Secondary Survey


General
  1. A detailed search for further injury (performed in under 15 min)
    • Used to prioritize Tx plan
  2. A thorough exam from head to toe (including a finger or tube in every orifice)
    • Focused pt Hx
    • Head/neck exam, Chest/Abd exam, Spine/Extremities exam, GU/Musculoskeletal exam
  3. Imaging (C-spine, CXR, pelvis X-rays)
  4. Draw trauma labs
    • CBC/FBC
    • T&C
    • ABG, lytes, BUN/Cr, glucose
    • U/A
    • PT/PTT
    • Pregnancy test
    • +/- amylase, lactate
    • DIC, drug/EtOH screen as needed
  5. Tetanus prophylaxis
  6. for any lacerations or penetrating injuries
  7. IV antibiotics for all open fractures or abd penetration
  8. Crush/compressed limbs should not be reperfused until fluid resuscitation initiated
    • Rapid fluid resuscitation protects kidneys & heart
  9. Eval & report all gunshot wounds
  10. If pt remains hypotensive despite fluid & blood replacement consider immediate abdominal or thoracic exploration
Head & Neck
Secondary Survey
  1. Head-to-toe eval
    • Complete Hx/physical exam
    • Reassessment of all vital signs, check heart tones, peripheral pulses, JVD, capillary refill
    • Head or brain injury is never cause of hypotension in adult trauma pt
    • GCS, lateralizing signs, pupillary reflex/size exam
      • Severe head injury: GCS of 8 or less
      • Moderate head injury: GCS between 9 and 12
      • Minor head injury: GCS between 13 and 15
  2. If during secondary survey pt deteriorates another primary survey is carried out (potential life threat may be present)
Head: Scalp, Face, Eyes, Nose, Ears
  1. Entire scalp & head should be examined for lacerations, contusions, fractures (fx)
    • Palpate for deformities (r/o depressed skull fx)
    • Control blood loss from lacerations (suture, Raney clips)
    • Check for Battle's sign (mastoid ecchymosis) (basilar skull fx)
  2. Check facial bones for stability
  3. Check eyes
    • Visual acuity
    • Pupils: size, reactivity, corneal abrasions, foreign bodies
      • Unequal or dilated pupils may indicate incr ICP
    • Dislocated lens
    • Ocular (rectus muscle) entrapment, extraocular movements
    • If unilateral dilation: r/o cerebral hemorrhage
    • "Raccoon eyes" (basilar skull fx)
  4. Check nose for patency, septal hematoma, CSF leak
    • If any CSF leaks are present, consider basal skull fx
  5. Check ears/TMs for perforation, hemorrhage, hemotympanum, CSF leak
    • If any CSF leaks are present, consider basal skull fx
Neck
  1. Exam of neck includes:
    • Inspection (expanding hematoma, penetrating wound, tracheal deviation)
    • Palpation (bony tenderness, carotid arteries for thrills, subQ [surgical] emphysema)
    • Auscultation (carotid arteries for bruits)
  2. May clinically clear c-spine
    • Nexus (US) Criteria, Canadian C-Spine Criteria
      • No neurological deficits
      • No illicit substance on board (EtOH, drugs, medications)
      • No midline bony tenderness
      • No distracting injury
    • Never explore penetrating neck wounds in ED
    • Maintain low threshold for intubation in pts w/ penetrating neck trauma
    • Blunt neck trauma may cause injuries w/ delayed presentation
  3. If unable to clinically clear c-spine
    • Maintain cervical immobilization
    • C-spine X-Ray/CT scan if suspect c-spine injury
Neurologic Assessment
  1. Calculate Glasgow coma scale if not yet done
  2. Examine for sensory or motor deficits
  3. See: Spinal cord Injury
  4.  Consider high-dose methylprednisolone for patients with evidence of non-penetrating spinal cord injury
    • Give within 8hrs of injury IF neurological injury:
    • Methylprednisolone 30 mg/kg IV bolus over 15 min THEN
      • 5.4 mg/kg/hr IV  for next 23hr
      • Start infusion 45 min. after bolus finished
Insert Catheters
  1. Insert nasogastric tube, if no contraindications
    • Contraindications
      • Midfacial fractures
      • Cribriform plate fractures
    • If unable to use an NG tube, place an OG tube after intubation
  2. Insert foley catheter if no contraindications
    • Contraindications
      • High-riding prostate
      • Blood at urethral meatus
Further Studies/Interventions
  1. CT scans
    • Head, chest, or abdomen/pelvis
  2. IV mannitol (to lower ICP in head injuries), if fluid resuscitated
  3. IV steroids (for spinal cord trauma)
  4. Angiography/duplex ultrasonography (for cervical vascular injury)
  5. PASG/external fixator (unstable pelvic Fx)
  6. Splint/traction to unstable fractures
 
