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 review the primary survey.

History

An adequate history taken from family members, bystanders or emergency personnel of the events surrounding the injury can assist with understanding the extent of the injury.
Use the AMPLE acronym to assist with gathering pertinent information:
Immunisation status: Immunisation history is important information - check that the child’s status is up to date, primarily tetanus.

Neurological exam

A focused neurological assessment using the Glasgow Coma Scale (GCS) should be performed. As many of the assessments for an adult patient would not be appropriate for infants, the GCS was modified slightly to form the paediatric GCS for children younger than 4. This assessment should include a description of the patient's level of consciousness as well as assessments of pupillary size and reactivity, gross motor function, and sensation. Document findings and reassess at frequent intervals.

Tips:

• Developmentally delayed children may not normally have age-appropriate responses. Enlist a care-giver’s assistance where possible. Ask parent – “is child behaving normally?”
• Assess sensation as “gentle tickle” rather than painful stimuli in a frightened child.
• Only use painful stimuli where there is no response to light touch. 

 

Head-to-toe examination

This is a systematic and careful review of each part of the injured child to look for less clinically critical and/or occult injuries.

Head and face

Inspect the scalp. Look for any bleeding or lacerations. Significant volumes of blood may be lost with scalp lacerations or haematomas. External compression using only dressing/bandage needs to be applied during the primary survey. Manual compression is not recommended as it may force blood back into the extradural space. Peri orbital bruising, haemotympanum and/or mastoid bruising is indicative of a base of skull fracture; however, mastoid bruising will only occur 12–24 hours post injury.¹⁶

Assess the fontanelles in infant. A bulging fontanelle may be a sign of raised intracranial pressure.

Gently palpate for any depressions or irregularities in the skull. If a penetrating object remains lodged, do not remove it.

Examine the eyes for any foreign body, subconjunctival haemorrhage, hyphaema, irregular iris, penetrating injury or contact lenses.

Examine the ears for any bleeding or blood behind the tympanic membrane, as well as any cerebrospinal fluid (CSF) leak.

Examine the nose for any deformities, bleeding, nasal septal haematoma, and CSF leak. If any fluid leak is present, do not pack the nose; apply an external bolster. The attempt to detect CSF versus other fluid at this stage is irrelevant as any fluid leak requires tertiary referral and a diagnostic workup. The nature of the fluid cannot be determined clinically.

Examine the oral cavity and pharynx for any lacerations or degloving injuries to the gums, lips, tongue or palate.

Inspect the teeth, noting if any are loose, missing or fractured.

Test eye movements, vision and hearing, using quick bedside tests only such as counting fingers and repeating whispered numbers.

Examine the jaw for any pain or trismus.

Neck and Spine

Examine the neck. Ensure another colleague maintains manual in-line stabilisation while the collar is removed and throughout the examination.

If the child is unable to comply with the cervical collar, it is safer to remove it. Combative children need senior assessment as to whether the collar is required. If the senior clinician deems cervical spine immobilization is required, then use manual in-line stabilization and reassurance from a parent/caregiver. 

Alternatively, sedation (likely a general anaesthetic) may be required. Two piece collars may be better tolerated than one piece collars and are less likely to cause pressure areas.

OOccipital-cervical dissociation is more prevalent in the under 8 age group and is not made stable by applying a collar. In the setting where the patient is intubated, unconscious or there is a high suspicion of this type of c-spine injury – lateral bolsters can be applied (e.g. rolled up towels on each side of the patient’s head.) Sandbags/tape should NOT be used.

Children will often hold their own necks in a position of comfort if a significant injury has occurred. Do not attempt to move the neck of a child with traumatic torticollis.

Gently palpate the cervical vertebrae over the posterior midline. 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 checking the carotid pulse; note any deviation of the trachea or crepitus.

Back

Log roll the patient. Maintain in-line stabilisation throughout. Inspect the entire length of the back noting any bruising or lacerations.

Paediatric spinal injuries are often characterized by injury at multiple levels. Note any bruising over the back or abdomen (seatbelt) as these may help target subsequent spinal investigations.

Palpate the spine for any tenderness or steps between the vertebrae. 

Buttocks and perineum

Look for any soft-tissue injury such as bruising, bleeding or lacerations.

Rectal exam in rectal trauma should only be performed by the surgeon undertaking definitive care, not in the peripheral ED. Rectal exam is not indicated in any other scenario. 

Chest

Inspect the chest, observing movements (excursion/symmetry). Look for any bruising, lacerations, penetrating injury or tenderness.

Palpate for tenderness or deformity of the clavicles, ribs and sternum. Note any surgical emphysema.

Auscultate and percuss the lung fields; note any abnormality or lack of breath sounds, wheezing or crepitation.

Auscultate the heart sounds (presence and quality), palpate the apex beat (strength and location).

Abdomen

Inspect the abdomen looking for distension, bruising, laceration or penetrating injury. Palpate for areas of tenderness, especially over the liver, spleen, kidneys and bladder. Auscultate the bowel sounds (absence, normalcy).

Note any abdominal distension on serial examinations.

Examine the pelvis. Gently palpate for any tenderness. Do not aggressively spring the pelvis. Any additional manipulation may exacerbate haemorrhage.¹⁷ Apply a binder if a pelvic fracture is suspected. If no pelvic binder is available or suitable for the size of the child, apply a sheet binder (see primary survey).

Genitalia

Inspect for soft-tissue injuries such as bruising or lacerations. Note any priapism that may indicate a spinal injury. Do not perform an internal exam.

Limbs

Look for spontaneous movement first (or on command.) Painful stimuli should only be used if no response to non-painful stimuli. 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 or lacerations and evidence of muscle, nerve or tendon damage. Look for any deformities, penetrating injuries or open fractures.

Consider splinting and elevation at this stage if injuries found in order to assist with pain control and to aid with circulation.

Look for any signs of compartment syndrome – i.e. loss of distal pulses, pale, cold limb etc.

Examine the sensory and motor function of any nerve roots or peripheral nerves that may have been injured. Instruct – “make a fist”, “make a star”, “hold a key”. A detailed sensory exam in a small child is challenging and may need to be repeated several times.