Updated: 12/28/2021

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.
  • introduction
    • 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
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