Secondary Survey


The secondary survey is only to be commenced once the primary survey has been completed and any life-threatening injuries have been treated. If during the examination any deterioration is detected, go back and reassess the primary survey.

History

Taking an adequate history from the patient, family members, bystanders or emergency personnel of the preceding events can assist with predicting possible injuries.
Elderly patients may require a longer period of time to divulge all elements of the history - be patient, listen and engage. It is also important to involve family members as well as the General Practitioner and the patient's local pharmacist in determining an accurate and comprehensive history. Note any history of drugs or alcohol prior to and at the time of injury.
Use the AMPLE acronym to assist with gathering pertinent information:
Allergies
Medication (especially anticoagulants, antiplatelet agents, cardiac medications etc.)
Past medical history (include any recent falls as well as normal functional status)
Last meal
Events leading to injury12

Medications

Elderly patients are likely to be on a number of medications prior to the traumatic event. Studies have shown that patients taking a combination of Beta blockers, calcium channel blockers and an angiotensin converting enzyme inhibitor or angiotensin receptor binding agent show blunted haemodynamic responses to trauma. Sedatives and antihypertensive medications can increase the chance of trauma, particularly falls. Oral anticoagulants are prescribed for a number of conditions and their use places those at greater risk of dying particularly from head or abdominal injuries.  A reduction in mortality of those with intracranial haemorrhage is seen when the International Normalised Ratio (INR) is rapidly reversed.

Limitation of treatment orders

It is vital to consider the patients requests with relation to resuscitation as well as the possible futility of efforts. The risk of mortality is increased in elderly patients who are hypotensive, aged greater than 74 years with a higher injury severity score. Early consultation with the patient and/or next of kin is essential to understand the patients’ wishes.

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Head-to-toe examination

During this examination, any injuries detected should be accurately documented and any required treatment should occur, such as covering wounds, managing non-life-threatening bleeding and splinting fractures.

Head and face

  • Inspect the scalp. Look for any bleeding or lacerations. Do not probe the scalp and be cautious when examining as bone fragments and fractures may be present. Gently palpate for any depressions or irregularities in the skull. If a penetrating object remains lodged, do not remove it.
Lacerations can bleed profusely; control bleeding with direct pressure and bandaging. If this is not controlling the bleeding, consider temporary closure with staples or suturing. The wound will need to be thoroughly irrigated at a later stage.
  • Inspect the face. Look for any lacerations or bruising. Periorbital bruising and/or mastoid bruising is indicative of a base of skull fracture; however, mastoid bruising will only occur 12–24 hours post injury.  13
  • Look in the eyes for any foreign body, subconjunctival haemorrhage with no posterior limit, hyphema, irregular iris, penetrating injury or contact lenses.
  • Assess the ears for any bleeding or blood behind the tympanic membrane, as well as any cerebrospinal fluid (CSF) leak.
Check the nose for any deformities, bleeding, nasal septal haematoma or CSF leak. If a CSF leak is present, do not pack the nose; apply a bolster. To determine whether any clear fluid is CSF, the easiest method is to sample the fluid onto filter paper: if there is a formation of two rings (the ‘halo’ sign) this indicates the presence of CSF. Glucose should also be detected in the fluid, helping to differentiate it from mucus.
  • Look in the mouth for any lacerations to the gums, lips, tongue or palate.
  • Inspect the teeth, noting if any are loose, missing or fractured.
  • Test eye movements, vision and hearing.
  • Palpate the bony margins of the orbit, maxilla, nose and jaw.
  • Inspect the jaw for any pain or trismus.

Neck

  • Inspect the neck. Ensure another colleague maintains manual in-line stabilisation while the hard collar is removed and throughout the examination.
  • Gently palpate the cervical vertebrae. Note any cervical spine pain, tenderness or deformity.
  • Check the soft tissues for bruising, pain and tenderness.
  • Complete the examination of the neck by observing the neck veins for distension and by palpating the trachea and the carotid pulse; note any tracheal deviation or crepitus
The patient will need to be log rolled to complete the full examination. This can be combined with the back examination. Elderly patients are at higher risk of pressure ulcers as a result of immobilisation in hard collars and may have difficulty tolerating lying flat. Those with severe degenerative neck problems (kyphosis or lordosis) may not tolerate standard rigid collars due to their postural alignment and should be held in the most comfortable position with soft padding and tape. 10
If able, replace hard collar with a correctly fitted, longer term, padded cervical collar, e.g. Philadelphia collar.

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Chest

  • Inspect the chest, observing movements. Look for any bruising, lacerations, penetrating injury or tenderness.
Blunt thoracic trauma carries a significant risk of complications and mortality, even with isolated rib fractures due to pneumonia and pulmonary contusions.
  • Palpate for clavicle or rib tenderness. Even isolated rib fractures in the elderly population carries a significant risk of complications and mortality.
  • Auscultate the lung fields; note any percussion, lack of breath sounds, wheezing or crepitation’s.
  • Check the heart sounds: apex beat and the presence and quality of heart sounds.

Abdomen

  • Inspect the abdomen. Palpate for areas of tenderness, especially over the liver, spleen, kidneys and bladder. Look for any bruising, lacerations or penetrating injuries.
The abdominal examination may be unreliable due to decreased perception of pain and cognitive decline.
  • Check the pelvis. Gently palpate for any tenderness. Do not spring the pelvis. Any additional manipulation may exacerbate haemorrhage.14
Pelvic fractures are less common but carry a high mortality with an increased risk of haemorrhage. Apply a binder if a pelvic fracture is suspected.
  • Auscultate bowel sounds.
  • Inspect the perineum and external genitalia.

Limbs

Musculoskeletal injuries are very common in the elderly population, with forearm fractures being the most common, followed by hip fractures.1
Older person patients have a high mortality following a hip fracture and it is essential that these patients receive timely care with early surgical repair.
  • Note any inequalities with limb response to stimulation and observe any shortening / rotation of lower limbs which may indicate a fracture to the hip.
  • Inspect all the limbs and joints; palpate for bony and soft-tissue tenderness and check joint movements, stability and muscular power. Note any bruising, lacerations, muscle, and nerve or tendon damage. Look for any deformities, penetrating injuries or open fractures.
  • Examine sensory and motor function of any nerve roots or peripheral nerves that may have been injured.

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Back

  • Log roll the patient. Maintain in-line stabilisation throughout. Inspect the entire length of the back and buttocks noting any bruising and lacerations.
  • Palpate the spine for any tenderness or steps between the vertebrae.
  • Digital examination should be performed only if a spinal injury is suspected. Note any loss of tone.

Buttocks and perineum

  • Look for any soft-tissue injuries such as bruising or lacerations.

Genitalia

  • Inspect for soft tissue injuries such as bruising or lacerations. Check the urethra for any bleeding.
The priorities for further investigation and treatment may now be considered and a plan for definitive care can be established in conjunction with Adult Retrieval Victoria (ARV).

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