What is the recommended approach for a trauma survey?

Recommended Approach for Trauma Survey

The recommended approach for trauma survey follows a structured, sequential assessment consisting of primary survey, secondary survey, and tertiary survey to systematically identify and address life-threatening injuries first, followed by other significant injuries, while minimizing missed injuries. 1

Primary Survey (Initial Assessment)

The primary survey follows the ABCDE approach to quickly identify and address immediate life-threatening conditions:

1. Airway with cervical spine protection

   • Assess patency and protect cervical spine
   • Clear airway of foreign bodies, blood, secretions
   • Consider early intubation for compromised airway

2. Breathing and ventilation

   • Assess respiratory rate, effort, symmetry
   • Look for signs of pneumothorax/hemothorax
   • Apply supplemental oxygen as needed

3. Circulation with hemorrhage control

   • Assess pulse, blood pressure, capillary refill
   • Control obvious external bleeding
   • Establish large-bore IV access (at least two lines)
   • Begin crystalloid fluid resuscitation targeting systolic BP 80-100 mmHg until major bleeding is controlled 2

4. Disability (neurological status)

   • Assess GCS, pupillary response
   • Brief neurological examination
   • Evaluate for signs of increased intracranial pressure

5. Exposure/Environmental control

   • Completely undress patient
   • Prevent hypothermia with warming measures
   • Log roll to examine posterior surfaces

Immediate Imaging During Primary Survey

• FAST (Focused Assessment with Sonography for Trauma) for detection of free fluid in chest, abdomen, and pericardium 1
• Chest and pelvic X-rays for immediate identification of life-threatening thoracic injuries and unstable pelvic fractures 1
• Point-of-care ultrasonography for detection of pneumothorax/hemothorax, hemopericardium, and free abdominal fluid 1

Secondary Survey

Once life-threatening conditions are addressed and the patient is stabilized, proceed with a comprehensive head-to-toe examination:

1. Head and face

   • Inspect for contusions, lacerations, deformities
   • Palpate for fractures, crepitus
   • Assess facial symmetry, ocular movements, visual acuity
   • Check for CSF leakage from ears or nose 1

2. Neck

   • Examine for tracheal deviation, jugular venous distention
   • Palpate for tenderness, subcutaneous emphysema
   • Assess carotid pulses

3. Chest

   • Inspect for contusions, paradoxical movement
   • Auscultate for breath sounds, heart sounds
   • Palpate for crepitus, tenderness

4. Abdomen

   • Inspect for contusions, distension
   • Palpate for tenderness, guarding, rigidity
   • Assess for peritoneal signs

5. Pelvis and perineum

   • Assess pelvic stability (single gentle compression)
   • Examine external genitalia
   • Consider rectal examination for sphincter tone, blood, high-riding prostate

6. Extremities

   • Inspect for deformity, open fractures
   • Palpate for tenderness, crepitus
   • Assess distal pulses, motor and sensory function
   • Evaluate for compartment syndrome

7. Neurological examination

   • Detailed cranial nerve assessment
   • Motor and sensory examination
   • Reflexes

Advanced Imaging After Stabilization

• Contrast-enhanced whole-body CT for hemodynamically stable patients to identify injury type and potential bleeding sources 1
• CT angiography for suspected vascular injuries
• Focused CT scans for specific suspected injuries based on mechanism and clinical findings 1

Tertiary Survey

A tertiary survey should be performed within 24-48 hours of admission to identify missed injuries:

• Complete re-examination of the patient from head to toe
• Review of all laboratory and imaging studies
• Additional targeted imaging as indicated by new findings
• Documentation using a standardized form

The tertiary survey is crucial as studies show it can detect clinically significant missed injuries in up to 19% of trauma patients 3. Missed injuries are particularly common in patients with altered mental status, those requiring immediate surgery, and those with distracting injuries 4, 5.

Special Considerations

• Hemodynamically unstable patients with identified bleeding source should undergo immediate surgical bleeding control 1
• Patients with unidentified bleeding source should undergo immediate further investigation using ultrasonography, CT, serum lactate, and/or base deficit measurements 1
• Pelvic ring disruptions should be closed and stabilized, followed by appropriate angiographic embolization or surgical bleeding control 1
• Damage control surgical approach is essential in severely injured patients 1

By following this structured approach to trauma survey, clinicians can systematically identify and address injuries in order of priority, minimizing the risk of missed injuries and improving patient outcomes.