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.
Cervical spine, chest and pelvic x-rays may be performed as part of the early assessment of a major trauma patient, where available and the patient condition allows.
Assess the patient’s level of consciousness
A baseline GCS should be taken to accurately assess the patient’s neurological status. It is the universally accepted gold standard for assessing disturbances in a patient’s conscious state in the adult population. The best eye opening, verbal and motor response is taken and given a score out of 15. Limb response to commands or painful stimulation is used to detect asymmetry between the right and left sides. Differing levels of GCS determine the severity of the TBI, as mentioned earlier. Note whether the patient is agitated or combative.
Assess the pupils
Pupils should be examined for their response to light and their symmetry. Note if the reaction is brisk, sluggish or unreactive. A difference of greater than 1 mm is considered abnormal.
Document the findings on the observation chart and reassess frequently.
|Best response||Eye opening||Verbal response||Motor response|
|1||Does not open eyes||Makes no sounds||Makes no movements|
|2||Opens eyes in response to painful stimuli||Incomprehensible sounds||Extension to painful stimuli (decerebrate response)|
|3||Opens eyes in response to voice||Utters inappropriate words||Abnormal flexion to painful stimuli (decorticate response)|
|4||Opens eyes spontaneously||Confused, disoriented||Flexion or withdrawal to painful stimuli|
|5||N/A||Oriented, converses normally||Localises painful stimuli|
Adult Neurological Observations Chart
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. A detailed neurological examination forms an important part of the secondary survey and can assist with guiding management and assessing the need for transfer.
Inspect the neck. Ensure another colleague maintains manual in-line stabilisation while the hard collar is removed and throughout the examination. Cervical fractures are an increased risk in patients with a head injury. Replace the cervical collar after examination of the neck.
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 examination. This can be combined with the back examination.
Inspect the abdomen. Palpate for areas of tenderness, especially over the liver, spleen, kidneys and bladder. Look for any bruising, lacerations or penetrating injuries.
Check the pelvis. Gently palpate for any tenderness. Do not spring the pelvis. Any additional manipulation may exacerbate haemorrhage.13 Apply a binder if a pelvic fracture is suspected.
Auscultate bowel sounds.
Inspect the perineum and external genitalia.
Note any inequalities with limb response to stimulation and document these findings.
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.
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 rectal examination should be performed only if a spinal injury is suspected. Note any loss of tone.