Chest

Goal of Secondary Survey

  1. Secondary survey involves in-depth physical exam
    • Identify the following potentially life threatening chest injuries
    • Simple Pneumothorax
    • Hemothorax
    • Pulmonary contusion
    • Tracheobronchial tree injuries
    • Blunt cardiac injury
    • Pericardial Tamponade
    • Traumatic aortic disruption
    • Traumatic diaphragmatic injury
    • Mediastinal traversing wounds
  2. Chest Exam
    • For crepitus, r/o pneumothorax, pneumomediastinum & tracheo-bronchial tree injury
    • For unilateral decr breath sounds r/o misplaced ETT, pneumothorax or hemothorax
    • R/O tamponade, thoracic aortic tears, & peripheral vascular injury
  3. Imaging: CXR, MRI, Spiral CT (check for aortic injury)
    • Aortogram PRN for wide mediastinum ( >8 cm at T4) or significant deceleration injury
  4. Thoracotomy w/ aortic cross clamping
    • Indications
      • Pericardial tamponade
      • Traumatic arrest
      • Penetrating chest injury w/ shock
      • Major vessel injury
      • Major air leak
Other Actions
  1. Re-assess
    • Repeat vital signs
    • Check heart tones
    • Check peripheral pulses
    • Assess JVD and capillary refill
  2. Obtain CXR
    • Upright film if possible
  3. ABG, ECG
    • Manage dysrhythmias if blunt cardiac injury
  4. Place chest tube for
    • Pneumothorax
    • Hemothorax
    • Hemodynamically unstable mediastinal traversing wounds
      • Bilateral chest tubes
  5. Selective intubation for pulmonary contusion
    • If room air SaO2 < 90%
  6. Consider selective mainstem intubation for severe tracheobronchial tree injuries
Diagnostic Imaging
  1. CXR
    • Upright if possible
  2. Thoracic aortic tears
    • Wide mediastinum ( > 8 cm at T4) on CXR
    • Significant deceleration injury
      • CXR
      • CT scan (spiral)
      • TEE
      • Aortogram if CT shows mediastinal hematoma
  3. Mediastinal traversing wounds
    • Helical, contrast-enhanced CT AND
    • Contrast esophagography AND
    • Bronchoscopy
 
