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.


Taking an adequate history from the patient, bystanders and 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 information14
Past medical history including tetanus status
Last meal
Events leading to injury

Head-to-toe examination

A thorough examination of motor, sensory and reflex capacity is crucial and systems should be assessed independently and systematically. A head-to-toe assessment is an established approach in assessing neurological function.

Motor: Muscle groups should be assessed. It is often difficult to test some segments due to traumatic injuries, therefore upper limbs are often most easily assessed. Strength rated 1/5 to 5/5 should be documented in addition to any deficits of left or right responses.

Sensory: Sensation should be assessed systematically with initial tests using light touch. If no response then increase to sharp stimulation. The trigeminal nerve, exiting above the spinal cord, is a useful reference point for assessing primary SCI where intact facial sensation is expected.

Reflexes: Reflex responses should be obtained by usual assessment practice.

Head and face

This examination should be conducted with the patient remaining supine. 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 cerebrospinal fluid leak, bleeding or blood behind the tympanic membrane. Check the nose for any deformities, bleeding, 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 further 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.

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NEXUS criteria

All potential major trauma patients suspected of having a cervical spine injury will arrive in the Emergency department with a rigid collar applied by ambulance crew. Assessment and imaging will occur while the patient has the rigid collar insitu. Clinical examination using the NEXUS low risk criteria should be performed, however this can only occur four hours after the last administration of narcotics.
The NEXUS low risk criteria constitute a decision tool for use in the initial assessment of conscious patients to indicate those at very low risk of cervical spine injury following blunt trauma who may not need radiographic imaging.
Patients are considered to be at extremely low risk of cervical spine injury if ALL of the following criteria are fulfilled:

  1. No midline cervical spine tenderness
  2. No focal neurologic deficit
  3. No evidence of intoxication
  4. No painful distracting injury
  5. No altered mental status

If all of the above criteria are satisfied, clinical examination may then proceed. If there is no evidence of any bruising, deformity or tenderness on examination, and if a full range of active movement can be performed without pain (including 45degree rotation to left and right), the cervical spine can be cleared without radiographic imaging and the cervical collar be removed.
Should the patient exhibit any of the criteria, however, clinical examination is unreliable and radiographic assessment of the cervical spine is advised. 

NEXUS criteria

1. Midline cervical spine tenderness

Present if the patient indicates the existence of neck pain on palpation of the posterior midline neck region from the nuchal ridge to the third thoracic prominence, or palpation of any cervical spinous process.

2. Focal neurologic deficit

Motor or sensory examination indicates the presence of a focal neurologic deficit eg. segmental weakness, numbness or paraesthesia.

3. Intoxication

The patient is considered to be intoxicated if:
  • the patient or an observer reports a recent history of intoxication or consumption of intoxicating substances
  • evidence exists of intoxication on physical examination eg. odour of alcoholic beverage, ataxia, slurred speech, dysmetria, other cerebellar signs or any behaviour suggestive of intoxication
  • tests of bodily fluids are positive for drugs or alcohol which affect mental alertness

4. Painful distracting injury

Any non-spinal related condition causing sufficient pain to distract the patient from a possible cervical spine injury. Suggestions include:
  • any long bone fracture
  • a visceral injury requiring surgical consultation
  • extensive laceration, crush or degloving injury
  • considerable burns
  • any other injury producing functional impairment
  • any other injury thought to impair the patient’s ability to appreciate cervical spine pain

5. Altered mental status

An altered state of mental alertness can be demonstrated by:
  • GCS < 15
  • disorientation to time, place, person or event
  • inability to recall 3 objects at 5 minutes
  • delayed or inappropriate response to stimulus
Clinical spinal clearance
If all of the NEXUS criteria are negative, there is no evidence of bruising or deformity, and if a full range of active neck movement (including 45° rotation to left and right) can be performed without pain, the cervical spine can be clinically cleared without radiographic imaging and the cervical collar can be removed. Documentation must be made on the electronic Spinal Assessment and Clearance Form.
Cervical spine imaging
Should the patient exhibit any signs of cervical spine tenderness, focal neurologic deficit, evidence of intoxication, painful distracting injury or altered mental status, however, clinical examination is unreliable and radiographic assessment of the cervical spine is advised.
  • Cervical Multi Segmental CT
MRI may be required if CT images are abnormal or if abnormal neurology is present

Adapted from The Alfred Spinal Clearance Management Protocol (November 2009). Developed by Helen Ackland. Accessed August 25 2014, available from

Neck Examination

To ensure adequate access have another colleague maintain manual in-line stabilisation while the collar is removed for palpation and throughout the examination.

Gently palpate the cervical vertebrae. Note any cervical spine pain, tenderness or deformity. The point of maximum tenderness should be noted. Deformity may be felt in significant vertebral disruption or dislocation.

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 should be combined with the back examination.


Inspect the chest, observing movements. Look for any bruising, lacerations or penetrating injury.

Palpate for clavicle or rib tenderness. Look for bilateral chest expansion.

Auscultate the lung fields; note any changes to percussion, lack of breath sounds, wheezing or crepitations.

Check the heart sounds: apex beat and presence and quality of heart sounds.


Inspect the abdomen. Look for any distension or swelling, bruising, lacerations or penetrating injuries.

Palpate for areas of tenderness, especially over the liver, spleen, kidneys and bladder.

Check the pelvis. Gently palpate for any tenderness. Do not spring the pelvis. Any additional manipulation may exacerbate haemorrhage14. Apply a binder if a pelvic fracture is suspected.

Auscultate bowel sounds.

Inspect the perineum and external genitalia.


Inspect all the limbs and joints. Note any bruising or lacerations and muscle, nerve or tendon damage. Look for any deformities, penetrating injuries or open fractures. Palpate for bony and soft-tissue tenderness and check joint movements, stability and muscular power.

Examine the 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.

Refer to Appendix 1: American Spinal Association: International Standards for Neurological Classification of Spinal Cord Injury


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. Many patients with SCI have vertebral injury at more than one level. Do not sit the patient up.

Digital examination should be performed in suspected SCI. Note any loss of tone or sensation.

Buttocks and perineum

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


Inspect for soft-tissue injury such as bruising or lacerations. Note any priaprism that may indicate spinal injury.