Trauma Secondary Survey


Article Author:
Michael Zemaitis
Jason Planas
Neal Shah


Article Editor:
Muhammad Waseem



Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
6/6/2019 6:02:40 PM

Introduction

Rendering care to a trauma patient can be a challenging endeavor due to the potential for numerous injuries.  Not all injuries will be immediately apparent. Occult injuries have the potential to be missed and delayed diagnosis can contribute to patient morbidity and mortality. The secondary survey is a rapid but thorough head-to-toe examination assessment to identify all potential injuries. It is helpful to determine the priorities for continued evaluation and management. It should be performed after the primary survey, and initial stabilization is complete. The purpose of the secondary survey is to obtain pertinent historical data about the patient and his or her injury, as well as to evaluate and treat injuries not found during the primary survey.[1][2][3][4][5]

Indications

The secondary survey is indicated in all trauma patients.  The purpose of the secondary survey is to obtain a complete history, perform a head to toe physical exam, and to reassess all vital signs.  

Contraindications

There are no contraindications to the secondary survey.  The secondary survey must be completed on all trauma patients.  If the patient is severely injured, they might not be capable of providing a history.  In these situations, the history can be obtained from EMS and family members. 

Personnel

Personnel would include members of the trauma team. 

Preparation

Observe standard precautions for blood or fluid-borne infection.

Technique

As stated earlier, the secondary survey should not be performed until:

  • The primary survey has been completed
  • Resuscitation has been initiated
  • Normalization of vital signs has begun.

Patients who are hemodynamically unstable should be stabilized before they are transferred to the operating room or angiography suite, unless they need to be transported to a state designated trauma center.

An attempt should be made to obtain the patient's history regarding the mechanism of injury, since certain mechanisms can raise the suspicion for certain injuries such as the following:

  • Blunt trauma (seat belt use, airbag deployment, extent of damage to the automobile, ejection, and distance ejected)
  • Penetrating trauma (which firearm and how many gunshots heard).

AMPLE History

This mnemonic device can be used for obtaining a quick, focused history:

  • Allergy
  • Medications
  • Previous medical history or illness/pregnancy
  • Last Meal
  • Events/environment related to injury: What happened (example mechanisms such as blunt, penetrating, burns or any hazardous environment, such as exposure to chemicals, toxins or radiation. These considerations are important for the following reasons due to exposure to chemical agents can cause pulmonary, cardiac and other internal organ dysfunction, or hazardous environment can pose a threat to the health.

Physical Examination

The purpose of the secondary survey is to identify injuries. Throughout the evaluation, standard precautions for blood or fluid-borne infections should be observed.

Head and Face Examination

Examine the head for scalp hematoma, skull depression, or laceration. The scalp should be palpated, since scalp lacerations or bony step-offs may be identified only by careful palpation. No nasogastric tube (NG) should be inserted if there is facial trauma or evidence of basilar skull fracture. Also, the ears should be evaluated for hemotympanum or retro-auricular ecchymosis (Battle's sign). The presence of blood or clear drainage from the ear canal indicates basilar skull fracture with cerebrospinal (CSF) leak.

The pupillary size and response, as well as eye movements, should be assessed. The ocular examination should also include ocular mobility/entrapment, or periorbital ecchymosis (Raccoon eyes).

Neck Examination

The neck should be carefully inspected and palpated. Beware that injuries under the hard collar may not be obvious. It is assumed that every patient with blunt trauma may have sustained an injury to the cervical spine, until proven otherwise. C-spine can be cleared either clinically by applying decision rules, or by obtaining imaging studies, such as plain radiographs or a CT scan.

Examination of the Chest

Palpate the entire chest wall for crepitus (subcutaneous emphysema) and tenderness. The area over the sternum and clavicles requires special attention as fractures involving these bones may suggest significant force and need further evaluation for other intrathoracic injuries. Assess any respiratory effort and work at breathing. Evaluate whether breath sounds are symmetrical and heart sounds are normal and not muffled.

Examination of the Abdomen

The abdomen should be examined for distension, bowel sounds, bruising or tenderness. The presence of these findings requires further evaluation. Also, the presence of a seatbelt sign or other marks to the abdomen should prompt further evaluation. It is important to keep in mind that the absence of abdominal tenderness does not eliminate the possibility of abdominal injury. In addition, the abdominal examination may not be reliable in the following cases:

  • Elderly population
  • Presence of distracting injuries
  • Altered mental state
  • Pregnant patient, especially late pregnancy
  • Examination of the rectum and the genitalia.

The perineum should be inspected for any evidence of injury. A digital rectal examination should be performed when there is a suspicion of urethral injury or penetrating rectal injury.

Look for the following:

  • Gross blood in the rectal vault, which may indicate bowel injury
  • Displaced or high-riding prostate, which may suggest urethral injury
  • Abnormal sphincter tone, which may be due to a spinal cord injury.

If blood is present at the meatus, the urethral injury should be suspected. In this situation, retrograde urethrography should be performed before a Foley catheter is inserted.

Consider vaginal injury in patients with lower abdominal pain, pelvic fracture or perineal laceration. In such situations, a vaginal examination should be performed.

