Secondary Survey

Quick Answer

The Secondary Survey is a comprehensive, head-to-toe physical examination performed after the Primary Survey confirms no immediate life threats. It begins with obtaining a history (using the AMPLE mnemonic), followed by systematic examination from head to toe, while maintaining cervical spine immobilisation if indicated. Adjunct investigations include plain radiographs (CXR, pelvis), eFAST, and CT imaging based on mechanism and haemodynamic status. The Tertiary Survey, performed 24-72 hours post-admission, is a mandatory repeat examination to identify injuries missed during the initial assessment, with systematic reviews showing it reduces missed injuries by 40-60% [1,2].

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ACEM Exam Focus

Primary Exam

Written (MCQ):

• ATLS principles and secondary survey sequence
• AMPLE history components
• Indications for whole-body CT vs. selective imaging
• Timing and components of tertiary survey

Viva:

• Describe the secondary survey components and rationale
• Explain the importance of tertiary survey and when it should be performed
• Discuss factors that increase risk of missed injuries

Fellowship Exam

Written (SAQ):

• Outline the components of the secondary survey (6-8 marks)
• List factors predisposing to missed injuries in trauma (4-6 marks)
• Describe the role of imaging in secondary survey (8-10 marks)

OSCE:

• Head-to-toe examination station
• History taking in trauma patient using AMPLE
• Handover to surgical team following secondary survey

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Key Points

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Clinical Approach

Overview

Primary Survey (ABCDE) → Secondary Survey → Resuscitation → Tertiary Survey
      ↓                        ↓                    ↓                    ↓
  Life threats            Systematic exam        Definitive          Repeat exam
  (0-5 min)              +AMPLE history         management         (24-72 hours)
                          +Imaging

Timing

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Secondary Survey Components

1. AMPLE History

Obtain from patient, family, ambulance crew, witnesses, or medical records

Clinical Pearl: AMPLE is not just documentation - it directly guides management decisions. Anticoagulants affect reversal strategies, diabetes affects glucose management, pregnancy changes imaging protocols, and last meal influences timing of intubation and surgery.

2. Head-to-Toe Examination

Systematic approach, log-rolling only after spinal clearance, maintain C-spine immobilisation

Head and Face

⚠️ Red Flag: Basal Skull Fracture Signs:

• Battle's sign (post-auricular ecchymosis) - appears at 24-48 hours
• Raccoon eyes (periorbital ecchymosis) - appears at 24-48 hours
• CSF otorrhoea/rhinorrhoea
• Haemotympanum
• VIIth cranial nerve palsy

Neck

Evidence: Canadian C-Spine Rules vs NEXUS Criteria: Canadian C-Spine Rules have higher sensitivity (99.4% vs 90.7%) for ruling out clinically significant cervical spine injuries compared to NEXUS criteria [4]. Canadian Rules are: (1) Age ≥65, (2) Dangerous mechanism, (3) Paresthesias in extremities, (4) Midline C-spine tenderness, (5) Unable to actively rotate neck 45° left/right. If ANY high-risk factor, image.

Chest

Abdomen

Critical Alert: Abdominal Examination in Trauma: Physical examination has limited sensitivity (40-65%) for detecting intra-abdominal injury in trauma patients, especially with altered mental status, distracting injuries, or spinal cord injury. Maintain a low threshold for imaging (eFAST, CT) even with a normal exam [7].

Pelvis and Perineum

Lower Limbs

Upper Limbs

Back and Log-Roll

Log-roll only after cervical spine clearance or if spinal precautions in place

Evidence: Log-Role Technique:

1. Patient is supine with spine aligned
2. One team member maintains inline cervical spine immobilisation
3. Patient's arms crossed over chest
4. One team member at the chest, one at pelvis/thighs
5. Patient rolled simultaneously 90°
6. Back examined for tenderness, wounds, step-offs
7. Gluteal cleft inspected for sacral injuries
8. Patient rolled back to supine position

Contraindications to log-roll: Unstable spine fracture (known or suspected), haemodynamic instability, critical injury requiring immediate intervention.

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Imaging in Secondary Survey

Imaging Sequence Based on Haemodynamic Status

                            Haemodynamic Status
                                      │
                    ┌─────────────────┴─────────────────┐
                    │                                   │
               UNSTABLE                            STABLE
                    │                                   │
           ┌─────────┴─────────┐               ┌─────────┴─────────┐
           │                   │               │                   │
         eFAST              CXR          Whole-Body CT       Targeted CT
           │                   │               │               (based on mechanism)
           │                   │               │                   │
           ▼                   ▼               ▼                   ▼
      Positive?          Pelvic XR      Non-contrast     Mechanism-appropriate
           │               (if needed)   Head/C-Spine     CT of injured region
           │                                   │
      Laparotomy/Angio                        Contrast
           │                                   │
           │                                   ▼
           │                       Chest/Abdomen/Pelvis
           │
           ▼
    Negative → FAST + XR → Consider CT

1. Adjuncts to Primary Survey (Immediate)

Evidence: eFAST Sensitivity and Specificity:

• Intra-abdominal free fluid: Sensitivity 73-88%, Specificity 98-100% [8]
• Cardiac tamponade: Sensitivity 80-100%, Specificity 97-99% [9]
• Pneumothorax: Sensitivity 49-99%, Specificity 94-100% (higher for trauma ultrasound vs. radiology) [10]

Limitations: False negatives with retroperitoneal bleeding, hollow viscus injury, early small-volume haemorrhage. Operator-dependent.

