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)
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).
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. The spine is cleared if there are none of the following:
- decreased alertness
- evidence of intoxication
- posterior midline tenderness
- distracting painful injury
- focal neuro deficit
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.
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.
SAM sling for open book fractures
Blood at the external meatus or scrotal bruising suggests urethral injury; attempts to catheterise the patient may worsen this.
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).
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.
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!
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).
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.