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Secondary Survey

Secondary survey does not

begin until the primary survey (ABCDEs) is completed, resuscitative efforts are well established, and the patient is demonstrating normalization of vital functions

History Physical examination: Head-to-toe Complete neuro exam Special diagnostic tests Reevaluation

HISTORY

Allergies Medications Past illnesses Last meal Events / Environment

PHYSICAL EXAMINATION
Head Neck Chest Abdomen Limbs Spine

Head
Scalp lacerations cephalohematoma skull fracture

Ears lacerations CSF otorrhea blood from ear canal blood behind TMs

GCS

Face
lacerations numbness stepoffs pain malocclusion dental injuries nasal injuries (septal hematoma)

Eyes:

-foreign body, -subconjunctival haemmorhage, -hyphaema, -irregular iris, -penetrating injury, -contact lenses.

Indications for Skull X-Rays


It should be done for all patients with GCS 13 and 14, and those with GCS 15 if the following are present: (1) Mechanism of injury suggests a severe blow. (2) Full thickness scalp laceration or boggy haematoma. (3) Loss of consciousness (any period of time). (4) Loss of memory. (5) Vomiting. (6) Inadequate history. (7) Difficulty in clinical assessment, for

When should CT head scans be done?


(1) All skull fractures. (2) Signs of skull base fracture (3) Deteriorating conscious level. (4) Neurological signs. (5) Seizure. (6) Patients with GCS 15 with a persistent severe headache, persistent vomiting, and/or neurological signs. (7) Patients with GCS 13 to 14 and who fail to improve after four hours of observation. (8) Patients with GCS 13 to 14 who need a general

extradural haematoma
high density of the haematoma. Slight

midline shift is present.

extradural haematoma
gas within the haematoma - this indicates a

basal skull fracture Note also the dilated lateral ventricle on the opposite side

subdural haematomas
subdural haematomas

Haemorrhagic contusion
There is a focal area of haemorrhagic

contusion in the right frontal lobe, with surrounding low density due to infarction or oedema. This is a frequent location for a contre-coup injury following a blow to the back of the head.

multifocal haemorrhagic contusion


This image demonstrates a small petechial

haemorrhage in a typical location at the grey-white matter interface (arrow). As is often the case, there were multiple such lesions on other slices.

Indications for Neurosurgical Consultation


Skull fracture with confusion or impairment

of conciousness, focal neurological signs, fits or any other neurological symptom and signs Coma continuing after resuscitation (GCS < 8) Deterioration in the level of conciousness Confusion or other neurological disturbances persisting for more 6-8 hours even if there is no skull Suspected fracture of the base of skull (CSF rhinorrhea or otorrhea, bilateral orbital

Neck
tracheal bruits crepitus swelling lacerations seat belt stripe bony

deviation

tenderness,

Protection of the spine Any injury above the clavicle -Unconscious polytrauma -Neck pain -Localizing signs

Chest
Chest wall: bruising, lacerations, penetrating injury, tenderness, flail segment.

reevaluate breath sounds chest wall motion crepitance areas of tenderness contusion previously missed penetrating

injuries take another look at your chest xray

Chest X-Ray
evaluate ribs mediastinum apices small effusion

(hemothorax

Tension Pneumothorax
Commonly due to positive-pressure

ventilation in patients with visceral pleural injury absence of breath sounds, deviated trachea

Unilateral limited chest excursions and Hyper-resonance on percussion

Clinical diagnosis; treatment should not be

delayed awaiting radiological confirmation

TENSION PT IS A CLINICAL DIAGNOSIS NOT A RADIOGRAPHIC DIAGNOSIS

Abdomen
Inspect for bruising, movement and wounds Palpate the abdomen Auscultate for bowel sound Squeeze the pelvis for tenderness Check the perineum and genitalia Perform rectal examination

Associated Conditions
Liver Laceration Splenic Rupture Renal Injury Hollow viscus (bowel perforation) or Lumbar

Spine Injury
Seat Belt Deceleration injury

Rectum or other bowel injury Gastrointestinal Bleeding Pelvic Fracture Urethral Injury Vaginal Injury Bladder rupture

FAST Scan
Focused assessment using sonography in

trauma
Four Quadrants : 1)Subxiphoid : Pericardium 2)RUQ : Morrisons pouch (potential space between the liver and kidney) 3)LUQ : Splenorenal recess and between the spleen and diaphragm 4)Pelvis : Pouch of Douglas

Assessment
CT Abdomen or CT Pelvis, as indicated

If patient is unstable and intra-abdominal injury is

suspected, should proceed with laparatomy

Indications for immediate laparatomy


Evisceration, stab wounds with implement

in-situ and gunshot wounds traversing the abdominal cavity Any penetrating injury to the abdomen with haemodynamic instability or peritoneal irritation Obvious/strongly suspected Intra-Abd Injury with shock or difficulty to stabilize haemodynamics Obvious signs of peritoneal irritation Rectal exam reveals fresh blood X-ray evidence of pneumoperitoneum or

Pelvis
Pain on palpation Symphysis width Leg length unequal Instability X-rays as needed

Pitfalls
Pelvic fractures Pelvic organ

trauma

Check for blood at the urethral meatus Any scrotal hematoma PR : high riding prostate?

Limbs
pulses sites of tenderness contusions deformities lacerations range of motion at joints neurologic function Pelvis stability

Compartment syndrome
Pain Pressure (pain on palpation) Paresthesia Paresis (late sign) Pallor (late sign) Pulseless (last sign to occur)

Spine
Spinal injuries can be partial or complete Test for sensory and motor deficits If there is evidence of spinal injury the

patient should not be moved X-ray of the affected site is required If there is no neurological deficit, the patient can be log rolled and the whole of the back examined
lacerations, contusions, penetrating wounds

missed previously

Spinal cord injury should be suspected and cervical immobilization maintained from the time of injury in the following : Unconcious trauma patient
Survivors of high velocity

accident Presence of associated injuries Significant head or facial trauma Scapular contusion Seat belt injuries Injury to feet/ankle from a fall from height