The document discusses the importance of performing a thorough secondary survey on trauma patients to identify injuries that may have been missed in the initial primary survey. It outlines the steps of the secondary survey including obtaining history, examining the head/face, neck, chest, abdomen, extremities, pelvis, neurologic status, and skin. The goal is to identify any injuries that require treatment to prevent morbidity and mortality that could result from delayed diagnosis.

1. Triage Primary & Secondary
Survey
Dr Iftikhar Ahmed Soomro

2. Secondary survey
• Rendering care to a trauma patient can be a
challenging endeavor due to the potential for
numerous injuries.
• Not all injuries will be immediately apparent.
• Occult injuries have the potential to be missed
and delayed diagnosis can contribute to
patient morbidity and mortality.

3. • The secondary survey is a rapid but thorough
head-to-toe examination assessment to
identify all potential injuries.
• The secondary survey should not be
performed until:
– The primary survey has been completed
– Resuscitation has been initiated
– Normalization of vital signs has begun.

4. • An attempt should be made to obtain the
patient's history regarding the mechanism of
injury
– Blunt trauma (seat belt use, airbag deployment,
extent of damage to the automobile, ejection, and
distance ejected)
– Penetrating trauma (which firearm and how many
gunshots heard).
• AMPLE History
• This mnemonic device can be used for obtaining a
quick, focused history:

5. AMPLE
• Allergy
• Medications
• Previous medical history or illness/pregnancy
• Last Meal
• Events/environment related to injury: What happened
(example mechanisms such as blunt, penetrating, burns or
any hazardous environment, such as exposure to chemicals,
toxins or radiation. These considerations are important for
the following reasons due to exposure to chemical agents
can cause pulmonary, cardiac and other internal organ
dysfunction, or hazardous environment can pose a threat to
the health.

6. Physical Examination
• The purpose of the secondary survey is to
identify injuries. Throughout the evaluation,
standard precautions for blood or fluid-borne
infections should be observed.

7. Head and Face Examination
• Examine the head for scalp hematoma, skull depression, or
laceration. The scalp should be palpated, since scalp
lacerations or bony step-offs may be identified only by
careful palpation. No nasogastric tube (NG) should be
inserted if there is facial trauma or evidence of basilar skull
fracture. Also, the ears should be evaluated for
hemotympanum or retro-auricular ecchymosis (Battle's
sign). The presence of blood or clear drainage from the ear
canal indicates basilar skull fracture with cerebrospinal
(CSF) leak.
• The pupillary size and response, as well as eye movements,
should be assessed. The ocular examination should also
include ocular mobility/entrapment, or periorbital
ecchymosis (Raccoon eyes).

8. Neck Examination
• The neck should be carefully inspected and
palpated. Beware that injuries under the hard
collar may not be obvious. It is assumed that
every 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.

9. Examination of the Chest
• Palpate the entire chest wall for crepitus
(subcutaneous emphysema) and tenderness. The
area over the sternum and clavicles requires
special attention as fractures involving these
bones may 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.

10. Examination of the Abdomen
• The abdomen should be examined for distension,
bowel sounds, bruising or tenderness
• The presence of a seatbelt sign or other marks to
the abdomen should prompt further evaluation.
• It is important to keep in mind that the absence
of abdominal tenderness does not eliminate the
possibility of abdominal injury
•

11. Examination of the Abdomen
• 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
• Examination of the rectum and the genitalia.

12. Examination of the Abdomen
• 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.

13. • 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. In such situations, a vaginal
examination should be performe

14. 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. Injured and Uninjured joints should be
immobilized, and radiographs should be obtained
• The neurovascular status of each extremity should be
assessed and documented.
• Check pulses, the capillary refill time and evaluate each
compartment. The presence of significant pain or tense
compartments. Pain with passive movement may indicate a
development of the compartment syndrome.

15. Pelvic Examination
• The pubis and anterior iliac spines should be
evaluated for any signs of pelvic instability.
The presence of ecchymosis over the iliac
wings, pubis, labia, or scrotum and tenderness
along the pelvic ring also, requires diagnostic
evaluation.

16. Neurologic Examination
• In this evaluation, the sensory and motor
functions should be assessed,
• 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.

18. 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.

19. Complications
• The risk of missed injuries 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