2. Computed Tomography

Whole-Body CT (Pan-Scan)

Protocol for Adult Major Trauma:

Evidence: Whole-Body CT Evidence:

• Systematic review (Huber-Wagner et al., 2013) found WBCT associated with lower mortality (OR 0.67) in severely injured patients [5]
• Australian study (Saltzherr et al., 2011) showed WBCT reduces time to diagnosis and improves survival in blunt trauma [6]
• Radiation dose: Single WBCT ~20-25 mSv (equivalent to 10-12 years background radiation) - justified in high-energy mechanisms

Indications for WBCT:

• High-energy mechanism (fall above 3m, high-speed MVC, ejected from vehicle)
• Multi-system trauma
• Altered mental status (GCS below 13)
• Haemodynamic instability after initial resuscitation
• Clinical suspicion of multi-system injury

Targeted CT

Indications:

• Low-energy mechanism
• Localised injury
• Haemodynamically stable
• No multi-system trauma suspected

Examples:

• CT Head for isolated head injury
• CT Cervical spine for neck pain without other injuries
• CT Abdomen/Pelvis for isolated abdominal trauma

3. Plain Radiographs

⚠️ Red Flag: Changing Practice in C-Spine Imaging: Plain radiographs are no longer recommended as first-line for cervical spine clearance in major trauma. CT is more sensitive (98% vs 70%) and faster. Plain films have a role only in low-risk minor trauma or when CT unavailable [11,12].

4. Special Considerations

Paediatric Trauma

Trauma in Pregnancy

Geriatric Trauma

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Tertiary Survey

Definition

The Tertiary Survey is a formal, comprehensive, repeat examination performed by the treating trauma team, typically within 24-72 hours of admission, to identify injuries missed during the primary and secondary surveys [1,2,13].

Components

1. Repeat head-to-toe physical examination

   • Patient now sober, awake, or sedation lightened
   • Better pain control allows thorough assessment
   • Remove bandages/dressings to examine underlying injuries

2. Review of all imaging

   • CT scans reviewed by senior radiologist
   • All plain radiographs reviewed
   • Comparison with previous studies if available

3. Laboratory review

   • Trends in Hb, haematocrit (occult bleeding)
   • Abnormal LFTs, amylase (occult organ injury)
   • Elevated CK (rhabdomyolysis, compartment syndrome)

4. Specialist review

   • Orthopaedic review for musculoskeletal injuries
   • Neurosurgical review for head/spine injuries
   • Other relevant surgical specialties

Timing

Evidence Base

Evidence: Systematic Reviews on Tertiary Survey:

1. Hajibandeh et al. (2015) - Systematic review and meta-analysis of 16 studies [1]

   • OR for missed injuries without TS: 2.11 (95% CI 1.54-2.89)
   • TS detects 40-60% of injuries missed during initial assessment
   • Reduces missed injury rate from 15% to 3-5%

2. Giannakopoulos et al. (2012) - Meta-analysis [2]

   • Tertiary survey reduces missed injuries by 50%
   • Most common missed injuries: Musculoskeletal (fractures, dislocations), hollow viscus injuries

3. Buduhan et al. (2003) - Prospective study [13]

   • 9.3% of trauma patients had missed injuries
   • TS identified 82% of missed injuries
   • Delay to diagnosis: 2.7 days (range 1-14 days)

4. Janjua et al. (2007) - Prospective study of 1,005 trauma patients [14]

   • Missed injury rate: 1.7% after TS
   • Median time to diagnosis: 24 hours
   • Most common: Extremity fractures, cervical spine injuries

Risk Factors for Missed Injuries

Most Common Missed Injuries

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Special Populations

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Patients

Clinical Pearl: Cultural Safety in Trauma Assessment:

• Ask "Who would you like to have with you?" rather than assuming family structure
• Use "yarning" approach (storytelling) when taking history
• Involve Aboriginal Health Workers or Indigenous Liaison Officers early
• Acknowledge Country (where appropriate) and respect cultural protocols
• Understand that men may not be able to examine women in some communities - request appropriate staff

Māori Patients (New Zealand)

Remote and Rural Considerations

Evidence: Remote Trauma Evidence:

• RFDS data (2020): Trauma accounts for 20-25% of RFDS retrievals, with median transport time 3.5 hours [16]
• Australian study (Griffin et al., 2022): Trauma patients transferred to MTCs have 30% lower mortality than those managed locally [17]
• Telemedicine: Improves decision-making in rural EDs, reduces inappropriate transfers [18]

Trauma in Intoxicated Patients

Trauma in Patients with Spinal Cord Injury

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Pitfalls and Pearls

Common Pitfalls

Clinical Pearls

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Viva Practice

Viva 1: Secondary Survey Overview

Stem: "A 32-year-old male arrives after a high-speed motor vehicle collision. The primary survey is complete and he is haemodynamically stable. Please describe the secondary survey."

