EM · Secondary survey
Secondary survey
The ATLS secondary survey — the head-to-toe examination of the stable trauma patient, the AMPLE history, the clinical decision rules for the head CT (the Canadian CT Head Rule) and the cervical spine clearance (the NEXUS and the Canadian C-Spine Rule), the special investigations (the FAST and eFAST, the whole-body CT, the pelvic film), the tertiary survey and the continuous re-evaluation for the missed injury.
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The secondary survey is the systematic, head-to-toe examination of the trauma patient that is performed after the primary survey is complete, the immediately life-threatening conditions are treated, and the patient is stable. It exists to find the injuries that were not immediately life-threatening and so were not addressed in the primary survey — the fractures, the lacerations, the nerve deficits, the occult organ injuries — before they become the source of the preventable morbidity. The Fellowship candidate must know the ATLS framework, the AMPLE history, the clinical decision rules for the imaging (the Canadian CT Head Rule and the NEXUS or the Canadian C-Spine Rule), and the principle that the examination is never truly complete until the tertiary survey and the continuous re-evaluation are done.[1][1]
When the secondary survey begins — the precondition and the timing
The single rule that governs the secondary survey is that it is earned, not assumed: it does not start until the primary survey (the A–B–C–D–E) is complete, the immediately life-threatening conditions are treated, and the patient is physiologically stable. The unstable patient does not get a secondary survey — the unstable patient gets a return to the primary survey and, in the bleeding or the shocked patient, the operating theatre or the angiography suite, not the computed-tomography scanner. The patient who is stable at the start of the secondary survey and then deteriorates is brought back to the primary survey: the deterioration means a life threat was missed, or a new one has developed, and the head-to-toe examination is suspended until the airway, the breathing and the circulation are again secured.[1][1]
The secondary survey has a fixed order — the head, the face, the neck and the cervical spine, the chest, the abdomen, the perineum and the rectum, the musculoskeletal system, the skin, and the complete neurological examination — and it is performed once the patient is exposed, the monitoring is in place, and the tubes and the lines are sited. It runs in parallel with the special investigations (the FAST, the radiographs, the laboratory bloods) and is followed by the definitive imaging (the CT) in the patient who remains stable. The examination is documented as it is done, and it is repeated — the tertiary survey within 24 hours, and the continuous re-evaluation throughout.[1]
The secondary survey — the order of the head-to-toe examination
0 — Confirm the precondition
The primary survey is complete, the life threats are treated, the airway, breathing and circulation are secured, and the vital signs are stable. If the patient deteriorates at any point, abandon the secondary survey and return to the A–B–C–D–E of the primary survey.<Cite id="1" />
1 — Head and face
The scalp (the lacerations, the depressions, the haematomas), the skull, the eyes, the ears, the nose, the mouth, the face, and the signs of the basal-skull fracture (the raccoon eyes, the Battle sign, the haemotympanum, the CSF leak).
2 — Neck and cervical spine
The penetrating wounds, the tracheal position, the neck veins, the laryngeal crepitus, the cervical-spine tenderness — and the formal cervical-spine clearance by the NEXUS or the Canadian C-Spine Rule, or the CT.
3 — Chest
Inspect, palpate, percuss, auscultate: the clavicles, the ribs, the sternum, the subcutaneous emphysema, the breath sounds, the murmurs. Re-review the chest radiograph and the FAST.
4 — Abdomen and pelvis
The distension, the tenderness, the guarding, the bruising (the seat-belt sign, the flank bruising), the bowel sounds, and the single gentle lateral compression of the pelvis (never repeated).
5 — Perineum, rectum and genitourinary
The perineal lacerations and bruising, the blood at the urethral meatus, the scrotal haematoma; the rectal tone, the prostate position, the blood; the vaginal examination in the female patient.
6 — Musculoskeletal and skin
Each limb for the deformity, the swelling, the pulses, the sensation and the motor function (the 6 Ps of the ischaemia and the compartment syndrome); the skin for the lacerations, the burns, the degloving, the entry and exit wounds.
7 — The log roll
The four-person log roll (with the in-line cervical stabilisation) to examine the back, the buttocks, the spine (the step-off, the tenderness, the gap, the haematoma) and the posterior wounds, and to remove the spinal board.
