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 and chest and pelvic x-rays may be performed as part of the early assessment of a major trauma patient, where available and the patient condition allows.

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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 predicting other damage that may have occurred.⁽¹²⁾ 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:^{(12, 13)}

Specifically referring to this cohort of patients, it is crucial that a detailed obstetric history is obtained and an early obstetric assessment is completed. This assessment should be thorough and also include a fetal assessment.

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).
• Where the gestational age is not known or unable to be determined, it may be estimated by the height of the fundus.
• Refer to Appendix 6: Fundal height palpation.

This provides early information that can help guide intervention and treatment.

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

Inspect the abdomen. Palpate for areas of tenderness, especially over the liver, spleen, kidneys, and bladder. Look for any bruising, lacerations, or penetrating injuries.

Assess uterine tone u2013 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. Assistance via an experienced practitioner may be required.

Check the pelvis. Gently palpate for any tenderness. Do not spring the pelvis. Any additional manipulation may exacerbate haemorrhage. Apply a binder if a pelvic fracture is suspected or if the patient is haemodynamically unstable, if not already applied from primary survey.

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.

Assess for fetal cervical effacement and dilatation.

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 injury.⁽¹⁴⁾

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 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 CSF 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 u2013 are any loose, fractured, or missing.

Test vision, and hearing.

Palpate the bony margins of the orbit, maxilla, nose, and jaw.

Inspect the jaw for any pain or trismus.

Neck

To examine the neck the cervical collar should be opened, and the head supported with manual in-line stabilisation throughout the exam. Two 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 and their estimated size.
• 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 u2013 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.

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 or adventitious sounds.

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

Limbs

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, lacerations, muscle, and 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.

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.

Digital rectal examination should be performed only if a spinal injury is suspected. Note any loss of tone.

Buttocks and perineum

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

Genitalia

Inspect for soft-tissue injuries such as bruising, lacerations or burns.

Check for any PV bleeding or discharge.