What is the approach to a secondary survey in a trauma patient?

Secondary Survey in Trauma: A Systematic Head-to-Toe Approach

The secondary survey in trauma should be performed after the primary survey (ABCDE) is completed and life-threatening conditions are addressed, consisting of a comprehensive head-to-toe examination to identify all non-life-threatening injuries that could have long-term impacts if missed. 1, 2

When to Perform the Secondary Survey

• Only after completion of the primary survey (ABCDE approach)
• After stabilization of life-threatening conditions
• When the patient is hemodynamically stable
• Can be delayed in patients requiring immediate surgical intervention

Systematic Head-to-Toe Examination

Head and Face

• Inspect and palpate the entire scalp and skull for lacerations, contusions, and fractures
• Examine facial bones for asymmetry, step-offs, or crepitus
• Assess eyes for visual acuity, pupillary response, and extraocular movements
• Check ears for hemotympanum, cerebrospinal fluid (CSF) leakage
• Examine nose for septal hematoma, CSF rhinorrhea
• Assess mouth for dental injuries, malocclusion, and intraoral lacerations

Neck

• Maintain cervical spine precautions during examination
• Inspect for deformities, tracheal deviation, jugular venous distention
• Palpate for subcutaneous emphysema, tenderness, step-offs
• Assess carotid pulses and presence of bruits

Chest

• Inspect for asymmetry, paradoxical movement, contusions
• Palpate for crepitus, tenderness, subcutaneous emphysema
• Auscultate for breath sounds, heart sounds, and murmurs
• Assess for flail segments and rib fractures

Abdomen

• Inspect for contusions, distention, evisceration
• Palpate all four quadrants for tenderness, guarding, rigidity
• Assess for peritoneal signs
• Evaluate for seat belt sign (associated with high risk of bowel injury) 1

Pelvis and Perineum

• Inspect for contusions, lacerations, bleeding
• Palpate pelvic ring for stability (once only)
• Perform rectal examination to assess tone, presence of blood, high-riding prostate
• In females, perform vaginal examination if indicated for bleeding or injury

Extremities

• Inspect all limbs for deformity, swelling, contusions
• Palpate for tenderness, crepitus, abnormal movement
• Assess distal pulses, motor function, and sensation in all extremities
• Evaluate for compartment syndrome

Neurological Examination

• Reassess Glasgow Coma Scale
• Perform detailed cranial nerve examination
• Assess motor and sensory function in all extremities
• Document spinal level if deficit present

Diagnostic Imaging During Secondary Survey

• Review imaging obtained during primary survey (chest X-ray, pelvic X-ray, FAST)
• Consider additional focused imaging based on physical findings:
  • CT scan for suspected facial fractures
  • Extremity X-rays for suspected fractures
  • CT angiography for suspected vascular injuries 2

Laboratory Studies

• Complete blood count
• Basic metabolic panel
• Coagulation studies
• Toxicology screen if indicated
• Type and cross-match if not already done
• Consider additional studies based on mechanism and findings:
  • Cardiac enzymes
  • Liver function tests
  • Amylase/lipase

Special Considerations

Unconscious Patients

• More thorough examination required as patient cannot report symptoms
• Higher risk of missed injuries
• Consider additional imaging based on mechanism 1
• Monitor inflammatory markers (though not specific) 1
• Assess tolerance to enteral feeding as potential indicator of bowel injury 1

Distracting Injuries

• Pain from obvious injuries may mask other significant injuries
• Complete exposure and thorough examination is essential
• Lower threshold for additional imaging

Documentation

• Document all findings systematically
• Note time of examination
• Record all positive and pertinent negative findings
• Document neurological status for future comparison

Pitfalls to Avoid

• Rushing through examination before stabilization
• Failing to completely expose the patient
• Inadequate lighting for examination
• Incomplete documentation
• Not repeating examination when clinical status changes

Follow-Up: Tertiary Survey

• A tertiary survey should be performed within 24-48 hours after admission
• Complete re-examination of the patient
• Review of all laboratory and imaging studies
• Additional targeted imaging as indicated by new findings
• Can detect clinically significant missed injuries in up to 19% of trauma patients 2, 3

The secondary survey is a critical component of trauma care that should be performed methodically to identify all injuries after life-threatening conditions have been addressed. This systematic approach minimizes the risk of missed injuries and improves patient outcomes.