The secondary survey is performed once the patient has been resuscitated and stabilised. It involves a more thorough head-to-toe examination, and the aim is to detect other significant but not immediately life-threatening injuries that were not detected or managed during the initial assessment and resuscitation.
Taking an adequate history from the patient, bystanders or emergency personnel of the events surrounding the injury can assist with understanding the extent of the injury and any possible other injuries. Use the AMPLE acronym to assist with gathering pertinent information:
Allergies Medication Past medical history including tetanus status Last meal Events leading to injury
During the secondary survey, the abdomen is systematically examined in greater detail. Any injuries detected should be accurately documented and any required treatment should occur, such as covering wounds, managing non-life-threatening bleeding and splinting of fractures.
Look for any obvious signs of injury, in particular any abrasions and/or ecchymosis.
Seat belt bruising indicates a large force has been applied to the abdomen and is associated with rupture of hollow viscus and an increased incidence of other intra-abdominal injury. Signs of hollow viscus injury are often delayed, serial abdominal examinations may be warranted.
Any obvious penetrating injury should have been identified in the primary survey, however further inspection should be undertaken in order to conclusively exclude this as a concern.
Note the contour of the abdomen, is it flat or distended? Abdominal distention is likely due to either air or blood, with the abdomen holding up to 1.5 litres of fluid before showing any signs of distention.4
Bruising and swelling to the flank may raise suspicion for retroperitoneal injury while Cullen’s sign (periumbilical ecchymosis) may indicate retroperitoneal haemorrhage; however this usually takes hours to develop.
Palpation of the injured abdomen should be commenced in an area where the patient is not complaining of pain.
Note if there is any guarding of the abdomen, both voluntary and involuntary, as well as any rebound tenderness.
Fullness to the abdomen may indicate haemorrhage, crepitation of the lower rib cage may be associated with underlying hepatic or splenic injury.
Significant abdominal tenderness on palpation and involuntary guarding are signs of peritonitis and are suggestive of leakage of intestinal contents but may take several hours to develop.
Slight movement of the peritoneum occurs on percussion and may show signs of peritoneal irritation.
Can be used to note the presence or absence of bowel sounds. An ileus (cessation of peristalsis) causes a quiet abdomen due to haemorrhage or spillage of intestinal contents. This finding is more significant when there has been a change from initial assessment.
Inspect the face and scalp. Look for any lacerations and bruising. Gently palpate for any depressions or irregularities in the skull and jaw. Test pupillary reflexes.
If a cervical collar is insitu it should be opened, the head supported with manual in-line stabilisation and the neck inspected. If there is no collar, consider the mechanism of injury and whether a cervical injury could be likely. Gently palpate the cervical vertebrae. Note any cervical spine pain, tenderness or deformity. Check the soft tissues for bruising, lacerations, emphysema, pain and tenderness. Note also the following • Veins: look for distension – neck vein distension may be seen in tension pneumothorax or pericardial tamponade. • Oesophagus: ask the patient to swallow – an oesophageal injury may be suspected if the patient has pain or difficulty swallowing. Re-apply the cervical collar carefully after examining the neck – the cervical spine will generally be cleared after transfer to a major trauma service and specialist assessment.
The chest should be palpated for any tenderness and deformities. Auscultate the lung fields; note any percussion abnormality, lack of breath sounds, wheezing or crepitation. If bowel sounds are heard over the thorax during auscultation there may be diaphragmatic rupture Check the heart sounds: apex beat and presence and quality of heart sounds.
Inspect all the limbs and joints, palpate for bony and soft-tissue tenderness. Note any bruising, lacerations, muscle, and nerve or tendon damage. Look for any deformities, penetrating injuries or open fractures. Assess distal colour, warmth, movement, sensation and capillary refill.
Log roll the patient. Maintain in-line stabilisation throughout. Inspect the entire length of the back noting any deformity, bruising and lacerations. Palpate the spine for any tenderness or steps between the vertebrae. Include a cervical examination at this stage.
Look for any soft-tissue injury such as bruising or lacerations. Penetrating injuries to this area have a high correlation intra-abdominal injuries. Digital rectal examination may be performed if there is an injury suspected to look for gross blood indicating bowel perforation and to assess tone and position of the prostate.
Soft-tissue injuries such as bruising or lacerations should be noted. Inspect for any blood at the meatus which may indicate urethral injury. Lacerations to the vagina may occur due to bony fragments from pelvic injury.
The priorities for further investigation and treatment may now be considered and a plan for definitive care established.