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, bystanders or emergency personnel of the events surrounding the injury can assist with understanding the extent of the injury, the likelihood of inhalation burns and any possible other injuries.
Use the AMPLE acronym8 to assist with gathering pertinent information:
Allergies
Medication
Past medical history (including tetanus status)
Last meal
Events leading to injury
Note what first aid has already been given to the patient.
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.Measuring burns
Assessing burn depth and calculating the percentage of the total body surface area burnt is important during the head-to-toe examination. This will allow fluid resuscitation requirements to be calculated and the severity of the injury to be determined to assess if transfer to a specialist facility is required.
The extent of the burn is measured as the percentage of TBSA. It is important to accurately document the location and area of the burn. The recommended tool for assisting in calculating this in adults is the Wallace rule of nines chart. While examining the patient it is helpful to have another staff member documenting the location and extent of the injuries as they are called out by the assessing clinician.
CLICK ON IMAGE TO ENLARGE
Used with permission from: Victorian Burns Unit
CLICK ON IMAGE TO ENLARGE
Used with permission from: Victorian Burns Unit
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.
Measuring burns
Assessing burn depth and calculating the percentage of the total body surface area burnt is important during the head-to-toe examination. This will allow fluid resuscitation requirements to be calculated and the severity of the injury to be determined to assess if transfer to a specialist facility is required.
The extent of the burn is measured as the percentage of TBSA. It is important to accurately document the location and area of the burn. The recommended tool for assisting in calculating this in adults is the Wallace rule of nines chart. While examining the patient it is helpful to have another staff member documenting the location and extent of the injuries as they are called out by the assessing clinician.
Head and face
Inspect the face and scalp. Look for any lacerations and bruising as well as mastoid or periorbital bruising, which is indicative of a base of skull fracture. Gently palpate for any depressions or irregularities in the skull. Check the eyelashes and eyebrows for singeing.
Look in the eyes for any burn injury, foreign body, subconjunctival haemorrhage, hyphaema, irregular iris, penetrating injury or contact lenses.
Assess the ears for any signs of cerebrospinal fluid leak, bleeding or blood behind the tympanic membrane.
Check the nose for any deformities, bleeding, nasal septal haematoma, cerebrospinal fluid leak or presence of any soot/ash as well as singeing of nasal hairs.
Look in the mouth for any lacerations to the gums, lips, tongue or palate. Note any swelling, which may indicate inhalation injury. Inspect the teeth, noting if any are loose, fractured or missing.
Test eye movements, pupillary reflexes, vision and hearing.
Palpate the bony margins of the orbit, maxilla, nose and jaw.
Inspect the jaw for any pain or trismus.
Neck
The cervical collar should be opened, the head supported with manual in-line stabilisation and the neck inspected.
Gently palpate the cervical vertebrae. Note any cervical spine pain, tenderness or deformity.
Check the soft tissues for bruising, pain and tenderness.
Complete the neck examination by observing the neck veins for distension and 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.
Chest
The chest should be palpated for rib tenderness and subcutaneous emphysema. The entire thorax must be palpated including the supraclavicular fossae, right and left ribs and both axillae. A hand can be slid posteriorly along a supine patient to check for occult blood loss; however, a formal examination of the back of the chest occurs when the patient is log rolled.
Palpate for clavicle or rib tenderness.
Auscultate the lung fields; note any percussion, altered/reduced breath sounds, wheezing or crepitations.
Check the heart sounds: apex beat and 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.
Check the pelvis. Perform a pelvic x-ray if there is any suspicion of injury. Gently palpate for any tenderness. Do not spring the pelvis..9 Any additional manipulation may exacerbate haemorrhage. Apply a binder if a pelvic fracture is suspected.
Auscultate bowel sounds.
Inspect the perineum and external genitalia.
Limbs
Image used with permission from the Alfred Hospital
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 or muscle, nerve or tendon damage. Look for any deformities, penetrating injuries or open fractures.
In electrical burns, look for any entry and exit wounds as well as signs indicating the development of compartment syndrome. These may be found centrally, not just on the limbs (check the head and chest).
Examine the sensory and motor function of any nerve roots or peripheral nerves that may have been injured.
Assess for circumferential burns that may constrict blood flow to all limbs or digits. Assess colour, warmth, movement, sensation and capillary refill distally.
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. Include a cervical examination at this stage.
Digital rectal examination should be performed in a trauma patient only if a spinal injury is suspected. This is unlikely following isolated burn injury unless there is concomitant multitrauma spinal injuries. Note any loss of tone or sensation.
Buttocks and perineum
Look for any soft-tissue injury such as bruising or lacerations.
Genitalia
Inspect for soft-tissue injury such as bruising, lacerations or burns. Note any priapism that may indicate spinal injury.
The priorities for further investigation and treatment may now be considered and a plan for definitive care established.