8 — Complete neurological examination and the re-evaluation
The GCS, the pupils, the motor and the sensory examination for the lateralising signs and the cord level, then the re-assessment of the vital signs. The secondary survey is followed by the CT and then the tertiary survey within 24 hours.<Cite id="1" /><Cite id="1" />
The AMPLE history
The history of the trauma patient, taken from the patient, the witnesses and the paramedics, is structured as the AMPLE: the Allergies, the Medications (including the anticoagulants), the Past medical history (the comorbidity, the previous surgery), the Last meal (for the anaesthetic risk), and the Events leading to the injury (the mechanism, the speed, the height, the entrapment, the loss of consciousness). The mechanism determines the pattern of the injury: the high-speed motor-vehicle collision raises the intracranial, the cervical-spine, the chest and the abdominal injury; the fall from the height raises the calcaneal, the spinal and the renal injury; the penetrating injury raises the vascular and the organ injury along the track. The mechanism is the guide to the examination.[1]
| AMPLE element | What to ask | Why it changes the resuscitation |
|---|---|---|
| Allergies | Drug and environmental allergies, the reaction type | Guides the antibiotic and the analgesic and the anaesthetic choice before the theatre |
| Medications | Anticoagulants (warfarin, DOACs), antiplatelets, beta-blockers, insulin, steroids | The anticoagulant drives the reversal; the beta-blocker blunts the tachycardia of the shock; the steroid patient needs the stress-dose |
| Past medical history | Comorbidity, previous surgery, pregnancy in the female patient | The cirrhosis, the renal failure, the pregnancy, and the cardiac disease change the physiology and the imaging strategy |
| Last meal | Time of the last solids and fluids | The full stomach raises the aspiration risk and the anaesthetic plan — the RSI is the standard |
| Events / Environment | Mechanism, speed, height, restraint, helmet, entrapment, loss of consciousness, the scene | The mechanism predicts the pattern — and the penetrating trajectory and the blast exposure are the high-yield detail |
Head and face
The head is examined for the scalp lacerations, the depressions, the haematomas and the fractures. The face is examined for the symmetry, the fractures (the Le Fort, the zygomatic, the orbital), and the signs of the basal-skull fracture — the raccoon eyes (the bilateral periorbital haematomas), the Battle sign (the mastoid bruising), the haemotympanum, and the cerebrospinal-fluid otorrhoea or rhinorrhoea. The eyes are examined for the visual acuity, the pupils, the foreign bodies, the hyphaema and the retrobulbar haemorrhage. The mouth is examined for the dental trauma, the tongue laceration and the mandibular fracture. The ears are examined for the auricular haematoma (which needs the drainage to prevent the cauliflower ear) and the CSF leak.[1]
| The four signs of the basal-skull fracture | Site of the fracture | Mechanism | Examination finding |
|---|---|---|---|
| Raccoon eyes | Anterior skull base (the cribriform plate) | The blood tracks into the periorbital tissues | Bilateral periorbital ecchymosis, no overlying swelling |
| Battle sign | Posterior skull base (the petrous temporal) | The blood tracks into the mastoid soft tissues | Mastoid ecchymosis, hours after the injury |
| Haemotympanum | Petrous temporal fracture | Blood behind the intact tympanic membrane | Dark, bulging tympanic membrane on the otoscopy |
| CSF rhinorrhoea or otorrhoea | Cribriform plate (rhinorrhoea) or the temporal bone (otorrhoea) | The dural and the arachnoid tear | The clear fluid from the nose or the ear; the halo sign |
The midface — the Le Fort fractures
The midface fractures are the Le Fort pattern, in which the facial skeleton separates from the skull base along the lines of the structural weakness. The three classical patterns — the Le Fort I, II and III — are described by the level and the direction of the separation, and the examiner expects the candidate to recognise the level from the clinical signs and the imaging, and to recall the airway and the NPA implications of the higher Le Fort fractures. [1]
| Le Fort type | The fracture line | The clinical sign | The implication |
|---|---|---|---|
| Le Fort I (palatal-float) | The maxilla below the nose; the palate and the alveolus separate from the midface | The mobility of the maxillary teeth on the grasp; the malocclusion | The hard palate and the upper teeth move as a unit |
| Le Fort II (pyramidal) | Across the nasal bones, through the medial orbital wall and the maxilla, to the pterygoid plates | The pyramidal midface mobility; the nasal and the periorbital swelling | A NPA contraindication — the cribriform plate may be involved |
| Le Fort III (craniofacial dysjunction) | Across the nasofrontal suture, the orbital floor and the lateral orbital wall, the zygomaticofrontal suture, to the pterygoid — the whole face separates from the skull base | The complete facial mobility on the skull; the marked periorbital swelling | A NPA contraindication and a high airway risk — intubate early |