Abdomen/Pelvis

Examination

  1. Complete abd physical exam
    • Inspect
      • Abrasions, contusions (esp. lapbelt injury-"seatbelt syndrome")
      • Wounds
      • Distention
      • Pregnancy
    • Auscultate
      • Bowel sounds (present or absent)
    • Percuss
      • Subtle signs of peritonitis
      • Gastric distention
    • Palpate
      • Tenderness, guarding
      • Pregnant uterus (gravid)
  2. Pelvis/GU/Rectal
    • Assess pelvis for stability
    • Gentle compression (AP, lateral)
  3. Males
    • Penile Exam
      • Blood at urethral meatus
      • Scrotal/perineal ecchymosis or hematoma
    • Rectal Exam
      • Rectal tone
      • Prostate position
      • Gross or occult blood
      • Pelvic fracture (fx)
  4. Females
    • Vaginal exam
      • Lacerations or bleeding
  5. Rectal exam
    • Rectal tone
    • Blood or pelvic fx
Imaging: Pelvic X-ray, CT, MRI, U/S
  1. Suspected intra-abd bleeding
    • FAST scan
    • Abd contrast CT if hemodynamically stable
    • U/S (hemoperitoneum)
    • Diagnostic peritoneal lavage (DPL: open or closed)
  2. Cystogram PRN (blood in urine or pelvic fx)
  3. Pelvic arteriogram w/ embolization for pelvic fx w/ massive hemorrhage
  4. Insert foley catheter if no contraindications
    • Contraindications
      • Scrotal ecchymosis
      • Blood at urethral meatus
      • High-riding prostate
      • If present, must do a urethrogram prior to insertion
  5. IV Abx for abd penetration (ampicillin/sulbactam or cefoxitin)
Surgical Interventions
  1. Consider local exploration of penetrating wounds
    • Assess for peritoneal violation
  2. Immediate celiotomy for
    • Ruptured GI tract, intraperitoneal bladder injury, renal injury
    • Visceral parenchimal injury after blunt or penetrating trauma
    • Blunt trauma w/ hypotension
    • Clinical evidence of intraperitoneal bleeding
    • Blunt trauma w/ positive DPL or U/S
    • Hypotension w/ penetrating abd wound
    • Gunshot wounds traversing peritoneal cavity
    • Evisceration
    • Bleeding from stomach, rectum, or GU tract from penetrating trauma
    • Peritonitis
    • Free air or ruptured hemidiaphragm
Other Interventions
  1. Pelvic arteriogram w/ embolization
    • Pelvic fx w/ massive hemorrhage
    • After attempted closed reduction
  2. IV Abx for abdominal penetration
    • Ampicillin/sulbactam
    • Cefoxitin
 
Extremities
General
  1. Secondary Survey
    • Head-to-toe eval
      • Complete Hx/physical exam
      • Reassessment of all vital signs, check heart tones, peripheral pulses, JVD, capillary refill
      • If during secondary survey pt deteriorates another primary survey is carried out (potential life threat may be present)
Extremities
  1. Movement
    • Strength, range of motion, sensation, reflexes
  2. Appearance
    • Look for color, temp, tenderness
    • Gross deformity
  3. Injury
    • Soft-tissue injury
    • Possible compartment syndrome?
Management
  1. Procedures
    • Splint fractures/dislocations as they are
    • Cover wounds w/ sterile dressings
  2. Imaging & Labs
    • CBC +diff, chemistry (r/o infxns)
    • X-rays (indicated by Hx/physical exam)
    • CT/MRI (soft tissue/bone injuries/deformities)
  3. Medical/pharmaceutical Tx
    • IV Abx for open fractures
      • Cefazolin and Aminoglycoside
    • Tetanus prophylaxis as needed for wounds
    • Surgical
      • Internal vs external fixation
      • Reductions
      • Debridement
      • Amputation
 
Laboratory
The following labs tests should be obtained for all major trauma
  1. Hgb/ Hct, WBC count, platelets
    • Serial Hgb/Hct not useful as screening test for occult bleeding
  2. Comprehensive chem panel
    • Electrolytes, glucose
    • BUN and creatinine
  3. Amylase, transaminases
  4. Coagulation studies
    • PT, PTT
  5. Urinalysis
  6. Blood products
    • Type & screen
    • Type & cross
      • Usually 2-4 units
  7. Toxicology screen
    • Serum AND urine
    • Serum EtOH level
  8. Other studies
    • Cardiac enzymes
      • If suspect blunt injury
        • CK MB
        • Troponin
    • Serum lactate level

 

Radiology

Head

  1. Skull x-rays rarely indicated
    • Penetrating trauma is exception
  2. Non-contrast CT for
    • Altered level of consciousness
    • Significant LOC
    • Severe headache
    • Persistent vomiting
    • Focal findings on neurologic exam
    • New seizure

