Secondary survey principles

Secondary Survey - The Grand Tour

• A systematic head-to-toe evaluation to identify all injuries after the primary survey and resuscitation are complete. It is performed on a stable patient.

• History (📌 AMPLE):

  • Allergies
  • Medications (especially anticoagulants, beta-blockers)
  • Past medical history / Pregnancy
  • Last meal (for anesthesia/surgery timing)
  • Events / Environment related to injury

• Comprehensive Physical Exam:

  • Head & Maxillofacial: Check for lacerations, fractures (palpate), and eye/ear/nose/throat injuries.
  • Cervical Spine & Neck: Maintain protection; inspect for trauma, hematomas, and tracheal deviation.
  • Chest: Palpate for tenderness, crepitus; auscultate heart and lung sounds.
  • Abdomen & Pelvis: Inspect, auscultate, palpate. Pelvic stability assessment if no fracture suspected.
  • Perineum/Rectal/Vaginal: Assess for bleeding, hematomas, and sphincter tone.
  • Musculoskeletal: Examine extremities for fractures, deformities, and compartment syndrome.
  • Neurological: Re-evaluate GCS, pupillary response, and check for focal deficits.

⭐ Continuous Re-evaluation: The secondary survey is a dynamic process. Patients must be frequently reassessed to identify missed injuries or deterioration, especially after any intervention.

Head-to-Toe Exam - A Systematic Sweep

• Head & Maxillofacial:
  • Inspect & palpate for lacerations, deformities, step-offs (e.g., basilar skull fracture signs: Raccoon eyes, Battle's sign).
  • Eyes: PERRLA, EOMI, fundoscopy for hemianopia, papilledema.
  • Maxillofacial: Palpate for instability (Le Fort fractures), check for malocclusion.
• Cervical Spine & Neck:
  • Maintain C-spine immobilization until cleared.
  • Palpate for tenderness, check for JVD, tracheal deviation, subcutaneous emphysema.
• Chest:
  • Inspect, Auscultate, Palpate, Percuss (IAPP).
  • Identify flail chest, open wounds, crepitus.
  • Auscultate heart and lung sounds.
• Abdomen & Pelvis:
  • IAPP: Note tenderness, guarding, ecchymosis (Grey Turner's, Cullen's sign).
  • Pelvis: Assess stability with gentle pressure. Do not rock the pelvis if fracture is suspected.
• Perineum & Rectal:
  • Check for blood at the urethral meatus, scrotal/vulvar hematoma.
  • Rectal exam for tone, wall integrity, and prostate position.

⭐ A high-riding prostate on DRE suggests significant pelvic trauma and potential urethral injury. A retrograde urethrogram is indicated before catheterization.

• Musculoskeletal & Back:
  • Inspect all extremities for deformity, swelling, open fractures.
  • Palpate for tenderness and crepitus. Check distal pulses, motor, and sensation (PMS).
  • Log-roll patient to examine the entire spine and back.

Adjuncts & Re-evaluation - Diagnostic Deep Dive

• Diagnostic Adjuncts: Specialized tests to identify specific injuries.

  • FAST (Focused Assessment with Sonography for Trauma): Screens for hemoperitoneum, pericardial effusion.
  • eFAST: Adds bilateral thoracic views for pneumothorax.
  • DPL (Diagnostic Peritoneal Lavage): Invasive; used if ultrasound is unavailable/equivocal in unstable patients.
  • X-rays: Chest (AP), Pelvis (AP), C-spine (lateral).
  • CT Scans: For stable patients to detail head, chest, abdominal, and spinal injuries.

• Monitoring & Tubes:

  • Urinary Catheter: Monitors output (goal: >0.5 mL/kg/hr in adults).
  • Gastric Tube: Decompresses stomach, reduces aspiration risk.

• Continuous Re-evaluation:

  • Vital signs, GCS, and urine output are monitored serially.
  • New findings prompt re-assessment, potentially repeating the primary survey.

⭐ DPL is considered positive in blunt trauma if >10 mL of gross blood is aspirated initially, or RBC count is >100,000/mm³ in the lavage fluid.

High‑Yield Points - ⚡ Biggest Takeaways

• The Secondary Survey is a comprehensive head-to-toe evaluation performed only after the primary survey is complete and the patient is hemodynamically stable.
• It includes a complete history using the AMPLE mnemonic: Allergies, Medications, Past medical history, Last meal, and Events of injury.
• A thorough physical examination is performed, including a complete neurological exam, and examination of all orifices.
• Continuous re-evaluation of vital signs is crucial to detect deterioration.
• Maintain a high index of suspicion for occult injuries.