Secondary survey

The secondary survey is performed if time permits once the patient has been resuscitated and stabilised. It involves a more thorough head-to-toe examination, and the aim is to detect any delayed injuries that were not detected or managed during the initial assessment and resuscitation. If during the examination or at any time a deterioration is detected, go back and reassess the primary survey using the ABCDE systematic approach. Consider further diagnostic imaging if available and indicated.

History

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 injury12

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 of fractures.

Head and face:

  • Face: examine & palpate for lacerations, depressions, swelling, bruising to mastoid / peri-orbital region
  • Ears: CSF, blood, blood behind tympanic membrane, hearing
  • Eyes: foreign body, Sub conjunctival haemorrhage, hyphaema, contact lenses, test eye movements / vision
  • Nose: Deformities, bleeding, nasal septal haematoma, CSF leak
  • Mouth: Lacerations, swelling, broken or loose teeth
  • Jaw: pain or trismus

Top of page

Neck:

Assume cervical spine injury until excluded, re-apply collar after examination. Examine:
  • Trachea (midline or deviated).
  • Upper airways- look for evidence of local trauma to the bruising, haematoma, crepitus, open wounds, subcutaneous emphysema.
  • Veins: distended / flattened.
  • Oesophagus: poorly localised chest pain, and almost always in association with major chest and/or abdominal trauma.

Chest:

  • Reassess: auscultate breath and heart sounds.
  • Palpate clavicle / ribs / apply gentle sternal compression.
  • Note any percussion abnormality, lack of breath sounds, wheezing or crepitations.

Back:

  • Log roll the patient while maintaining in-line stabilisation.
  • Inspect the entire length of the back noting any deformity, bruising and lacerations.
  • Palpate for any tenderness or steps, including the posterior ribs, and thoraco-lumbar spine.

Top of page

Abdomen:

  • Palpate for areas of tenderness including flank, note any guarding.
  • Look for any bruising, lacerations or penetrating injuries.
  • Check the pelvis - apply a binder if fracture suspected.
  • Auscultate bowel sounds.

Limbs:

  • Inspect all limbs for bruising, lacerations, deformities, wounds.
  • Palpate for bony and soft-tissue tenderness, check movements, stability and muscular power.
  • Assess distal colour, warmth, movement, sensation and capillary refill.
  • Complete sensory and motor function, especially in suspected spinal injury.