Primary and secondary survey

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The primary survey

The purpose of the primary survey is to rapidly identify and manage
impending or actual life threats to the patient.

Introduction
Always assume all major trauma patients have an injured spine and maintain spinal
immobilisation until spine is cleared.
Priorities are the assessment and management of:

 c Catastrophic haemorrhage
 A Airway (and C-spine control)
 B Breathing
 C Circulation
 D Disability
 E Exposure / Environment

Prior to arrival:

 Activate Trauma Team (as per Trauma Team Activation criteria).

 Pre-arrival briefing for team with synthesis
 Use of Pre-arrival checklist to help with role and task allocation
 Estimate the child's weight using the formula:
 Prepare age / weight appropriate doses of medication (use the Monash Drug
book or other similar resource)
 Prepare age appropriate equipment
 Ensure personal protective equipment and lead aprons are worn by the
trauma team

On arrival:

 Obtain a I-MIST-AMBO handover from ambulance staff

 Perform a primary survey
 Obtain further information from parents / caregivers where possible
 Ensure a dedicated member of staff is available to provide support for parents
/ caregivers

Airway and the cervical spine

The life threat to identify and manage when assessing the Airway is airway
obstruction
This is typically the responsibility of the "Airway Doctor" although it is a role which
may be shared with the "Assessment Doctor". The Airway Doctor is typically
responsible for assessing the airway, the anterior neck and the GCS. Their goal is
to ensure and maintain a patent airway, through which the patient can be
successfully oxygenated.
When assessing the airway. The airway doctor should start with assessing for:

 Evidence of facial fractures

 Contaminants such as blood, vomit or teeth in the mouth / airway
 Epistaxis

Where the patient has suffered a burn, the airway doctor should look in particular for:

 Singing of facial / nasal hair

 Facial burns
 Hoarseness or change in voice
 Harsh cough
 head or neck swelling
 Soot in the mouth, nose or saliva

A complete airway assessment also requires an assessment of the anterior neck -

looking in particular for signs of blunt or penetrating trauma, or an impending airway
life threat. This requires the airway doctor to open the C-spine collar whilst an
assistant maintains manual in-line stabilization of the cervical spine. The Airway
doctor should then examine the anterior neck to look / feel for the following
(TWELVE-C):

 Tracheal deviation
 Wounds
 Emphysema (subcutaneous)
 Laryngeal tenderness / crepitus
 Venous distension
 oEsophageal injury (injury unlikely if able to swallow easily)
 Carotid haematoma / bruits / swelling

The airway doctor also needs to assess the GCS

The life threat to identify when assessing the Airway is airway
obstruction. Causes of airway obstruction may be due to:

 Direct trauma to the airway or surrounding structures (maxilo-facial / laryngeal

/ tracheal injury / compression due to anterior neck haematoma)
 Contamination of the airway due to debris (vomitus / blood / teeth or other
foreign bodies)
 Loss of pharygeal tone (due to head injury or intoxication with drugs/alcohol)
 Incorrect positioning (hyperflexion of the infant due to their large occiput)
The management of airway obstruction is to ensure a patent airway through which
the patient can effectively be oxygenated. This may require some or all of the
following techniques:

 Age appropriate positioning of the head into a neutral position (utilising a

thoracic elevation device if <8yrs old or a towel under the shoulder blades to
provide thoracic elevation)
 Gentle suction of the airway to remove blood / vomitus / secretions
 Application of high flow oxygen
 Jaw thrust - avoiding head-tilt or chin lift
 Use of an oropharyngeal airway if tolerated, or naso-pharygeal airway (if head
injury is excluded / unlikely)
 Intubation - by an experienced operator

The cervical spine should be protected by manual in-line stabilisation, followed by

the rapid (gentle) application of a properly fitted hard collar, sandbags and
strap. (see cervical spine assessment clinical practice guideline)

Breathing
The life threats to identify and manage with regards to breathing include:

 Tension pneumothorax
 Open pneumothorax
 Massive haemothorax
 Flail chest

The assessment of breathing, in the spontaneously ventilating child, is the

responsibility of the assessment doctor. Where a child requires positive pressure
ventilation (either bag-valve-mask ventilation, or intubated) there will be a shared
responsibility for the assessment of breathing by the airway and the assessment
doctors. At the start of the assessment, ensure all patients who are spontaneously
breathing have high flow oxygen applied – typically 10-15L O2 via a non-rebreather
mask. The child’s breathing is then assessed by observing:

 The work of breathing (recession, respiratory rate, accessory muscle use)