Cervical Spine

  1. Maintain high index of suspicion for injury
  2. Maintain inline immobilization
  3. May obtain after Primary survey
  4. 3 views
    • AP, lateral, odontoid
      • Standard for all pts w/suspected C-spine injury
      • MUST visualize top of T1
    • Other views
      • Oblique views
        • Not routinely necessary, but complement 3 view
        • Obtain when possible fx identified
      • Flexion-extension view
        • Ordered when adynamic view negative & high clinical suspicion
        • Pt must have normal mental status to perform
        • Physician must be present
        • Have pt flex & extend; stop at point of pain or neuro symptoms (generally performed at follow-up visit)
  5. CT of C-spine
    • Indicated when
      • Plain films unable to visualize entire C1-T1
      • Patients with negative x-rays but a high clinical suspicion of a fracture
    • Used to better identify fx
    • Does not reveal ligamentous damage

Chest X-Ray

  1. Portable AP view
    • Obtained in resuscitation room
  2. Assess for:
    • Mediastinal width
      • Evidence of great vessel injury
    • Fractures
    • Pneumo/hemothorax
  3. Upright film
    • Perform after spine cleared if question about mediastinal widening on supine film
  4. Do multiple views to localize foreign body (e.g. bullet)
  5. CT of chest with IV contrast
    • More sensitive for pneumothorax, mediastinal injury

Abdomen

  1. Plain films generally not useful
    • Exception is penetrating trauma
      • May show missiles or other foreign material
        • AP and lateral projections to try to localize
  2. FAST Exam:
    • Evaluate for hemoperitoneum, hemopericardium, and hemothorax
  3. CT of abdomen with PO and IV contrast:
    • For detecting intraabdominal and retroperitoneal injuries

Pelvis

  1. Obtain portable AP view
    • Blunt trauma to the torso
    • Pelvic instability
    • Gross blood and/or disrupted prostate on rectal exam
    • Gross blood on vaginal examination
    • Gross hematuria
    • Unexplained hypotension
  2. Used to identify fx

Spine

  1. Obtain thoracic, lumbosacral spine as needed
    • Patient C/O localized pain
    • Neurologic deficit
  2. CT scan of spine
    • Can help identify fractures
  3. MRI of spine
    • Indicated for patients with neuro deficit

Extremities

  1. Obtain x-rays as needed
    • Evaluate pain or deformity
 
Reassessment/ Disposition

Re-Assessment

  1. Pt should be continuously monitored
    • Vital signs
    • Pulse oximetry
  2. Perform serial exams
    • Abdominal exam
    • Neurological exam
  3. Return to Primary survey if:
    • Any change in vital signs
    • Any change in mental status
  4. Watch for development of new life threatening problems:
    • Ongoing occult bleeding leading to hypotension
    • Tension pneumothorax
      • Intubated patients
    • Pericardial tamponade

 

Patient Transfer

  1. Transfer pt to higher level care when:
    • The patients needs exceed hospital capabilities
  2. Must comply w/COBRA regulations
  3. Stabilize pt according to available resources
    • Discuss with receiving hospital
    • Medications / procedures as they ask, if possible
  4. Obtain & document from receiving hospital
    • Consent to transfer
    • Acceptance of patient
  5. Send copies of
    • Medical record
    • All labs
    • All radiographs
  6. Arrange advance life support ambulance transfer
 
OTHER TREATMENT
  • Any patient with concern for circulatory compromise needs to have 2 large-bore IVs for fluid resuscitation.
  • In the setting of hypovolemia, administer an initial 1-2 L of crystalloid.
  • If the patient remains hypotensive, transfuse with O-negative blood or type specific blood if available.
  • This treatment should be provided concurrent with efforts to identify and treat sources of hemorrhage as well as other possible causes of hypotension including cardiac, chest, and spinal injury.