The secondary survey is performed once the patient has been resuscitated and stabilised. It involves a more thorough head-to-toe examination, and the aim is to detect other significant but not immediately life-threatening injuries. If during the examination any deterioration is detected, go back and reassess the primary survey.
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
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.
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 cerebrospinal fluid 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, 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.
A plain lateral neck x-ray may be indicated when assessing a poly-trauma patient but if normal does not clear the C spine. This is particularly relevant in the intubated patient. To examine the neck the cervical collar should be opened and the head supported with manual in-line stabilisation throughout the exam. Three 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, size and depth.
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.
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. Auscultate the lung fields; note any percussion abnormality, lack of breath sounds, wheezing or crepitations. Check the heart sounds: apex beat and presence and quality of heart sounds.
Inspect the abdomen. Palpate for areas of tenderness especially over the liver, spleen, kidneys and bladder. Look for any bruising, lacerations or penetrating injuries. Document seat belt marks. 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. Any additional manipulation may exacerbate haemorrhage.13 Apply a binder if a pelvic fracture is suspected even if low clinical suspicion. Auscultate bowel sounds. Inspect the perineum and external genitalia for bruising or haemorrhage
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, 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. Assess distal colour, warmth, movement, sensation and capillary refill.
Log roll the patient. Try to do this once. It can be achieved at the time of patient transfer when you have the most personnel to do it safely. Maintain in-line stabilisation throughout. Inspect the entire length of the back noting any deformity, bruising and lacerations. Palpate the spine for any tenderness or steps between the vertebrae. Include a cervical examination at this stage. A digital rectal examination should be performed only if a spinal injury suspected. Note any loss of tone or sensation.