Secondary Survey
The secondary survey should only be started once the primary survey has been completed and any life-threatening injuries have been identified and treated. If during the examination any deterioration is detected, go back and reassess the primary survey.
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Use the AMPLE acronym to assist with gathering pertinent information:11
Note what first aid has already been given to the patient.
Cornerstones include:
Identifying the top of the fundus
Measuring fundal height. Each increment is approximately two fingers’ width.
Courtesy of: http://www.open.edu/openlearnworks/mod/oucontent/view.php?id=40Assess uterine tone – firmness greater than expected associated with pain or uterine tenderness may indicate placental abruption.
Assess for uterine contractions.
Assess for uterine pain or tenderness, which may also indicate placental abruption.
Identify the fetal position including its orientation and head position.
Inspect the abdomen, palpate for areas of tenderness, especially over the liver, spleen, kidneys and bladder. Look for any bruising, lacerations or penetrating injuries. Auscultate for bowel sounds.Check the pelvis. Gently palpate for any tenderness. Do not spring the pelvis as any additional manipulation may exacerbate haemorrhaging.12 Apply a binder if a pelvic fracture is suspected. Inspect the perineum and external genitalia and examine for externally visible blood or fluid loss.
A pelvic examination should only be undertaken by an appropriately experienced doctor or obstetrician. This examination may be used to:
Fetal assessment in pregnancies less than 24 weeks is difficult without specialist equipment and personnel.
CTG allows monitoring of the fetal heart rate and uterine contractions. An experienced operator is required to manage this and interpret the results. CTG monitoring should be continued for a minimum of 4 hours after any maternal trauma, and admission for monitoring for 24 hours should be considered in well women with a significant mechanism of injury13.
If not available, the fetal heart rate should be measured by auscultation using a Pinard horn or a handheld Doppler. The fetal heart rate may also be assessed by ultrasound at the bedside by an operator with appropriate experience in the technique.
Normal fetal heart rate ranges from 120 to 160 bpm, with the average being 140 bpm, and varies according to gestation. Fetal heart rates generally decrease towards the lower ranges of normal closer to full term.
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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 other possible other injuries.Use the AMPLE acronym to assist with gathering pertinent information:11
Allergies
Medication
Past medical history (including tetanus status)
Last meal
Events leading to injury
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 fractures.Abdomen/obstetric examination
Obtaining an early and accurate history is important in identifying any information that may guide patient management and intervention.Cornerstones include:
- The date of the last menstrual period or the estimated date of delivery, if known.
- Current gestation.
- Any conditions related to the pregnancy or any complications identified.
- Plurality of the pregnancy (singleton, twins or other multiple).
Identifying the top of the fundus
Measuring fundal height. Each increment is approximately two fingers’ width.Courtesy of: http://www.open.edu/openlearnworks/mod/oucontent/view.php?id=40Assess uterine tone – firmness greater than expected associated with pain or uterine tenderness may indicate placental abruption.
Assess for uterine contractions.
Assess for uterine pain or tenderness, which may also indicate placental abruption.
Identify the fetal position including its orientation and head position.
Inspect the abdomen, palpate for areas of tenderness, especially over the liver, spleen, kidneys and bladder. Look for any bruising, lacerations or penetrating injuries. Auscultate for bowel sounds.Check the pelvis. Gently palpate for any tenderness. Do not spring the pelvis as any additional manipulation may exacerbate haemorrhaging.12 Apply a binder if a pelvic fracture is suspected. Inspect the perineum and external genitalia and examine for externally visible blood or fluid loss.
A pelvic examination should only be undertaken by an appropriately experienced doctor or obstetrician. This examination may be used to:
- Look for vaginal blood loss.
Fetal assessment
Electronic monitoring of the fetus is instituted where there is a viable fetus (greater than 24 weeks gestation) and the appropriate equipment is available (cardiotocography/CTG).Fetal assessment in pregnancies less than 24 weeks is difficult without specialist equipment and personnel.
CTG allows monitoring of the fetal heart rate and uterine contractions. An experienced operator is required to manage this and interpret the results. CTG monitoring should be continued for a minimum of 4 hours after any maternal trauma, and admission for monitoring for 24 hours should be considered in well women with a significant mechanism of injury13.
If not available, the fetal heart rate should be measured by auscultation using a Pinard horn or a handheld Doppler. The fetal heart rate may also be assessed by ultrasound at the bedside by an operator with appropriate experience in the technique.
Normal fetal heart rate ranges from 120 to 160 bpm, with the average being 140 bpm, and varies according to gestation. Fetal heart rates generally decrease towards the lower ranges of normal closer to full term.
Head and face
Inspect the face and scalp. Look for any lacerations and bruising including mastoid or periorbital bruising, which is 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 a 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 an 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
To assist with adequate access, ensure another colleague maintains manual in-line stabilisation while the collar is removed and throughout the examination.
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
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, wheezing or crepitations.
Check the heart sounds: apex beat and presence and quality of heart sounds.
Limbs
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 perfusion for capillary refill, pulse and warmth.
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 examination should be performed only if a spinal injury is suspected. Note any loss of tone or sensation.