Updated: 11/1/2016

Secondary Survey

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Snapshot
  • A 45-year-old woman is brought to the ED after falling 6 feet from a ladder into a bed of bushes while cleaning windows during work as a housemaid. She is brought bound to a backboard with a C-collar. She is breathing spontaneously, but with light and shallow breaths. Her blood pressure is 90/60 mmHg, pulse is 110/min, respirations are 25/min, and SaO
    2
    92% on room air. The patient's pupils are 3 mm bilaterally, reactive to light; she blinks appropriately. She has scrapes throughout her lower and upper extremities, but no hemorrhaging wounds. Two 18-gauge IVs are inserted and 1 L Lactated Ringer's is started.
Overview
  • Secondary survey is done after rapid primary survey problems have been addressed
  • Major injuries, areas of concern, points of contact are identified
  • Full physical exam and radiographs are needed (C-spine, chest, pelvis especially in blunt trauma)
Presentation
  • Trauma-focused history using AMPLE mnemonic
  • Often obtained by emergency medical technician to guide primary survey interventions, but needs to be reviewed again
    • Allergies
    • Medications
    • Past medical history
    • Last meal
    • Events related to injury
Diagnosis
  • Head and neck 
    • pupils
      • assess equality, size, symmetry, reactivity to light
        • relative afferent pupillary defect: optic nerve damage
        • extraocular movements and nystagmus
        • fundoscopy (papilledema, hemorrhages)
      • reactive pupils + decreased level of consciousness (LOC) metabolic or structural cause
      • non-reactive pupils + decreased LOC structural cause (especially if asymmetric)
        • if unilateral, dilated, non-reactive pupil, think focal mass lesion, epidural / subdural hematoma
          • if slow loss of consciousness over a few days in an elderly patient suspect subdural hematoma
          • if sudden loss of consciousness with return to consciousness with head trauma (talk and die syndrome) think epidural hematoma
        • best initial diagnostic test: non-contrast head CT if intracranial injury is suspected
    • palpation of facial bones, scalp
  • Chest
    • inspect for midline trachea, flail segment: ≥ 2 rib fractures in ≥ 2 places; if present, look for associated hemothorax, pneumothorax, contusions
    • auscultate lung fields
    • palpate for subcutaneous emphysema
    • chest radiograph
  • Abdomen
    • assess for peritonitis, abdominal distention, evidence of intra-abdominal bleeding
    • FAST ultrasound or CT (if stable)
    • rectal exam for GI bleed, high-riding prostate and anal tone (best to do during log roll)
    • bimanual exam in females as appropriate
  • Musculoskeletal
    • examine all extremities for swelling, deformity, contusion, tenderness, range of motion
    • check for pulses and sensation in all injured limbs
    • log roll and palpate thoracic and lumbar spines
    • palpate iliac crests and pubic symphysis, pelvic stability (lateral, AP, vertical)
    • pelvic radiograph
  • Neurological
    • repeat Glasgow Coma Scale assessment
      • remember, change in score is more important than absolute score
    • full cranial nerve exam
    • alterations of rate and rhythm of breathing are signs of structural or metabolic abnormalities
      • progressive deterioration suggests elevating intracranial pressure (and worsening CNS injury)
    • spinal cord integrity
      • conscious patient: assess distal sensation and motor
      • unconscious patient: response to painful or noxious stimulus applied to extremities
Management
  • Based on history and physical exam, obtain:
    • complete blood count
    • electrolytes
    • BUN and Cr
    • glucose
    • INR/PTT
    • β-hCG for women
    • toxicology screen
    • type and cross
  • Imaging workup based on mechanism of trauma
  • Urgent consultations based on differential diagnosis

References

 

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