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.
eFAST point of care ultrasound and chest and pelvic x-rays may be performed as part of the early assessment of a major trauma patient, when required, available and the patient condition allows.
History
Taking an adequate history from the patient, bystanders or emergency personnel of the events surrounding the injury can assist with predicting other damage that may have occurred.(14) Emphasis should be placed on understanding the mechanism, initial level of consciousness and any concurrent injuries noted. Note any history of drugs or alcohol prior to and at the time of injury.
Use the AMPLE acronym to assist with gathering pertinent information:(14, 15)
Allergies
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.
Measuring burns
Assessing burn depth and calculating the percentage of the total body surface area burnt is important during the head-to-toe examination. This will allow fluid resuscitation requirements to be calculated and the severity of the injury to be determined to assess if transfer to a specialist facility is required.
The extent of the burn is measured as the percentage of total body surface area (TBSA). It is important to accurately document the location and area of the burn. The recommended tool for assisting in calculating this in adults is the Wallace rule of nines chart. While examining the patient it is helpful to have another staff member documenting the location and extent of the injuries as they are called out by the assessing clinician.
CLICK ON IMAGE TO ENLARGE
Used with permission from: Victorian Burns Unit
CLICK ON IMAGE TO ENLARGE
Victorian Burns Unit
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.
Measuring burns
Assessing burn depth and calculating the percentage of the total body surface area burnt is important during the head-to-toe examination. This will allow fluid resuscitation requirements to be calculated and the severity of the injury to be determined to assess if transfer to a specialist facility is required.
The extent of the burn is measured as the percentage of total body surface area (TBSA). It is important to accurately document the location and area of the burn. The recommended tool for assisting in calculating this in adults is the Wallace rule of nines chart. While examining the patient it is helpful to have another staff member documenting the location and extent of the injuries as they are called out by the assessing clinician.
Head and face
Inspect the face and scalp. Look for any lacerations and bruising as well as mastoid or periorbital bruising, which is indicative of a base of skull fracture. Gently palpate for any depressions or irregularities in the skull. Check the eyelashes and eyebrows for singeing.
Look in the eyes for any burn injury, 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, cerebrospinal fluid leak or presence of any soot/ash as well as singeing of nasal hairs.
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.
Neck
The cervical collar should be opened if in-situ, the head supported with manual in-line stabilisation and the neck inspected.
Gently palpate the cervical vertebrae. Note any cervical spine pain, tenderness, or deformity.
Check the soft tissues for burns, 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 burns, bruising, lacerations, penetrating injury, or tenderness.
Identify any concerns regarding circumferential chest burns or other significant chest burns injury.
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.
Abdomen
Inspect the abdomen.
Check the pelvis. Burns patients may be involved in multi trauma and can also have significant internal injuries.
Limbs
Image used with permission from the Alfred Hospital
Note any inequalities with limb response to stimulation and document these findings.
Inspect all the limbs and joints.
In electrical burns, look for any entry and exit wounds as well as signs indicating the development of compartment syndrome. These may be found centrally, not just on the limbs (check the head and chest).
Examine the sensory and motor function of any nerve roots or peripheral nerves that may have been injured.
Assess for circumferential burns that may constrict blood flow to all limbs or digits. Assess colour, warmth, movement, sensation and capillary refill distally.
Back
Log roll the patient. Maintain in-line stabilisation throughout. Inspect the entire length of the back and buttocks noting any burns or other injuries.
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 burn injury.
Genitalia
Inspect for burn injury, lacerations or bruising.
The priorities for further investigation and treatment may now be considered and a plan for definitive care established.