The Secondary Survey

BTLS for PPW

4/12/15

When do we do secondary survey?

The secondary survey is done after

Primary survey is completed,
resuscitative efforts are on going
and normalization of vital signs

What is secondary survey?

A head to toe examination of the

trauma patient with a complete
history & physical examination
including reassessment of vital
signs

Aim: not to miss any injuries

History

A allergies
M medications currently used
P past illnesses/pregnancy
L last meal
E events/environment related to
the injury

Mechanisms of injury & Suspected injuries

Frontal impact automobile collision

- bent steering wheel

- knee imprint, - dashboard injury
- Bulls eye fracture, windscreen

Need to suspect:
Cervical spine fracture
Anterior flail chest
Pneumothorax
Traumatic aortic dissection
Spleen & liver injury
Posterior fracture/ dislocation of hip and/orknee

Other mechanisms

Side impact - #pelvis/acetabulum

Rear impact - cervical spine injury
Ejection
- high risk
MVA with pedestion - # lower
extremities,
traumatic aortic
disruption

Physical examination
Follows sequence of
head,
maxillofacial structures,
cervical spine & neck,
chest,
abdomen,
perineum/rectum/vagina,
musculoskeletal and neurologic system

Head

Entire scalp and head should be

examined for lacerations,
contusions, evidence of fractures
Oedema around the eyes can later
deter examination, eyes should be
evaluated for visual acuity, pupil
size, occular entrapment, injuries

Maxillofacial structures

Examine face palpate all bony

structures, assess occlusion, intraoral
examination & assessment soft tissues

Maxillofacial trauma not associated with

airway obstruction or major bleeding
should be treated after patient stabilized
& life threatening injuries managed

Frequent assessment often needed to

identify

Cervical spine & Neck

Stabilization cervical spine priority

Examination: inspection, palpation
& auscultation
Cervical spine tenderness,
subcutaneous emphysema, tracheal
deviation, laryngeal fracture
Carotid arteries palpated and
auscultated for bruits seat belt
sign high index suspicion!

Chest

Complete examination : inspection, palpation,

percussion, auscultation
CXR

Elderly may not tolerate even minor chest injuries

& progress to acute respiratory insufficiency &
support should be given before collapse

Children: often sustain significant injuries without

evidence of thoracic skeletal trauma so high index
of suspicion is essential

Abdomen

Specific diagnosis not important

Recognizing injury exists that
require urgent surgical intervention
is
Dont do excessive manipulation of
pelvis pelvic spring only once

Perineum, Rectum & Vagina

Examine for contusions, haematomas,

lacerations & urethral bleeding

Rectal examination before placing CBD,

look for blood, high riding prostate,
integrity rectal wall, presence of pelvic
fractures, quality of sphincter tone

Vaginal examination in those at risk

pelvic fractures

Musculoskeletal system

Look, feel, move

Palpate all pulses
Look out for compartment
syndrome

Neurological system

GCS
Pupils
Any paralysis, loss of sensation,
weakness suggests major injury to
spinal cord
Neurological deficits should be
documented when identified

Adjuncts to secondary survey

Missed injuries can be minimized by

maintaining high index of suspicion
Specialized diagnostics tests may be
performed to identify specific
injuries
Include x-rays, CTs, angiography,
USS, bronchoscopy,
oesophagoscopy etc

Important

Reevaluated constantly to ensure

new findings not overlooked and to
discover deterioration

Continuous monitoring of vital signs

& urine output essential
Pain relief essential

Definitive care

Thank you