Examination of the Extremities

The extremities should be assessed for fractures by carefully palpating each extremity over its entire length for tenderness and decreased the range of motion. Assess the integrity of uninjured joints by both active and passive movements. Uninjured joints should be immobilized, and radiographs should be obtained. Injured joints should also be immobilized, and radiographs should be obtained.

The neurovascular status of each extremity should be assessed and documented. Check pulses, the capillary refill time and evaluate each compartment. The presence of significant pain or tense compartments. Pain with passive movement may indicate a development of the compartment syndrome.

Pelvic Examination

The pubis and anterior iliac spines should be evaluated for any signs of pelvic instability. The presence of ecchymosis over the iliac wings, pubis, labia, or scrotum and tenderness along the pelvic ring also, requires diagnostic evaluation.

Neurologic Examination

In this evaluation, the sensory and motor functions should be assessed, and the Glasgow Coma Scale score should be repeated. This is important, since a patient's condition may change rapidly over time. The neurological assessment should also include an examination of the pupils, including pupils' responses to light.

Skin Examination

This examination should include the locations of lacerations, abrasions, ecchymosis, hematoma, marks or bruises. Pay attention to the following areas:

  • Scalp
  • Axillary abdominal and gluteal folds
  • Perineum
  • Back should be evaluated by log-rolling the patient, and the spine should be palpated for step-offs or focal tenderness.

Complications

The risk of missed injuries. This risk may be higher for the following injuries:

  • Abdominal Trauma
  • Blunt Trauma: Bowel injury, pancreatic and duodenal injuries, diaphragmatic rupture
  • Penetrating Trauma: Rectal injuries
  • Thoracic Trauma: Aortic injuries, pericardial tamponade, esophageal perforation
  • Extremity Trauma: distal extremity fractures, compartment syndrome

Note that to avoid the risk of any missed injuries a tertiary survey should be required in patients with multisystem trauma.

Clinical Significance

The secondary survey is a systematic head-to-toe evaluation of trauma patients to identify injuries which were not discovered during the primary survey.[6][7][8][9]

Enhancing Healthcare Team Outcomes

All healthcare workers who look after trauma patients should be familiar with the ATLS protocol and how to perform the primary and secondary survey. The key is not to miss any serious injury. The management of trauma patients is with a multidisciplinary team that includes a surgeon, anesthesiologist, nurses, intensivist and a trauma team. The secondary survey is more thorough and assesses the entire body systematically.


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Trauma Secondary Survey - Questions

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Which of the following is not a true statement regarding trauma?



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Which of the following conditions is a contraindication to a secondary survey?



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Which of the following is not required before performing a secondary survey in the evaluation of trauma patients?



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Which of the following may not be disclosed on the history during the secondary survey evaluation?



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A 23-year-old female is driving her car with her sister. She is stung by a bee and crashes into a ditch. She presents to the trauma bay flushed and in respiratory distress. She is subsequently intubated. She is hemodynamic stable, and the remainder of the primary survey is unremarkable. A secondary survey (AMPLE history) is being conducted. Which of the following aspects of the patient's history would be most useful in managing this patient?



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Trauma Secondary Survey - References

References

Galvagno SM Jr,Nahmias JT,Young DA, Advanced Trauma Life Support{sup}®{/sup} Update 2019: Management and Applications for Adults and Special Populations. Anesthesiology clinics. 2019 Mar;     [PubMed]
Bieler D,Hörster A,Lefering R,Franke A,Waydhas C,Huber-Wagner S,Baacke M,Paffrath T,Wnent J,Volland R,Jakisch B,Walcher F,Kulla M, Evaluation of new quality indicators for the TraumaRegister DGU{sup}®{/sup} using the systematic QUALIFY methodology. European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2018 Dec 14;     [PubMed]
Çorbacıoğlu ŞK,Aksel G, Whole body computed tomography in multi trauma patients: Review of the current literature. Turkish journal of emergency medicine. 2018 Dec;     [PubMed]
Gala SG,Crandall ML, Global Collaboration to Modernize Advanced Trauma Life Support Training. Journal of surgical education. 2019 Mar - Apr;     [PubMed]
Jacquet GA,Hamade B,Diab KA,Sawaya R,Dagher GA,Hitti E,Bayram JD, The Emergency Department Crash Cart: A systematic review and suggested contents. World journal of emergency medicine. 2018;     [PubMed]
Blatz D,Ross B,Dadabo J, Cervical spine trauma evaluation. Handbook of clinical neurology. 2018;     [PubMed]
Sidwell R,Matar MM,Sakran JV, Trauma Education and Prevention. The Surgical clinics of North America. 2017 Oct;     [PubMed]
Petrosoniak A,Hicks C, Resuscitation Resequenced: A Rational Approach to Patients with Trauma in Shock. Emergency medicine clinics of North America. 2018 Feb;     [PubMed]
Rodrigues IFDC, To log-roll or not to log-roll - That is the question! A review of the use of the log-roll for patients with pelvic fractures. International journal of orthopaedic and trauma nursing. 2017 Nov;     [PubMed]

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