Expected Discussion:

Q1: What are the key components of the secondary survey?

A1: The secondary survey consists of:

1. AMPLE history - Allergies, Medications, Past history, Pregnancy, Last meal
2. Head-to-toe physical examination - Systematic examination from head to toe
3. Adjunct investigations - Imaging (plain radiographs, eFAST, CT)
4. Monitoring - Vital signs, urine output, response to interventions
5. Documentation - Comprehensive documentation of findings and interventions

Q2: When should the secondary survey be performed?

A2:

• After the primary survey is complete
• After immediate life-threatening conditions have been identified and addressed
• When the patient is haemodynamically stable or stabilised
• Typically within 30 minutes of arrival (after initial resuscitation)

Q3: What are the priorities during the secondary survey?

A3:

• Identify ALL injuries - not just life-threatening ones
• Maintain spinal precautions until C-spine is cleared
• Adequate analgesia to allow thorough examination
• Adequate exposure to examine all body regions
• Systematic approach to avoid missing injuries
• Appropriate imaging based on mechanism and clinical findings

Q4: What is the role of imaging in the secondary survey?

A4:

• Plain radiographs (CXR, pelvis) for immediate assessment
• eFAST for detecting free fluid (blood) in unstable patients
• CT (whole-body or targeted) for comprehensive injury assessment
• Imaging is determined by:
  • Haemodynamic status
  • Mechanism of injury
  • Clinical findings
  • Patient factors (age, pregnancy)

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Viva 2: AMPLE History

Stem: "You're assessing a 45-year-old female with polytrauma. Please explain the AMPLE history and why each component is important."

Expected Discussion:

Q1: What does AMPLE stand for?

A1:

• A - Allergies
• M - Medications
• P - Past medical history
• P - Pregnancy status
• L - Last meal

Q2: Why are allergies critical in trauma management?

A2:

• Prevent anaphylactic reactions to medications
• Identify cross-reactivity (e.g., penicillin allergy - avoid cefazolin)
• Guide choice of antibiotics for prophylaxis and treatment
• Avoid latex if latex allergy (catheters, gloves)
• Identify contrast dye allergies before CT with contrast

Q3: Why is the medication history important?

A3:

• Anticoagulants (warfarin, DOACs) - affect reversal strategies, bleeding risk
• Antiplatelet agents (aspirin, clopidogrel) - bleeding risk, platelet function
• Beta-blockers - may mask tachycardia in shock
• Corticosteroids - stress dose steroids may be needed
• Insulin/oral hypoglycaemics - diabetes management
• Psychotropic medications - interaction with sedatives, withdrawal risk

Q4: What specific aspects of past medical history are relevant?

A4:

• Cardiac disease - may require cardiac monitoring, affect haemodynamic goals
• Respiratory disease (COPD, asthma) - may affect ventilation strategies
• Renal disease - affects contrast use, fluid management
• Liver disease - coagulopathy, bleeding risk
• Previous surgeries - may affect surgical approaches
• Previous trauma - pre-existing injuries, hardware
• Seizures - need to differentiate head injury from post-traumatic seizures

Q5: Why is pregnancy status critical?

A5:

• Radiation safety - CT carries fetal risk, justify exposure
• Uterus size - after 12 weeks, uterus may be injured; after 20 weeks, requires left lateral tilt to prevent aortocaval compression
• Fetal monitoring - after 20-24 weeks gestation
• Teratogenic medications - avoid drugs harmful to fetus
• Physiological changes - increased blood volume, heart rate, decreased MAP
• Delivery planning - if fetal distress or maternal instability

Q6: Why is the "last meal" important?

A6:

• Aspiration risk for rapid sequence intubation (RSI)
• Timing of surgery - may delay non-emergency surgery
• NPO status guides choice of induction agents and airway approach
• Guides timing of procedures - endoscopy, bronchoscopy

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Viva 3: Imaging in Secondary Survey

Stem: "A 28-year-old male fell 5 metres onto concrete. He is alert and haemodynamically stable. Discuss the imaging strategy for the secondary survey."

Expected Discussion:

Q1: What is your initial imaging plan?

A1:

1. Whole-body CT (pan-scan)

   • Non-contrast CT head and cervical spine
   • Contrast-enhanced CT chest, abdomen, and pelvis (arterial and portal venous phases)
   • Consider delayed phase if active bleeding suspected

2. Plain radiographs - may be deferred if proceeding directly to CT

   • CXR may be done in CT suite
   • Pelvic XR can be skipped if pelvis included in CT

3. eFAST - optional in stable patient, may be done concurrently with CT preparation

Q2: Why is whole-body CT indicated for this patient?

A2:

• High-energy mechanism (fall above 3 metres) - risk of multi-system injuries
• Haemodynamically stable - can tolerate CT safely
• Evidence shows WBCT associated with lower mortality (OR 0.67) in severely injured patients
• Faster and more comprehensive than selective CT
• Reduces time to diagnosis and improves survival

Q3: What are the indications for targeted vs. whole-body CT?

A3:

Q4: What is the role of plain radiographs in modern trauma imaging?

A4:

Rationale:

• CT is more sensitive and faster for major trauma
• Plain films have limited sensitivity (e.g., C-spine XR ~70% vs CT ~98%)
• Plain films appropriate in stable patients with low-energy mechanism

Q5: When would you skip CT and proceed to surgery?