 The effectiveness of breathing (oxygen saturation, symmetry and degree of
chest expansion, breath sounds)
 The effects of inadequate respiration (heart rate, mental state)
 Signs of injury (seat belt marks, bruising, wounds)

Assessment of the thoracic cage requires feeling for:

 Emphysema / crepitus
 Clavicle / chest wall tenderness
 Request a chest X-ray – this is an important addition to the primary survey

The life threats to identify with regards to breathing include:

  Tension pneumothorax
 Open pneumothorax
 Massive haemothorax
 Flail chest

The management of these life threats is typically carried out by the procedure
doctor under direction from the Team Leader. Once a life threat has been identified,
the assessment doctor should communicate this to the Team Leader, and then
continue on with the primary survey allowing the procedure doctor to carry out any
interventions. Typical interventions include:

 Chest decompression (by needle decompression / finger thoracostomy) for a

tension pneumothorax - followed immediately by insertion of a chest drain
 Chest drain insertion for a massive hameothorax
 Closure of an open pneumothorax, and insertion of a chest drain
 Positive pressure ventilation and insertion of a chest drain for a flail chest.

Intubated children may also benefit from the early insertion of a large oro-gastric
tube to treat and prevent gastric dilatation which in infants and young children
especially, can impair effective ventilation.

Circulation
The major life threat to identify and manage with regards to circulation
is haemorrhagic shock. However, obstructive shock does also occur, and causes
for this should also be actively sought and managed.
The assessment of the circulation is the responsibility of the “Assessment”
Doctor. They should assess the child’s circulatory state by:

 checking the pulse rate, skin colour, capillary refill time, blood pressure
 looking for other effects of an inadequate circulation (increased respiratory
rate, decreased mental state).

It is useful for the assessment doctor to calling out the patients vital signs at this
stage of the assessment - so the team is aware of them. The assessment doctor
should continue with a focused assessment that involves looking for sites of potential
bleeding. These include the following sites:

 External bleeding – assess by exposing wounds and look for ongoing

bleeding - do not remove penetrating foreign bodies
 Intra-thoracic bleeding – assess for massive haemothorax (as per breathing
above)
 Intra-abdominal bleeding – inspect for abdominal distension, bruising, and
palpation for tenderness / guarding
 Intra-pelvic bleeding – gently assess the pelvis for stability by by compressing
the iliac crests
 Long bone fractures – in particular assess the femurs as a site for major
bleeding
  Retroperitoneal bleeding – this can be hard to identify – but maintain a high
level of suspicion in those with signs of haemorrhagic shock and no obvious
signs of bleeding elsewhere or flank tenderness

The assessment doctor should, in consultation with the Trauma Team Leader,
consider the need for a pelvic x-ray (see also Pelvic Injury CPG).
The major life threat to identify with regards to circulation is haemorrhagic
shock
However, care should be taken to actively look and exclude:

 obstructive cause for shock - for example tension pneumothorax or cardiac

tamponade)
 neurogenic shock - associated with spinal injury above the level of T6

The management of haemorrhagic shock is to identify and stop the source(s)

of bleeding whilst concurrently resuscitating the patient. The management of
these life threats may need multiple team members and is co-ordinated by the
Trauma Team Leader. Once the assessment doctor has identified these life threats,
they must communicate their findings to the Trauma Team Leader, then continue
with the primary survey. The management of haemorrhagic shock may include:

 In external haemorrhage bleeding may be stopped through the use of direct

pressure, or in some cases the judicious use of a tourniquet.
 Inserting a chest drain into a patient with a massive haemothorax may
improve ventilation, but stopping ongoing bleeding can only be done in
theatre.
 Similarly life threatening bleeding into the abdomen / pelvis
or retroperitoneum that is not otherwise controlled will require surgery or
interventional radiology to stop the bleeding. Early consultation with a senior
paediatric surgeon +/- an interventional radiologist is required. Rapid transit
to theatre, prior to completion of the secondary survey, may be required to
manage patients with ongoing bleeding that cannot be controlled in the
emergency department.
 Application of the pelvic binder is a haemostatic adjunct
 Bleeding from bone fractures may be reduced through traction
 Resuscitation of shock requires intravenous access with two cannulae that
are as large as practicable - ideally one situated in each cubital fossa.
 If an IV cannula cannot be sited rapidly (within 90 seconds), consider
the use of an intra-osseous needle inserted into a non-traumatised leg
or humerus in the older child.
 As the IV is inserted, take blood for a VBG, FBE, cross-match, UEC,
LFTs, lipase and coagulation screen
 If circulation is inadequate, give an initial fluid bolus. If there is ongoing
bleeding this may be packed red blood cells (10ml/kg), if bleeding is
controlled and blood loss is not thought to be major, you may opt to
give of 10-20 ml/kg of crystalloid however care needs to be given to
avoid contributing to coagulopathy, acidosis and hypothermia that can
occur with excessive crystalloid administration
Assess the child's circulatory state by observing:

79. pulse rate, skin colour, capillary refill time, blood pressure;
80. the effects of an inadequate circulation (respiratory rate, mental state).
 Establish intravenous access with two cannulae that are as large as
practicable - ideally one situated in each cubital fossa.
 If an IV cannula cannot be sited rapidly, consider the use of an intra-osseous
needle inserted into a non-traumatised leg.
 As the IV is inserted, take blood for a blood sugar, FBE, cross-match.
 If circulation is inadequate, give a fluid bolus of 20 ml/kg of normal saline.
 Tamponade any continuing external haemorrhage.
 If the circulation continues to be unstable, repeat the fluid bolus using normal
saline or a colloid solution. If a third bolus is necessary, consider using
packed cells (O negative, group-specific or cross-matched, as available), and
arrange early surgical intervention

Disability (mental state)

The life threat to identify is traumatic brain injury
The assessment of 'Disability' is typically the responsibility of the airway doctor -
although the assessment doctor may add and complement to this by assessing
peripheral function. Initial assessment of the level of consciousness may be done
using the AVPU assessment:

 A = Alert
 V = responds to Voice
 P = responds to Pain
 U = Unresponsive

Any impairment on detected on the AVPU scale should prompt a formal assessment
of the patient’s GCS (link to GCS-level of consciousness in Head Injury CPG). Pupil
response to light should be noted, as should movement in all four limbs. The
assessment doctor should check for this as well as reflexes if the prior to intubation
where possible. The blood glucose level should be measured on arrival and
periodically during the management of the trauma patient.
The life threat to identify is traumatic brain injury - whilst the primary brain injury
cannot be reversed, secondary brain injury can be minimised by the prevention of
hypoxia/hypotension and instigation of neuroprotective strategies to minimise
intracranial pressure, along with the expedited progress of the patient to CT imaging
of the brain, and then to a site capable of any necessary neurosurgical intervention.

Exposure and environmental control

Remove clothing initially and look for any other obvious life threatening injury. Avoid
hypothermia by limiting exposure of the body, and by warming all ongoing fluids.

Radiology
  Arrange for chest to be done in the resuscitation room as part of the primary
survey.
 Pelvic injury is rare in children, the pelvic x-ray does not always need to be
requested in paediatric trauma. However, it is done where there are risk
factors for pelvic injury and the patient is unlikely to need CT imaging of the
abdomen and pelvis. The risk factors for pelvic injury include:
 high risk mechanisms - these include:
 high speed / rollover or lateral impact motor vehicle accidents
 Pedestrian vs car
 Cyclist vs car
 MVA where another person has died
 Abnormal pelvis examination
 Significant lower limb injury (eg femur fracture)
 Intubated or unable to assess pelvis
 If there is no high risk mechanism, no clinical suspicion of a pelvic injury AND
the child is haemodynamically stable withhas a normal conscious state, the
pelvic X-ray may be omitted.
 Arrange additional radiology as indicated

References
95. Browne GJ, Cocks AJ, McCaskill ME. Current trends in the management of
major paediatric trauma. Emergency Medicine (Fremantle, W.A.).
2001;13(4):418-25.
96. Cantor RM, Leaming JM. Evaluation and management of pediatric major
trauma. Emergency Medicine Clinics of North America. 1998;16(1):229-56.
97. Mackway-Jones K, Molyneux E, Phillips B, Wieteska S, eds. Advanced
Paediatric life Support - the Practical Approach. Third ed. London: BMJ
Books, 2001.
98. Rothrock SG, Green SM, Morgan R. Abdominal trauma in infants and
children: Prompt identification and early management of serious life-
threatening injuries. Part 1: injury patterns and initial assessment. Paediatric
Emergency Care 2000;16:106-115.
99. Royal Children's Hospital Melbourne. Clinical Practice Guidelines

-Trauma (Major)

Secondary survey
Introduction
The secondary survey is commenced after the primary survey has been completed,
immediate life threats identified and managed, and the child is stable. Continue to
monitor the child’s:

 Mental state
 Airway, respiratory rate, oxygen saturation
 Heart rate, blood pressure, capillary refill time.
Any unexpected deterioration in these parameters require reassessment and
management of evolving life threats.

