Secondary Survey

Dr.Shaesta Tabassum
 Adjuncts to Primary Survey

Vital signs
ECG ABGs
Urinary Adjuncts
Pulse
output oximeter
and CO2
Urinary/gastric
catheters unless
contraindicated
 PRIORITY PLAN
X-RAYS
(should be used judiciously and should
not delay resuscitation)

Lateral cervical spine

AP chest
AP pelvis
 Adjuncts to Primary Survey

Diagnostic Tools
• Chest and pelvic x-
rays
• DPL
• Ultrasound
 Imaging – Ultrasound

• Quick
• Can be performed at bedside
• FAST: Focused Assessment with
Sonography for Trauma
• Rapid examination to identify free
intraperitoneal fluid and/or pericardial fluid
 DPL
• Procedure
• local anesthesia,
• a vertical skin incision is made one third of the distance
from the umbilicus to the pubic symphysis.
• The linea alba is divided and the peritoneum entered
after it has been picked up to prevent bowel perforation.
A catheter is inserted towards the pelvis and aspiration
of material attempted using a syringe.
• If no blood is aspirated, 1 litre of warm 0.9% saline is
infused and after a few (usually 5) minutes this is drained
and sent for analysis.
 Secondary Survey

What is secondary survey?

– Available history and head-to-toe examination

When do I start?
– After primary survey complete
– After ABCDE’s re-assessed
– Vital functions are returning to normal
 Secondary Survey

Key Components
• History
• Physical examination: Head-to-toe
• “Tubes and fingers in every orifice”
• Complete neuro exam
• Special diagnostic tests
• Re-evaluation
 Secondary Survey

History
A Allergies
M Medications
P Past illnesses
L Last meal
E Events / Environment
 Secondary Survey
Mechanisms of
Injury
 Secondary Survey
Head
Complete neurologic exam
GCS score determination
Comprehensive eye exam
Pitfalls
– Unconscious patient
– Periorbitaloedema
– Occluded auditory canal
 Secondary Survey
Maxillofacial
• Bony crepitus/stability
• Palpable deformity
Pitfalls
– Potential airway obstruction
– Cribriformplate fracture
– Frequently missed injury
 Secondary Survey
Cervical Spine
• Palpate for tenderness
• Complete motor/sensory exams
• Reflexes
• C-spine imaging
Pitfalls
– Altered LOC for any reason
– Other severe, painful injury
 Secondary Survey
Neck (Soft tissues)
• Mechanism: Blunt vsPitfalls
penetrating  Delayed
symptoms/signs
• Symptoms: Airway
obstruction,  Progressive
hoarseness airway
obstruction
• Findings: Crepitus,
 Occult injuries
haematoma, stridor,
bruit
 Secondary Survey

Chest
• Inspect
• Palpate Pitfalls
• Auscultation  Elderly
• Percussion  Children
• X-rays
 Secondary Survey

Abdomen
• Inspect, auscultate, palpate, and percuss
• Re-evaluate frequently
• Special studies
Pitfalls
– Hollow viscus and retroperitoneal injuries
– Excessive pelvic manipulation
 Secondary Survey

PerineumContusions, haematomas,
lacerations, urethral blood
RectumSphincter tone, high-riding prostate,
pelvic fracture, rectal wall
integrity, blood
VaginaBlood, lacerations
PitfallsUrethral injury in women, pregnancy
 Secondary Survey

Musculoskeletal: Extremities
• Contusion, deformity
• Pain
• Perfusion
• Peripheral neurovascular status
• X-rays as needed
Imaging – CT

•Detailed
•Requires
patient to leave
the department
•Necessary for
head trauma
 Secondary Survey

Musculoskeletal: Pelvis

• Pain on palpation
• Symphysiswidth
• Leg length uneven
• X-rays as needed
 Secondary Survey

Musculoskeletal
Pitfalls
– Potential blood loss
– Missed fractures
– Soft-tissue or ligamentous injury
– Occult compartment syndrome (especially
with altered LOC/hypotension)
 Secondary Survey

Neurologic
Pitfalls
– Incomplete immobilisation
– Subtle in ICP with manipulation
– Rapid deterioration
 Re-evaluation

Minimising Missed Injuries

• High index of suspicion
• Frequent re-evaluation and
monitoring
 Re-evaluation

Pain Management
Relief of pain/anxiety as
appropriate
Administer intravenously
Careful monitoring is essential
 PRIORITY PLAN
DEFINITIVE CARE

After identifying the patients

injuries,
managing life threatening problems
and
obtaining special studies
 SUMMARY

1. Primary survey
2. Resuscitation
Adjuncts
3. Secondary survey
4. Definitive care