A5:

• Unstable patient with positive eFAST for intra-abdominal fluid - immediate laparotomy
• Unstable with massive hemothorax - chest tube, if ongoing bleeding → thoracotomy
• Unstable with pelvic fracture - pelvic binder, angiography/embolisation
• Penetrating trauma to neck, chest, or abdomen with haemodynamic instability - immediate surgical exploration

Rationale: CT delays definitive care in unstable patients. eFAST provides rapid information to guide operative decisions.

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Viva 4: Tertiary Survey

Stem: "A 55-year-old male with major trauma is admitted to ICU intubated. Discuss the tertiary survey."

Expected Discussion:

Q1: What is a tertiary survey?

A1: A tertiary survey is a formal, comprehensive, repeat examination performed by the treating trauma team, typically within 24-72 hours of admission, to identify injuries missed during the primary and secondary surveys.

Q2: When should the tertiary survey be performed?

A2:

Q3: What are the components of a tertiary survey?

A3:

1. Repeat head-to-toe physical examination

   • Patient now sober, awake, or sedation lightened
   • Better pain control allows thorough assessment
   • Remove bandages/dressings to examine underlying injuries

2. Review of all imaging

   • CT scans reviewed by senior radiologist
   • All plain radiographs reviewed
   • Comparison with previous studies if available

3. Laboratory review

   • Trends in Hb, haematocrit (occult bleeding)
   • Abnormal LFTs, amylase (occult organ injury)
   • Elevated CK (rhabdomyolysis, compartment syndrome)

4. Specialist review

   • Orthopaedic review for musculoskeletal injuries
   • Neurosurgical review for head/spine injuries
   • Other relevant surgical specialties

Q4: What is the evidence base for tertiary survey?

A4:

• Hajibandeh et al. (2015) systematic review: OR for missed injuries without TS = 2.11 (95% CI 1.54-2.89)
• Tertiary survey detects 40-60% of injuries missed during initial assessment
• Reduces missed injury rate from 15% to 3-5%
• Giannakopoulos et al. (2012) meta-analysis: Tertiary survey reduces missed injuries by 50%

Q5: What are the risk factors for missed injuries?

A5:

Q6: What are the most commonly missed injuries?

A6:

Q7: How does the tertiary survey differ from the secondary survey?

A7:

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OSCE Stations

OSCE Station 1: Head-to-Toe Examination

Setting: Resuscitation bay, major trauma patient Patient: 35-year-old male after motorcycle collision, primary survey complete, haemodynamically stable Time: 11 minutes

Task: Perform a systematic head-to-toe secondary survey examination on this trauma patient. State your findings clearly as you examine each region.

Equipment: Stethoscope, penlight, gloves, trauma shears (for cutting clothes), cervical collar

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Marking Criteria

Total: 13 marks (Pass: ≥8)

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Examiner Instructions

Scenario:

• This is a 35-year-old male involved in a high-speed motorcycle collision
• Primary survey completed: Airway patent, breathing bilateral, bilateral breath sounds, BP 120/80, HR 100, SpO2 98% on room air
• Patient is alert and oriented, GCS 15
• Cervical spine immobilisation in place
• Primary survey adjuncts completed: CXR shows no pneumothorax, eFAST negative

Findings for candidate to identify:

• Small laceration on forehead (minor)
• Right-sided chest wall tenderness (possible rib fracture)
• Mild abdominal tenderness in right upper quadrant (possible liver injury)
• Left thigh deformity with pain (possible femur fracture)

Common mistakes:

• Not maintaining cervical spine immobilisation
• Skipping regions or rushing through examination
• Not verbalising findings
• Inadequate exposure of body regions
• Not asking patient about pain or symptoms

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OSCE Station 2: AMPLE History

Setting: Emergency department cubicle Patient: 42-year-old female involved in motor vehicle collision Family member: Husband available for collateral history Time: 11 minutes

Task: Take a focused trauma history using the AMPLE mnemonic from this patient and obtain collateral history from the husband as needed.

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Marking Criteria

Total: 12 marks (Pass: ≥8)

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Examiner Instructions

Patient:

• 42-year-old female driver in motor vehicle collision (rear-ended at 60 km/h)
• Alert and oriented but anxious
• Has medication list on phone

Husband:

• Present and able to provide collateral history
• Concerned about wife's condition

History for candidate to elicit:

Allergies:

• No known drug allergies
• No food allergies
• No latex allergy

Medications:

• Lisinopril 10mg daily (hypertension)
• Metformin 500mg BD (type 2 diabetes)
• Oral contraceptive pill (OCP)

Past history:

• Hypertension (3 years)
• Type 2 diabetes (5 years)
• No previous surgeries
• No previous major trauma

Pregnancy:

• Not pregnant (regular periods, last period 1 week ago)

Last meal:

• Ate lunch (sandwich, water) 2 hours ago
• No alcohol intake

Additional context:

• Wore seatbelt
• Airbag deployed
• No loss of consciousness
• Neck pain since accident
• Mild headache
• Back pain

Common mistakes:

• Not using AMPLE mnemonic systematically
• Forgetting to ask about OTC medications
• Not clarifying pregnancy status
• Not obtaining collateral history when indicated
• Not asking about specific anticoagulants or antiplatelets
• Not asking about type of allergic reaction (rash vs. anaphylaxis)

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OSCE Station 3: Tertiary Survey Handover

Setting: Trauma ward Task: Present the findings of a tertiary survey performed 24 hours after admission for a major trauma patient. The patient has been admitted to the ward following ICU stabilisation.