Preparation:
Before commencing the examination:

 develop a rapport with the child, offer reassurance and explain what you are
doing
 involve the parents or other adults accompanying the child by telling them
what you are doing and using them to comfort or distract the child
 keep the child warm and - as far as possible - covered
 remove clothing judiciously - a full examination is necessary, but ensure the
child is covered up following examination

Performing the examination:

Head and face
Inspect the face and scalp. Look for:

 Bleeding, lacerations, bruising, depressions or irregularities in the skull,

Battles sign (bruising behind the ear indicative of a base of skull fracture).

Look specifically at the:

 Eyes: for foreign bodies, subconjunctival haemmorhage, hyphaema, irregular

iris, penetrating injury, contact lenses.
 Ears: for bleeding, blood behind tympanic membrane (suggestive of base of
skull fracture)
 Nose: for deformities, bleeding, nasal septal haematoma, CSF leak
 Mouth: for lacerations to the lips, gums, tongue or palate.
 Teeth: for subluxed, loose, missing or fractured teeth
 Jaw: for pain, trismus, malocclusion suggestive of fracture.

Palpate the:

 bony margins of the orbit, the maxilla, the nose and jaw.
 the scalp / skull looking for evidence of fracture

Test eye movements, pupillary reflexes, vision and hearing

Neck
Inspect the neck - it is necessary to open the collar to do this - whilst maintaining
manual in-line stabilisation of the neck. Examine the anterior neck (as per the
primary survey) checking for:

 tracheal deviation
 wounds / bruising to the neck
 subcutaneous emphysema
  laryngeal tenderness
 distension of the neck veins
 carotid pulsation and the presence of a haematoma, listen for a bruit

Asses the c-spine by palpation of the cervical vertebrae (see Cervical spine
assessment CPG)

Chest
Inspect the chest, observe the chest movements. Look in particular for:

 bruising (from seat-belts)

 asymmetric or paradoxical chest wall movement
 penetrating wounds are rare in children, but in cases where there is a
stabbing or other assault look for "hidden" wounds - checking areas such as
the axilla and back

Palpate for clavicular and rib tenderness and auscultate the lung fields and heart
sounds.
Abdomen
Inspect the abdomen, the perineum and external genitalia. Look for in particular for:

 seat-belt bruising / handle-bar injuries

 distension
 blood at the urinary meatus / introitus

Palpate for areas of tenderness especially over the liver, spleen, kidneys and
bladder, and auscultate bowel sounds.
Pelvis
Inspect the pelvis for grazes over the iliac crest. Examine for bruising, deformity,
pain or crepitus on movement.
Limbs
Inspect all the limbs and joints, palpate for bony and soft tissue tenderness and
check joint movements, stability and muscular power. Examine sensory and motor
function of any nerve roots or peripheral nerves that may have been injured.

Back
A log roll should be performed either in the primary survey or in the secondary
survey.

 Inspect the entire length of the back and buttocks.

 Palpate, then percuss, the spine for tenderness,
 Palpate the scapulae and sacroiliac joints for tenderness
 Inspect the anus. Digital examination is rarely needed – if it is indicated it
should only be performed once.

Urinalysis
Interpretation of the urine dipstick in blunt paediatric trauma suffers from high rates
of false positive and false negative results – formal microscopy is the better test
where renal injury is suspected.
Disposition planning
During the examination, any injuries detected should be accurately documented, and
any urgent treatment required should occur, such as covering wounds and splinting
fractures. Appropriate analgesia, antibiotics or tetanus immunisation should be
ordered. Following the secondary survey, the priorities for further investigation and
treatment may now be considered and a plan for definitive care established. At this
stage the patient may require advanced imaging in CT, or transfer to the ward,
intensive care or theatre.
Typically the trauma team leader will remain responsible for the patient until they
have completed their imaging and arrived at their inpatient destination. Handover of
care may occur sooner than this – for example if the anaesthetist is present in the
ED and will accompany the patient to theatre or intensive care. On these occasions
formal handover where the new team leader and team acknowledge
that responsibility for the patient has been transferred. A departure checklist made
aid in this process.

References
132. Browne GJ, Cocks AJ, McCaskill ME. Current trends in the
management of major paediatric trauma. Emergency Medicine (Fremantle,
W.A.). 2001;13(4):418-25.
133. Cantor RM, Leaming JM. Evaluation and management of pediatric
major trauma. Emergency Medicine Clinics of North America. 1998;16(1):229-
56.
134. Mackway-Jones K, Molyneux E, Phillips B, Wieteska S, eds. Advanced
Paediatric life Support - the Practical Approach. Third ed. London: BMJ
Books, 2001.
135. Royal Children's Hospital Melbourne. Clinical Practice Guidelines