Secondary Survey in Trauma

1. SECONDARY
SURVEY
A D I B M U R S Y I D I I S K A N D A R M I R Z A
E T D, I I U M M E D I C A L C E N T R E

2. INTRODUCTION
• Not all injuries will be immediately apparent e.g occult injuries (delayed and missed)
• Secondary survey is a rapid but thorough head-to-toe examination assessment to identify
all potential injuries
• Performed after the primary survey, and initial stabilization is complete.
• The purpose - to obtain pertinent historical data about the patient and his or her injuries
• Indicated in all trauma patients
• Secondary survey should not be performed until:
– The primary survey has been completed
– Resuscitation has been initiated
– Normalization of vital signs has begun

3. 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
• Standard precaution must be applied !

6. HEAD AND FACE EXAMINATION
• Examine the head for scalp hematoma, skull depression, or laceration.
• No nasogastric tube (NG) should be inserted if there is facial trauma or evidence of
basilar skull fracture.
• Ears - hemotympanum or retro-auricular ecchymosis (Battle's sign) -basilar skull
fracture with cerebrospinal (CSF) leak.
• The pupillary size and response, as well as eye movements - to look for ocular
mobility/entrapment, or periorbital ecchymosis (Raccoon eyes).

7. NECK EXAMINATION
• The neck should be carefully inspected and palpated.
• Assumed 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.

8. EXAMINATION OF THE CHEST
• Palpate the entire chest wall for crepitus (subcutaneous emphysema) and tenderness.
• The area over the sternum and clavicles - 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
• Palpate and pressure given bilateral rib cage to see any rib spring condition.

9. EXAMINATION OF THE ABDOMEN
• The abdomen should be examined for distension, bowel sounds, bruising or
tenderness.
• Presence of a seatbelt sign or other marks
• 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

10. 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

11. FAST (FOCUSED ASSESSMENT
SONOGRAPHY FOR TRAUMA)
• RUQ
• Pericardium
• LUQ
• Suprapubic
• Anterior Thoracic

12. 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.
– Pain/Swelling/Deformity/Crepitus
– Long bone fracture/Open fracture
– Pulses/Vascular Injuries
– Muscles – compartment
– Tendon/Joint stability

13. 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

14. 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.

15. CONCLUSION
• The primary and secondary survey is a systematic head-to-toe evaluation of trauma
patients to identify injuries – to avoid 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
• Missed or delayed  morbidity!

16. THANK YOU
• Questions?