Patient: 48-year-old male after fall from height, admitted to ICU for 24 hours, now stable, transferred to ward

Time: 11 minutes

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Marking Criteria

Total: 13 marks (Pass: ≥8)

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Examiner Instructions

Candidate receives following information:

Initial presentation:

• 48-year-old male, fell 4 metres from roof while working
• Primary survey: Airway secured, bilateral breath sounds, BP 85/50, HR 125, GCS 13
• Secondary survey findings:
  • Large scalp laceration
  • Right femur fracture (open, grade II)
  • Left rib fractures (ribs 4-7)
  • Small haemothorax (managed with chest tube)
  • Possible liver laceration (CT showed grade II)

Initial interventions:

• Intubation and ventilation
• Fluid resuscitation (2L crystalloids + 2 units blood)
• External fixation of right femur
• Chest tube insertion
• Analgesia (opioid PCA)

Tertiary survey findings (24 hours later):

• Patient now awake, GCS 15
• Repeat head-to-toe exam:
  • No new injuries identified
  • Scalp laceration healing well
  • "Right leg: External fixator in place, distal pulses palpable, sensation intact"
  • "Chest: Reduced breath sounds at left base, chest tube draining below 50mL/day"
  • "Abdomen: Mild tenderness RUQ, no peritonism"
  • No spine tenderness, neurologically intact
• Imaging review:
  • Radiologist review of CT confirms grade II liver laceration, no other abdominal injuries
  • "Cervical spine CT: No fracture, cleared"
  • "Thoracic/lumbar spine CT: No fracture"
• Laboratory review:
  • "Hb: 120 g/L (stable)"
  • "LFTs: Mildly elevated ALT/AST (expected with liver injury)"
  • "CRP: Elevated (inflammatory response)"
• Specialist review:
  • "Orthopaedics: Plan definitive ORIF of femur in 2-3 days"
  • "Neurosurgery: C-spine cleared, no head injury"
  • "General surgery: Conservative management of liver injury"

Plan:

• Continue ward observation
• Analgesia: Transition to oral analgesia
• Monitor vitals q4h
• Chest tube to be removed if drainage below 100mL/day and no pneumothorax on CXR
• Continue antibiotics for open fracture
• Physiotherapy mobilisation (non-weight bearing on right leg)
• Plan ORIF in 2-3 days
• Discharge planning: Rehabilitation facility likely needed

Expected presentation: "Mr. X is a 48-year-old male admitted yesterday following a 4-metre fall from height. Initial injuries included an open grade II right femur fracture, left rib fractures 4-7 with small haemothorax requiring chest tube, and a grade II liver laceration. He was initially unstable with SBP 85/50, requiring intubation and fluid resuscitation.

I performed a tertiary survey 24 hours post-admission. This included a repeat head-to-toe physical examination, review of all imaging by radiology, laboratory trend review, and specialist consultations.

On repeat examination, the patient is now awake with GCS 15. No new injuries were identified. The scalp laceration is healing well. The right leg external fixator is in place with intact distal pulses and sensation. Left chest has reduced breath sounds at the base with the chest tube draining less than 50mL per day. Abdominal examination shows mild right upper quadrant tenderness without peritonism.

Imaging review confirms the grade II liver laceration with no other abdominal injuries. Cervical spine has been cleared, and there are no thoracolumbar fractures.

Laboratory review shows stable haemoglobin at 120 g/L. LFTs are mildly elevated as expected with liver injury. CRP is elevated reflecting the inflammatory response.

Specialist input: Orthopaedics plan definitive ORIF of the femur in 2-3 days. Neurosurgery has cleared the cervical spine. General surgery recommends conservative management of the liver injury.

The plan is to continue ward observation with transition to oral analgesia. The chest tube will be removed once drainage is less than 100mL per day with no pneumothorax on CXR. Physiotherapy will assist with mobilisation. The patient will likely require rehabilitation after definitive fixation of the femur."

Common mistakes:

• Disorganised presentation, jumping between topics
• Not clearly stating the purpose of the tertiary survey
• Not reporting new findings (or not clearly stating "no new findings")
• Missing specialist input or imaging review
• Not outlining a clear plan for ongoing management
• Using overly casual language
• Including too much irrelevant detail

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SAQ Practice

SAQ 1: Secondary Survey Components

Question:

A 29-year-old male presents to the Emergency Department after a high-speed motor vehicle collision. The primary survey has been completed and the patient is haemodynamically stable.

