Secondary Survey

The secondary survey is only to be performed once the primary survey has been completed and any life-threatening injuries have been managed. If during the examination any deterioration is detected, reassess the primary survey from the beginning.

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 ⁽²⁰⁾.

Use the AMPLE acronym to assist with gathering pertinent information ^{(20, 21)}:

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.

A detailed neurological examination forms an important part of the secondary survey and can assist with guiding management and assessing the need for transfer.

Neurological assessment

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 potential severity of the TBI ⁽²²⁾. 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 non-reactive. A difference of greater than 1 mm is considered abnormal.
• Where appropriate, assess for raised intra-orbital pressure that may require urgent canthotomy.
• Document the findings on the observation chart and reassess frequently.

Head and face

• Inspect the face and scalp. Look for any lacerations or bruising, including mastoid or periorbital bruising which may be indicative of a base of skull fracture. Gently palpate for any depressions or irregularities in the skull.
• Look in the eyes for any foreign body, subconjunctival haemorrhage, hyphaema, irregular iris, penetrating injury or contact lenses.
• Assess the ears for any signs of CSF leak, bleeding, or blood behind the tympanic membrane.
• Check the nose for any deformities, bleeding, nasal septal haematoma, or cerebrospinal fluid leak.
• 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 – are any loose, fractured, or missing.
• Test vision, and hearing.
• Palpate the bony margins of the orbit, maxilla, nose, and jaw.
• Inspect the jaw for any pain or trismus.

Neck

To examine the neck the cervical collar should be opened, and the head supported with manual in-line stabilisation throughout the exam. Two staff members are normally required to conduct a neck examination safely.

• Gently palpate the cervical vertebrae. Note any cervical spine pain, tenderness, or deformity. Check the soft tissues for bruising, pain, and tenderness.

Note the following:

• Trachea (midline or deviated): The trachea may deviate away from the side of a tension pneumothorax.
• Wounds: blunt or penetrating injuries and their estimated size.
• Subcutaneous emphysema: The presence indicates an airway disruption such as a laryngeal fracture or pneumothorax.
• Larynx: Laryngeal tenderness or crepitus; this may indicate an underlying laryngeal fracture. Caution: firm palpation may disrupt a fractured larynx leading to total airway obstruction.
• Veins: Look for distension – neck vein distension may be seen in tension pneumothorax or pericardial tamponade (a late and peri-arrest sign).
• Oesophagus: To assess the 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.

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Chest

• Inspect the chest, observing movements. Look for any bruising, lacerations, penetrating injury, or tenderness.
• Palpate for clavicle or rib tenderness.
• Auscultate the lung fields; note any percussion, lack of breath sounds or adventitious sounds.
• Check the heart sounds: apex beat and the presence and quality of heart sounds.
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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. Gently palpate for any tenderness. Do not spring the pelvis. Any additional manipulation may exacerbate haemorrhage. Apply a binder if a pelvic fracture is suspected or if the patient is haemodynamically unstable, if not already applied from primary survey.
• Inspect the perineum and external genitalia.

Limbs

• 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.

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 rectal examination should be performed only if a spinal injury is suspected. Note any loss of tone.

Buttocks and perineum

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

• Inspect for soft-tissue injuries such as bruising, lacerations or burns. Note any priapism that may indicate a spinal injury.

The priorities for further investigation and treatment may now be considered and a plan for definitive care established.

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