identify important, but not immediately treatable life-threatening injuries
• Only begins once primary survey is completed and resuscitation is underway
• Should include actively looking for and excluding the following injuries:
  • Tracheobronchial tree injury
  • Pneumothorax
  • Pulmonary contusions
  • Haemothorax
  • Blunt cardiac injury
  • Traumatic aortic injury
  • Oesophageal rupture
  • Traumatic diaphragmatic injury

Imaging will be required for exclusion.

Process

A thorough head-to-toe evaluation, including complete history, physical examination, and reassessment of vitals.

• Head
  • Scalp & Skull
    Lacerations and fractures.
  • Brief cranial nerve examination
  • Eye
    • Acuity
    • Mobility
      May be reduced with entrapment.
    • Pupil size
    • Penetrating injury
    • Contact lenses
    • Lens dislocation
  • Ear
    • Base of skull fracture
      • Blood
      • Haemotympanum
      • CSF otorrhoea
    • Membrane integrity
  • Midface
    • CSF rhinorrhoea
  • Mandible

Scalp lacerations may bleed extensively and are often under-appreciated.

• Neck
  • C-spine tenderness
  • SC emphysema
  • Tracheal deviation
  • Laryngeal fracture
  • Carotid palpation and auscultation
    • Overlying blunt injury may require angiography
    • Blunt carotid injuries may cause intimal tears and present late
  • Lacerations
  • Distension of neck veins
    • Tamponade/tension pneumothorax will ↑ right sided filling pressures and ↑ CVP
    • Hypovolaemia will reduce filling pressures

Laryngotracheal injury is an airway emergency, and covered under Laryngotracheal Trauma.

• Chest
  • Palpate ribs, clavicle, sternum
  • Auscultate anterior chest wall and bases
    
    
• Abdomen
  
  
• Pelvis
  • Bruising of iliac wings, scrotum/labia suggests pelvic fracture
  • Pelvic spring
  • Rectal examination
    • If mechanism suggests injury
    • If patient is unconscious
  • Vaginal examination
    • If mechanism suggests injury
    • Consider retained tampon
      
      
• Extremities
  • Tenderness
  • Abnormal movement
    The ability to move a joint through its full range of motion usually indicates that the muscle unit is intact and the joint is stable.
  • Distal pulses

Investigations

Laboratory:

• Blood
  • Alcohol

Imaging:

Unhelpful investigations include:

• C-spine XR
  Essentially deprecated by CT>
• Skull XR
• Abdominal XR
  May have a role in determining trajectory of high-velocity GSW.

• X-Ray
  • CXR
    • Pneumothorax
    • Haemothorax
    • Abdominal free gas
    • Mediastinal widening
  • Pelvis
    • Pelvic fracture
  • Long bones
    • Any identified abnormalities on secondary survey
• CT
  • Brain
    Early identification and triage of traumatic brain injuries.
  • C-spine
    Rapid identification or exclusion of cervical spine injuries.
  • Chest
    Diagnosis of aortic injury; other diagnoses adequately identified on XR.
  • Abdomen
    Source of intrabdominal bleeding in a patient stable enough to transfer to CT.

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References

1. Bersten, A. D., & Handy, J. M. (2018). Oh’s Intensive Care Manual. Elsevier Gezondheidszorg.