SECONDARY Survey

SECONDARY Survey

Introduction

The secondary survey is only to be commenced after the primary survey has been completed and the patient is stable. Continue to monitor the patient's :

• Mental state,
• Airway, respiratory rate, oxygen saturation,
• Heart rate, blood pressure, capillary refill time.

If there is any deterioration detected in these parameters, the primary survey MUST be repeated immediately and measures taken to rectify the problem.

Preparation

Before commencing the examination, develop a rapport with the patient , offer reassurance and explain what you are doing. Involve the parents or other adults accompanying the patient by telling them what you are doing and using them to comfort or distract attention of patient.
keep the patient warm and - as far as possible - covered.



Remove clothing judiciously; a patient may be upset by the sudden and unexplained disappearance of their favorite item.

History

Taking an adequate history from the patient, bystanders or emergency personnel of the events surrounding the injury can assist with understanding the extent of the injury and any possible other injuries.

Use the AMPLE acronym to assist with gathering pertinent information:

• Allergies
• Medication
• Past medical history including tetanus status
• Last meal
• Events leading to injury

"W5H" of Secondary Survey 

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.


Performing the examination
 
1. Head and skull ( including ENT ) , Maxilofacial
Inspect the face and scalp.
Look in the eyes, ears, nose and mouth.
Palpate the bony margins of the orbit, the maxilla, the nose and jaw.
Palpate the scalp.
Test eye movements, pupillary reflexes, vision and hearing.

Cervical Spine And Neck
Inspect the neck through the hard collar. Palpate the cervical vertebrae. (To clear the cervical spine, see cervical spine assesment clinical practice guideline)
Complete examination of the neck by observing the neck veins and palpating the trachea and the carotid pulse.

Chest
Inspect the chest, observe the chest movements ,
Palpate for clavicular and rib tenderness and auscultate the lung fields and heart sounds.

Abdomen
Inspect the abdomen, palpate for areas of tenderness especially over the liver, spleen, kidneys and bladder, and auscultate bowel sounds.


Pelvic
Gently palpate for any tenderness. Do not spring the pelvis. Any additional manipulation may exacerbate haemorrhage. Apply a binder if a pelvic fracture is suspected even if low clinical suspicious.
Perineum

Inspect the perineum and external genitalia for bruises , bleeding  laceration and burns. Note any priapism that may indicate a spinal injury.

Orifices
A digital rectal examination , vaginal examination should be performed only if a spinal injury suspected. Note any loss of tone or sensation.

Neurological


Determine GCS score , re-evaluate pupils and examine sensory and motor function of any nerve roots or peripheral nerves that may have been injured.

Musculoskletal
Inspect all the limbs and joints, palpate for bony and soft tissue tenderness and check joint movements, stability and muscular power. Log roll the patient , inspect the entire length of the back and buttocks and palpate the spine for tenderness, brusises , vertebrae step deformity , open wound and penetrating wound.

Definitive Care Plan
Early referal , surgical intervention and tranfer to appropriate care unit , proper documentation , consent and forensic evidence.

Adjunct To Secondary Survey
Monitoring
Capnography
Pulse oximetry
ECG monitoring
Urine output in response to fluids

Investigation
Xrays of the limbs, C-spine
CT-Scan
FAST Ultrasound
Blood Investigations