Secondary Survey

This does not begin until the 2 - Primary Survey is complete, resuscitation is underway, and improvement of the vital status is demonstrated. The primary survey is the highest priority.

This is a head to toe comprehensive examination of the trauma patient, with a complete history and physical.

History

  1. Mechanism of injury (SAMPLE).
    1. Blunt trauma
      1. MVC, falls, domestic violence, sports, etc?
      2. Seat belt use, steering wheel deformation, air-bag devices, direction of impact, passenger status, patient positioning in the vehicle. Was the patient ejected?
    2. Penetrating trauma
      1. Body area, missile characteristics, GSW caliber and distance, etc.
    3. Thermal injury
      1. inhalation or CO poisoning risk?
    4. Hazardous environment
      1. chemicals, toxins, radiation?

Physical Examination

  1. Head
    1. eyes - visual acuity, pupillary size, hemorrhage of conjunctiva or fundi, penetrating injuries, contact lenses, dislocation of lens, ocular entrapment
    2. scalp
  2. Maxillofacial structures
    1. palpation of bony structures, assessment of occlusion, intraoral examination, and assessment of soft tissues
    2. midfacial fractures can be associated with cribriform plate fractures
  3. C-spine and neck
    1. maxillofacial or head trauma patients should be presumed to have C-spine injury; restrict C spine motion in these patients
    2. use CT/XR to rule out orthopedic C spine injury
    3. inspect, palpate, and auscultate the carotid arteries
  4. Chest
    1. visual examination, palpation, auscultation, percussion
    2. CXR
  5. Abdomen and pelvis
  6. Perineum/rectum/vag
    1. Pelvic fractures can be suspected by the identification of ecchymosis over the iliac wings, pubis, labia, or scrotum. Pain on palpation of the pelvic ring is an important finding in alert patients. In addition, assessment of peripheral pulses can identify vascular injuries.
    2. examine the perineum, consider rectal examination
    3. perform vaginal exam in patients who are at risk of vaginal injury - blood in the vault? vaginal lacerations?
  7. MSK - include the back!
  8. Neurologic

Adjuncts

Consider the following once the patient is stable and the primary injuries are addressed:

  1. CT head, chest abdomen, spine.
  2. Urography and angiography
  3. Further XR films

Re-evaluation

Do this constantly. Maintain analgesia, adequate UOP