trauma - secondary survey

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 EXAMINATIONHeadNeckChestAbdomenLimbsSpine

HeadScalp

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-RaysIt 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

example, alcohol intoxication, epilepsy, uncommunicative children.

(8) Depressed fracture or foreign body suspected.

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 fourhours of observation.(8) Patients with GCS 13 to 14 who need a general

anaesthetic for another reason, e.g. orthopaedic injury.(9) All patients with GCS 12 or lower.

extradural haematomahigh density of the haematoma. Slight

midline shift is present.

extradural haematomagas within the haematoma - this indicates a

basal skull fractureNote also the dilated lateral ventricle on the opposite side

subdural haematomas

subdural haematomas

Haemorrhagic contusionThere 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 contusionThis 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 ConsultationSkull 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 conciousnessConfusion 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 hematoma, mastoid hematoma) or other penetrating injury

Necktracheal

deviation

bruits

crepitus

swelling

lacerations

seat belt stripe

bony tenderness, stepoffs

Protection of the spine

Any injury above the clavicle

-Unconscious polytrauma

-Neck pain-Localizing signs

ChestChest wall:

bruising, lacerations, penetrating injury, tenderness, flail segment.

reevaluate breath soundschest wall motioncrepitanceareas of tendernesscontusionpreviously missed penetrating

injuriestake another look at your chest xray

Chest X-Ray✤evaluate ribs✤mediastinum✤apices✤small effusion (hemothorax

Tension PneumothoraxCommonly due to Commonly due to positive-pressure positive-pressure

ventilationventilation in patients with in patients with visceral pleural visceral pleural injuryinjury

Unilateral limited chest excursions and Unilateral limited chest excursions and absence of breath sounds, deviated tracheaabsence of breath sounds, deviated trachea

Hyper-resonance on percussionHyper-resonance on percussion

Clinical diagnosisClinical diagnosis; treatment should not be ; treatment should not be delayed awaiting radiological confirmationdelayed awaiting radiological confirmation

TENSION PT IS A CLINICAL DIAGNOSIS – NOT A RADIOGRAPHIC DIAGNOSIS

AbdomenInspect for bruising, movement and woundsPalpate the abdomenAuscultate for bowel soundSqueeze the pelvis for tendernessCheck the perineum and genitaliaPerform rectal examination

Associated ConditionsLiver LacerationSplenic RuptureRenal InjuryHollow viscus (bowel perforation) or Lumbar

Spine InjurySeat BeltDeceleration injury

Rectum or other bowel injuryGastrointestinal BleedingPelvic FractureUrethral InjuryVaginal InjuryBladder rupture

FAST ScanFocused assessment using sonography in

trauma

Four Quadrants :1)Subxiphoid : Pericardium2)RUQ : Morrison’s pouch (potential space between the liver and kidney)3)LUQ : Splenorenal recess and between the spleen and diaphragm4)Pelvis : Pouch of Douglas

AssessmentCT Abdomen or CT Pelvis, as indicated

If patient is unstable and intra-abdominal injury is suspected, should proceed with laparatomy

Indications for immediate laparatomyEvisceration, 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 irritationRectal exam reveals fresh bloodX-ray evidence of pneumoperitoneum or

diaphragmatic rupture

PelvisPain on palpationSymphysis width Leg length unequalInstabilityX-rays as needed

PitfallsPelvic fracturesPelvic organ

trauma

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

Limbs

pulsessites of tendernesscontusionsdeformitieslacerationsrange of motion at jointsneurologic functionPelvis stability

Compartment syndromePainPressure (pain on palpation)ParesthesiaParesis (late sign)Pallor (late sign)Pulseless (last sign to occur)

SpineSpinal injuries can be partial or completeTest for sensory and motor deficitsIf there is evidence of spinal injury the

patient should not be movedX-ray of the affected site is requiredIf there is no neurological deficit, the

patient can be log rolled and the whole of the back examinedlacerations, 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 patientSurvivors of high velocity accidentPresence of associated injuries

Significant head or facial traumaScapular contusionSeat belt injuriesInjury to feet/ankle from a fall from height