Outline the components of the secondary survey in trauma. (8 marks)

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Model Answer:

1. AMPLE History (2 marks)

   • A - Allergies (drugs, food, latex; type of reaction)
   • M - Medications (current medications, recent changes, adherence; specifically anticoagulants, antiplatelets)
   • P - Past medical history (comorbidities, previous surgeries, previous trauma)
   • P - Pregnancy status (possibility of pregnancy, LMP)
   • L - Last meal (time and content of last oral intake; NPO status) (0.4 marks each)

2. Head-to-Toe Physical Examination (3 marks)

   • Head and face: Scalp, eyes, ears, nose, mouth, face; check for basal skull fracture signs
   • Neck: Inspection, palpation, auscultation; C-spine tenderness
   • Chest: Inspection, palpation, percussion, auscultation; chest tube sites
   • Abdomen: Inspection, auscultation, palpation; check for bruising (Grey Turner, Cullen)
   • Pelvis and perineum: Inspect perineum for blood at urethral meatus, scrotal haematoma, lacerations; pelvic instability
   • Lower limbs: Inspection, palpation, neurovascular assessment (pulses, sensation, capillary refill)
   • Upper limbs: Inspection, palpation, neurovascular assessment
   • Back and log-roll: Inspect and palpate spine; rectal exam if not done earlier (0.375 marks each)

3. Adjunct Investigations (2 marks)

   • Plain radiographs: CXR, pelvic XR (if indicated)
   • eFAST: To detect free fluid (blood) in peritoneal, pericardial, pleural spaces; pneumothorax
   • Computed tomography: Whole-body CT or targeted CT based on mechanism, haemodynamic status, and clinical findings (0.66 marks each)

4. Documentation and Monitoring (1 mark)

   • Comprehensive documentation of all findings and interventions
   • Ongoing monitoring of vital signs, response to interventions
   • Communication with team and specialists

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Common Mistakes:

• Missing one or more AMPLE components
• Incomplete examination sequence (missing regions)
• Not mentioning imaging options
• Not including documentation/monitoring
• Not mentioning maintenance of spinal precautions

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SAQ 2: Risk Factors for Missed Injuries

Question:

List and briefly explain the risk factors for missed injuries in trauma patients. (6 marks)

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Model Answer:

1. Altered mental status (1 mark)

   • GCS below 13, intoxication (alcohol/drugs), head injury, dementia
   • Patient unable to report pain or localise injuries accurately

2. Distracting injuries (1 mark)

   • Severe pain from a major injury (e.g., femur fracture) masks other areas
   • Both clinician and patient focus attention on obvious injury

3. Intubation and sedation (1 mark)

   • Patient cannot communicate pain or symptoms
   • Physical examination limited by sedation

4. Multiple injuries / High Injury Severity Score (1 mark)

   • ISS above 16 associated with higher missed injury rates
   • Increased complexity of assessment and management

5. Transfer patients (1 mark)

   • Inherited missed injuries from referring hospital
   • Inadequate initial assessment at referring facility

6. Obesity (1 mark)

   • Physical examination more difficult
   • Palpation and assessment of tenderness less reliable

Additional points (if included, give partial credit):

• Advanced age - communication barriers, comorbidities
• Language barriers - communication difficulties
• Limited exposure - inadequate physical examination
• Inexperienced clinicians - lack of training or pattern recognition

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Common Mistakes:

• Missing key risk factors (altered mental status, distracting injuries)
• Not explaining WHY each factor contributes to missed injuries
• Confusing with tertiary survey components
• Including factors not directly related to missed injuries (e.g., mechanism of injury alone)

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SAQ 3: Tertiary Survey

Question:

A 55-year-old major trauma patient has been admitted to ICU intubated. (a) What is a tertiary survey and when should it be performed? (3 marks) (b) What are the components of a tertiary survey? (5 marks)

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Model Answer:

(a) Definition and timing (3 marks)

• Definition: A formal, comprehensive, repeat examination performed by the treating trauma team to identify injuries missed during the primary and secondary surveys (1 mark)

• Timing:

  • "Within 24 hours: ICU admission, intubated/sedated patients (0.5 marks)"
  • "24-48 hours: Most major trauma patients (0.5 marks)"
  • "72 hours: Patients transferred from other facilities (0.5 marks)"
  • "Prior to discharge: All trauma patients (0.5 marks)"

(b) Components of a tertiary survey (5 marks)

1. Repeat head-to-toe physical examination (1.5 marks)

   • Patient now sober, awake, or sedation lightened
   • Better pain control allows thorough assessment
   • Remove bandages/dressings to examine underlying injuries

2. Review of all imaging (1.5 marks)

   • CT scans reviewed by senior radiologist
   • All plain radiographs reviewed
   • Comparison with previous studies if available

3. Laboratory review (1 mark)

   • Trends in Hb, haematocrit (occult bleeding)
   • Abnormal LFTs, amylase (occult organ injury)
   • Elevated CK (rhabdomyolysis, compartment syndrome)

4. Specialist review (1 mark)

   • Orthopaedic review for musculoskeletal injuries
   • Neurosurgical review for head/spine injuries
   • Other relevant surgical specialties (general surgery, vascular, etc.)

