The document outlines the steps of a secondary survey performed on trauma patients after initial stabilization. The secondary survey is a thorough head-to-toe examination to identify all potential injuries and obtain relevant history. It involves examining the head and face, neck, chest, abdomen, genitals, extremities, skin, and performing a neurological exam. Key areas of focus include identifying signs of skull, cervical spine, rib, abdominal, urethral or rectal injuries. Sonography may also be used to identify internal injuries. The goal is to avoid missing injuries that could lead to morbidity if not identified.

1. SECONDARY
SURVEY
A D I B M U R S Y I D I I S K A N D A R M I R Z A
E T D, I I U M M E D I C A L C E N T R E

2. INTRODUCTION
• Not all injuries will be immediately apparent e.g occult injuries (delayed and missed)
• Secondary survey is a rapid but thorough head-to-toe examination assessment to identify
all potential injuries
• Performed after the primary survey, and initial stabilization is complete.
• The purpose - to obtain pertinent historical data about the patient and his or her injuries
• Indicated in all trauma patients
• Secondary survey should not be performed until:
– The primary survey has been completed
– Resuscitation has been initiated
– Normalization of vital signs has begun

3. AMPLE HISTORY
• This mnemonic device can be used for obtaining a quick, focused history:
– Allergy
– Medications
– Previous medical history or illness/pregnancy
– Last Meal
– Events/environment related to injury
• Standard precaution must be applied !

6. HEAD AND FACE EXAMINATION
• Examine the head for scalp hematoma, skull depression, or laceration.
• No nasogastric tube (NG) should be inserted if there is facial trauma or evidence of
basilar skull fracture.
• Ears - hemotympanum or retro-auricular ecchymosis (Battle's sign) -basilar skull
fracture with cerebrospinal (CSF) leak.
• The pupillary size and response, as well as eye movements - to look for ocular
mobility/entrapment, or periorbital ecchymosis (Raccoon eyes).

7. NECK EXAMINATION
• The neck should be carefully inspected and palpated.
• Assumed patient with blunt trauma may have sustained an injury to the cervical spine,
until proven otherwise!
• C-spine can be cleared either clinically by applying decision rules, or by obtaining
imaging studies, such as plain radiographs or a CT scan.

8. EXAMINATION OF THE CHEST
• Palpate the entire chest wall for crepitus (subcutaneous emphysema) and tenderness.
• The area over the sternum and clavicles - suggest significant force and need further
evaluation for other intrathoracic injuries.
• Assess any respiratory effort and work at breathing.
• Evaluate whether breath sounds are symmetrical and heart sounds are normal and not
muffled
• Palpate and pressure given bilateral rib cage to see any rib spring condition.

9. EXAMINATION OF THE ABDOMEN
• The abdomen should be examined for distension, bowel sounds, bruising or
tenderness.
• Presence of a seatbelt sign or other marks
• Keep in mind that the absence of abdominal tenderness does not eliminate the
possibility of abdominal injury.
• In addition, the abdominal examination may not be reliable in the following cases:
– Elderly population
– Presence of distracting injuries
– Altered mental state
– Pregnant patient, especially late pregnancy

10. EXAMINATION OF THE RECTUM AND
THE GENITALIA
• The perineum should be inspected for any evidence of injury.
• A digital rectal examination should be performed when there is a suspicion of urethral
injury or penetrating rectal injury.
• Look for the following:
– Gross blood in the rectal vault, which may indicate bowel injury
– Displaced or high-riding prostate, which may suggest urethral injury
– Abnormal sphincter tone, which may be due to a spinal cord injury.
– If blood is present at the meatus, the urethral injury should be suspected. In this situation,
retrograde urethrography should be performed before a Foley catheter is inserted.
• Consider vaginal injury in patients with lower abdominal pain, pelvic fracture or perineal
laceration

11. FAST (FOCUSED ASSESSMENT
SONOGRAPHY FOR TRAUMA)
• RUQ
• Pericardium
• LUQ
• Suprapubic
• Anterior Thoracic

12. EXAMINATION OF THE EXTREMITIES
• The extremities should be assessed for fractures by carefully palpating each extremity
over its entire length - for tenderness and decreased the range of motion.
• Assess the integrity of uninjured joints by both active and passive movements.
– Pain/Swelling/Deformity/Crepitus
– Long bone fracture/Open fracture
– Pulses/Vascular Injuries
– Muscles – compartment
– Tendon/Joint stability

13. NEUROLOGIC EXAMINATION
• In this evaluation, the sensory and motor functions should be assessed, and the
Glasgow Coma Scale score should be repeated.
• This is important, since a patient's condition may change rapidly over time.
• The neurological assessment should also include an examination of the pupils,
including pupils' responses to light

14. SKIN EXAMINATION
• This examination should include the locations of lacerations, abrasions, ecchymosis,
hematoma, marks or bruises. Pay attention to the following areas:
– Scalp
– Axillary abdominal and gluteal folds
– Perineum
• Back should be evaluated by log-rolling the patient, and the spine should be palpated
for step-offs or focal tenderness.

15. CONCLUSION
• The primary and secondary survey is a systematic head-to-toe evaluation of trauma
patients to identify injuries – to avoid missed injuries
• This risk may be higher for the following injuries:
– Abdominal Trauma
– Blunt Trauma: Bowel injury, pancreatic and duodenal injuries, diaphragmatic rupture
– Penetrating Trauma: Rectal injuries
– Thoracic Trauma: Aortic injuries, pericardial tamponade, esophageal perforation
– Extremity Trauma: distal extremity fractures, compartment syndrome
• Missed or delayed  morbidity!

16. THANK YOU
• Questions?