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Secondary survey










Do NOT start the secondary survey until the primary survey has been completed and all immediate life threats addressed.

"W5H"

What?

The secondary survey is a full assessment (history and clinical examination).

Why?

The aim of the clinician performing the secondary survey is to detect all injuries/comorbidities or other important issues

When?

After (and only after) the primary survey + resuscitation phase has been completed.

Where?

In a remote environment, where evacuation may not be delayed too long, then it may be better to defer the secondary survey until the patient has reached a hospital rather than risk losing heat on a mountainside. If part of the secondary survey has been omitted/delayed then this MUST be handed over to the receiving clinician.

Who?

Anyone and everyone unless you can be certain they have an isolated problem

How?

Systematically is the key word. The components of the secondary survey is described below.


If the condition of the casualty/patient changes while the secondary survey is being performed or during evacuation then a repeat primary survey is carried out immediately.

This page covers the assessment carried out in the secondary survey but not the interventions that would be carried out in response to problems found.

In a remote setting it may be necessary to carry out a full secondary survey (e.g. on expedition with long evacuation times) but in other circumstances (e.g. UK mountain rescue) the potential harms of carrying out a full secondary survey (time delay & increased risk of hypothermia) may make it safer to delay the secondary survey. It should, however, always be a conscious and informed decision to omit some or all of the secondary survey and documentation and handover must make it clear this has happened.

AMPLE history

Allergies
Medication
Past medical history & Pregnancy
Last ate and drank (and time of injury)
Events/Environment (what happened)

This minimum amount of information should be collected during the primary survey if possible, or as soon afterwards otherwise.

Structure of the secondary survey

Once the primary survey has been completed - together with any resuscitation needed for life threatening problems found at that stage - a more detailed assessment is carried out.
The secondary survey is a detailed and thorough examination of the whole patient - head to toe, front and back, both sides.
Its aim is to detect all injuries/problems.

This mnemonic may help to ensure no areas are omitted from the secondary survey:
Has
Head & skull (inc. eyes and ears)
My
Maxillofacial
Critical
Cervical spine & neck
Care
Chest
Assessed
Abdomen
Patient
Pelvis
Priorities
Perineum
Or
Orifices (e.g. rectum)
Next
Neurological
Management
Musculoskeletal
Decision
Definitive care plan (inc evacuation)
(if sticking rigidly to the ATLS approach MSK will include pelvis and is done before neurological assessment). Some of these are not so easy on the side of a crag / stuck in a cave etc - if any steps are not possible it is important to note that they have not been done and to carry them out as soon as possible.

Secondary survey "mind map":

When carrying out a secondary survey and checking for tenderness ensure the casualty is being touched in only one place at a time - one operator and either one hand on the casualty or two hands that are touching.

Prehospital pain management

Head

Look and feel for scalp wounds and evidence of skull fractures, including basal skull fractures which may give the following signs:
• Periorbital bruising (Racoon eyes) without local injury
• Haemotympanum (blood "behind" the eardrum - unlikley to be found in a wilderness setting, though bleeding from the ear may be seen if the ear drum is damaged)
• Mastoid bruising (Battle's sign) - found behind the ear: sometimes concealed by a cervical collar
• CSF from ear, CSF from nose
You also need to assess the the eyes (for injuries).

Head injury
Head injury "in the field"

Maxillofacial

Examine for evidence of facial injury, the most serious being a facial fracture causing bleeding into the airway or an airway burn.

Cervical spine & neck

Repeat the TWELV assessment and then assess the cervical spine for midline bony tenderness and deformity/steps.

The c spine can be cleared in the field using NEXUS criteria or the Canadian C spine rules.

Nexus

The spine is cleared if there are none of the following:
1) decreased alertness
2) evidence of intoxication
3) posterior midline tenderness
4) distracting painful injury
5) focal neuro deficit

Canadian c spine rule

canadian_c_spine_rule.jpg

It is not possible to clear the c spine until the secondary survey has been completed - it should be immobilised until then (often requiring collar, blocks and tape).
Application of cervical collar:


Chest

A full assessment of the chest is carried out - the aim is to detect all injuries affecting the chest. The back of the chest is examined when the patient is log rolled but while the patient is supine examination must go as far posteriorly as possible.

Abdomen

Abdo evaluation
A full examination is performed, the main features to note being tenderness. When there is tenderness of lower ribs it is vital to fully assess for possible liver/spleen injury. The flanks are examined more fully when the patient is log rolled.

Pelvis

SAM sling for open book fractures


Perineum

Blood at the external meatus or scrotal bruising suggests urethral injury; attempts to catheterise the patient may worsen this.

Orifices

PR exam is needed in trauma that may have caused spinal cord injury (decreases tone) or abdominal/pelvic injury. The position of the prostate should be confirmed to be normal before catheterising a man (if "high-riding" it indicates urethral injry).

Neurological

If the casualty is not fully conscious work through DERM:
Depth of coma (using the Glasgow coma scale)
Eyes (pupil reflexes and eye movements - but don't move the head looking for "doll's eyes" movements if there are worries about the spine!)
Respiration (rate and pattern)
Motor function (limb weakness - "wiggle your toes and fingers" if the casualty is conscious)

The neurological status of the limbs should be assessed. If any abnormality is found a full neuro exam is needed. One approach is to carry out the most objective elements of the examination first: tone, reflexes, power, co-ordination, sensation.

Although the mnemonic has neuro before musculoskeletal examination, it would probably be wise to carry out the musculoskeletal examination first - weakness etc cannot really be assess in the presence of a fracture or joint dislocation.

Log rolling
All patients must undergo examine of their back in the secondary survey ("top to toe, front and back").
If the spine has not been cleared before this the patient is examined by performing a log roll, For an adult this requires 4 people (+ person examining the casualty). The aim is to roll the casualty onto their side without bringing about any movement of the spine. As a practical skill this is best learned hands on - sadly I could not find an image on the internet that I thought demonstrated the correct technique!

Spinal boards
These are sometimes called long boards, but either way they are very uncomfortable to lie on (and can quickly cause pressure area problems) and should be viewed as a tool for exrication rather than for transfer or immobilisation (a vacuum mattress being preferred for these requirements).

Musculoskeletal

All joints and bones should be assessed. If there is any wound distal tendon function must also be assessed. The sequence of examination is look, feel, move.
Active movement should be assessed before passive movement.
If a splint is applied to a limb, distal circulation and nerve function must be assessed begorehand and afterwards.

Ottawa ankle and knee rules tutorial: http://www.ohri.ca/emerg/cdr.html

Lower limb injuries:

Links

Secondary survey
Pitfalls in the secondary survey