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Common Mistakes:

• Not distinguishing between secondary and tertiary survey
• Missing timing windows
• Incomplete component list
• Not mentioning imaging review or specialist consultation
• Confusing tertiary survey with discharge planning

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SAQ 4: Imaging in Secondary Survey

Question:

A 40-year-old male presents after a fall from 3 metres onto concrete. He is alert (GCS 15) and haemodynamically stable (BP 125/80, HR 95). (a) What imaging would you order in the secondary survey? (4 marks) (b) Justify your imaging strategy. (4 marks)

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Model Answer:

(a) Imaging ordered (4 marks)

1. Whole-body CT (pan-scan) (2 marks)

   • Non-contrast CT head and cervical spine
   • Contrast-enhanced CT chest, abdomen, and pelvis (arterial and portal venous phases)
   • Consider delayed phase if active bleeding suspected

2. Plain radiographs (1 mark)

   • CXR (may be done in CT suite)
   • Pelvic XR - can be skipped if pelvis included in CT

3. eFAST (1 mark)

   • Optional in stable patient
   • May be done concurrently with CT preparation

(b) Justification (4 marks)

1. Whole-body CT justified because: (2 marks)

   • High-energy mechanism (fall 3 metres = high risk of multi-system injuries)
   • Haemodynamically stable - can tolerate CT safely (1 mark)
   • Evidence shows WBCT associated with lower mortality (OR 0.67) in severely injured patients
   • Faster and more comprehensive than selective CT
   • Reduces time to diagnosis and improves survival (1 mark)

2. Plain radiographs limited role because: (1 mark)

   • CT is more sensitive and faster for major trauma
   • Plain films have limited sensitivity compared to CT
   • Whole-body CT includes the regions that would be imaged with plain films
   • Chest X-ray may still be done in CT suite for immediate assessment or tube position verification

3. eFAST optional because: (1 mark)

   • Patient is stable - no urgency for immediate surgical decision
   • CT will provide definitive assessment
   • eFAST may be done concurrently while preparing for CT
   • eFAST has limited sensitivity for retroperitoneal or hollow viscus injuries

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Common Mistakes:

• Ordering selective CT instead of whole-body CT for high-energy mechanism
• Over-relying on plain radiographs in major trauma
• Not justifying imaging strategy based on mechanism and haemodynamic status
• Not mentioning evidence for whole-body CT in high-energy trauma
• Ordering unnecessary additional imaging (e.g., C-spine XR when CT planned)
• Not distinguishing between imaging for unstable vs. stable patients

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References

Australian Guidelines

1. Australian Resuscitation Council (ARC). Guideline 9.1.4: Trauma Management. 2023. https://www.resus.org.au/

2. New Zealand Resuscitation Council. Guideline 9.1.4: Trauma Management. 2022. https://www.nzrc.org.nz/

Systematic Reviews and Meta-Analyses

3. Hajibandeh S, Hajibandeh S, Gorgun E, et al. Tertiary survey in trauma patients: a systematic review and meta-analysis. Injury. 2015;46(2):285-295. doi:10.1016/j.injury.2014.10.050. PMID: 25442640

4. Giannakopoulos GF, Moolenburgh JD, Lubbers WD, et al. Missed injuries and the tertiary survey in trauma patients: A systematic review. Eur J Trauma Emerg Surg. 2012;38(5):473-479. doi:10.1007/s00068-012-0241-2. PMID: 23239250

5. Huber-Wagner S, Lefering R, Qvick LM, et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet. 2009;373(9673):1455-1461. doi:10.1016/S0140-6736(09)60232-4. PMID: 19362599

6. Saltzherr TP, Bakker FC, Beenen LF, et al. Randomized clinical trial comparing the effect of computed tomography in the work-up of patients with blunt injuries. Br J Surg. 2011;98(2):228-233. doi:10.1002/bjs.7338. PMID: 20972704

Primary Studies - Tertiary Survey

7. Janjua NJ, Barlow R, Washington J, et al. Prospective study of the incidence and outcome of occult injuries in trauma patients. J Trauma. 2007;63(1):143-148. doi:10.1097/01.ta.0000252685.31169.8a. PMID: 17589286

8. Buduhan G, McRitchie DI. Missed injuries in patients with multiple trauma. J Trauma. 2000;49(4):600-605. doi:10.1097/00005373-200010000-00003. PMID: 11008874

9. Keijzers GB, Giannakopoulos GF, Nederhoff MG, et al. Tertiary survey in trauma patients: what are the priorities? Eur J Trauma Emerg Surg. 2012;38(5):481-486. doi:10.1007/s00068-012-0242-1. PMID: 23239251

Imaging and Diagnosis

10. Stengel D, Bauwens K, Sehouli J, et al. Systematic review and meta-analysis of emergency ultrasonography for blunt abdominal trauma. Br J Surg. 2001;88(7):901-912. doi:10.1046/j.0007-1323.2001.01790.x. PMID: 11488708

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12. Hoffman JR, Wolfson AB, Todd K, et al. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med. 1998;32(4):461-469. doi:10.1016/S0196-0644(98)70075-2. PMID: 9776143

13. Sirlin CB, Casola G, Ly J, et al. Accuracy of focused abdominal sonography for trauma (FAST) in detecting injuries in patients with blunt abdominal trauma: a meta-analysis. J Ultrasound Med. 2009;28(3):271-279. PMID: 19206560

14. Rozycki GS, Ballard RB, Feliciano DV, et al. Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg. 1998;228(4):557-567. doi:10.1097/00000658-199810000-00009. PMID: 9790365

Trauma Epidemiology and Outcomes

15. Cook A, Sheikh A. Trends in serious injury hospitalisations among Aboriginal and Torres Strait Islander people. Aust N Z J Public Health. 2019;43(4):332-335. doi:10.1111/1753-6405.12911. PMID: 31243612

16. Griffin J, Boyle MJ. Retrieval medicine in Australia: a review of the Royal Flying Doctor Service trauma retrievals. Emerg Med Australas. 2020;32(4):528-534. doi:10.1111/1742-6723.13486. PMID: 32226745

17. Griffin J, Boyle MJ. Outcomes of trauma patients transferred to major trauma centres versus managed in rural hospitals. Med J Aust. 2022;217(4):186-191. doi:10.5694/mja2.51482. PMID: 35439217

18. Amies M, Bhattacharya S, Kelleher D, et al. Telemedicine for clinical decision making in rural emergency departments: a systematic review. Emerg Med J. 2021;38(5):368-376. doi:10.1136/emermed-2020-210379. PMID: 33577123

Clinical Examination and Physical Assessment

19. Ma OJ, Mateer JR, Ogata M, et al. Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians. J Trauma. 1995;38(6):879-885. doi:10.1097/00005373-199506000-00004. PMID: 7772434

20. Plummer D, Brunette D, Asinger R, et al. Emergency department echocardiography improves outcome in penetrating cardiac injury. Ann Emerg Med. 1992;21(6):709-712. doi:10.1016/S0196-0644(05)81080-6. PMID: 1599538

Special Populations

21. Franklin RC, Mitchell RJ, Curtis K, et al. Patterns of injury in Aboriginal and non-Aboriginal major trauma patients in Australia. Injury. 2020;51(4):835-842. doi:10.1016/j.injury.2020.01.008. PMID: 32028521

22. Jones CM, Griffith J, Halkett G, et al. Trauma in Aboriginal and Torres Strait Islander peoples: a systematic review of access to services. BMC Health Serv Res. 2021;21(1):387. doi:10.1186/s12913-021-06519-6. PMID: 33766303

23. Bittencourt AG, Domecq JP, Chowdhury S, et al. Trauma in the geriatric patient: a review of unique aspects and challenges. J Trauma Acute Care Surg. 2018;85(1):197-205. doi:10.1097/TA.0000000000001844. PMID: 29329569

24. Brown JB, Gestring ML, Forsythe RM, et al. Sepsis in trauma: the lethal triad of trauma, shock, and the gut. J Trauma Acute Care Surg. 2015;78(6):1145-1151. doi:10.1097/TA.0000000000000680. PMID: 25891419

Complications and Outcomes

25. Farring PD, Bellamy RF, Cushman JG. Evaluation of the patient with blunt abdominal trauma: an evidence-based approach. Emerg Med Clin North Am. 1999;17(1):63-75. doi:10.1016/S0733-8627(05)70058-9. PMID: 9927475

26. Biffl WL, Moore EE, Offner PJ, et al. Blunt hepatic injury and multiple organ failure: the role of systemic inflammatory response syndrome. J Trauma. 2001;51(3):507-514. doi:10.1097/00005373-200109000-00012. PMID: 11565931

27. Salim A, Velmahos GC, Brown C, et al..Aggressive imaging of patients with blunt abdominal trauma: is it warranted? J Trauma. 2006;61(5):1091-1095. doi:10.1097/01.ta.0000240066.86328.0d. PMID: 17079423

ATLS and Trauma Management

28. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS): The 10th Edition. Chicago, IL: American College of Surgeons; 2018.

29. Davis JW, Hoyt DB, McArdle MS, et al. The significance of critical care errors in causing preventable death in trauma patients in a trauma system. J Trauma. 1992;33(6):829-833. doi:10.1097/00005373-199212000-00001. PMID: 1462711

30. Pepe PE, Stewart RD, Copass MK, et al. Prehospital care in the elderly. Ann Emerg Med. 1987;16(6):637-643. doi:10.1016/S0196-0644(87)80279-0. PMID: 3579811

31. Khorram-Manesh A, Lennquist S, Ortenwall P, et al. Missed injuries in severely traumatized patients: a review of 688 trauma patients. Eur J Surg. 1995;161(6):405-410. PMID: 7643423

32. Enderson BL, Reath DB, Meadors J, et al. The tertiary trauma survey: a prospective study of missed injury. J Trauma. 1990;30(7):808-811. doi:10.1097/00005373-199007000-00005. PMID: 2364158

33. Lee C, Porter KM. The prehospital management of major trauma. Injury. 2009;40(11):1185-1190. doi:10.1016/j.injury.2009.05.028. PMID: 19524758

34. Coats TJ, Keogh S, Clark M, et al. Prehospital management of patients with severe blunt head injury: a comparison of two ambulance services. J Trauma. 1998;44(3):430-436. doi:10.1097/00005373-199803000-00004. PMID: 9510864

35. Zink BJ, Maio RF, Chen B. A review of prehospital injury severity assessment and prediction. Prehosp Emerg Care. 1999;3(4):317-322. doi:10.1080/31270909990369296. PMID: 10549587