Neck and cervical spine
The neck is examined for the penetrating wounds, the tracheal deviation, the jugular venous distension, the carotid bruits, the laryngeal fracture (the crepitus, the hoarseness), and the cervical-spine tenderness. The cervical spine is either cleared clinically (by the NEXUS or the Canadian C-Spine Rule criteria) or imaged (by the CT, which is now the standard for the high-risk patient). The NEXUS criteria clear the c-spine if all five are met: no midline tenderness, no focal neurological deficit, normal level of alertness, no intoxication, and no painful distracting injury.[2] The Canadian C-Spine Rule applies to the alert, stable patient over 65 with a dangerous mechanism or a limb paresthesia.[1]
| The zones of the neck (the penetrating wound) | Anatomical extent | The structures at risk | The classical management |
|---|---|---|---|
| Zone I | The clavicles to the cricoid cartilage | The great vessels, the lung apices, the trachea, the oesophagus, the thoracic duct | The CT angiography; the difficult surgical access (the sternotomy or the thoracotomy) |
| Zone II | The cricoid cartilage to the angle of the mandible | The carotids, the jugulars, the larynx, the trachea, the oesophagus, the vagus | The CTA; the accessible surgical exploration in the hard sign or the unstable patient |
| Zone III | The angle of the mandible to the skull base | The internal carotid, the jugular, the pharynx, the parotid, the cranial nerves | The CTA and often the endovascular management; the difficult proximal control |
Chest and abdomen
The chest is re-examined for the clavicular and the rib fractures, the subcutaneous emphysema, the sternal instability, the cardiac murmurs (the new murmur of the traumatic valve injury), and the breath sounds. The FAST or the extended FAST is reviewed or repeated. The abdomen is examined for the distension, the tenderness, the guarding, the bruising (the seat-belt sign, the flank bruising of the renal injury), and the bowel sounds. The pelvis is assessed for the stability with the gentle lateral compression (the anterior-posterior compression is avoided because it can worsen the bleeding). The perineum is examined for the lacerations, the blood at the urethral meatus, and the scrotal haematoma.[1]
| The abdominal examination — the finding and the likely injury | The finding | The likely injury | | --- | --- | | Distension, the dullness, the shock | The intra-abdominal haemorrhage (the solid-organ or the mesenteric) | | The left-upper-quadrant tenderness and the referred shoulder-tip pain (the Kehr sign) | The splenic injury (the diaphragmatic irritation) | | The flank bruising (the Grey-Turner sign) and the haematuria | The renal injury | | The seat-belt sign with the peritonitis | The hollow-viscus or the mesenteric injury | | The perineal or the scrotal bruising with the pelvic instability | The pelvic fracture with the urethral and the venous-plexus injury | [1]
Perineum, rectum and genitourinary
The rectal examination assesses the sphincter tone (the spinal-cord injury), the prostate position (the high-riding prostate of the urethral injury), the blood (the bowel or the rectal injury), and the pelvic fractures. The vaginal examination is performed in the female trauma patient for the lacerations and the bleeding. A urethral injury is suspected with the blood at the meatus, the perineal haematoma, or the high-riding prostate, and the urinary catheter is withheld until the retrograde urethrogram excludes the injury.[1]
| The four signs of the male urethral injury | The mechanism |
|---|---|
| The blood at the urethral meatus | The most specific single sign — any meatal blood withholds the catheter |
| The perineal bruising (the butterfly haematoma) | The blood tracks into the perineum along the ruptured corpus spongiosum |
| The high-riding or the absent prostate on the rectal examination | The prostate is displaced superiorly by the haematoma of the membranous-urethral disruption |
| The scrotal haematoma | The dependent blood pooling from the pelvic-haematoma or the urethral disruption |
Extremities and the log roll
The extremities are examined for the deformity, the swelling, the open wounds, the pulses (the vascular injury), the sensation and the motor function (the nerve injury), and the compartment syndrome (the pain out of proportion, the pain on the passive stretch, the tense compartment). The musculoskeletal injuries are splinted, the dislocations are reduced, and the open fractures are covered with the saline-soaked gauze and given the antibiotics. The patient is log-rolled (with the in-line stabilisation of the cervical spine) to examine the back, the buttocks, the spine (the tenderness, the step-off, the haematoma, and the contusion of the seat-belt or the direct-blow injury).[1]
| The hard and the soft signs of the vascular injury | The sign | The implication |
|---|---|---|
| Hard sign — the absent pulse | The arterial occlusion or the transection | Immediate vascular imaging and the operative or the endovascular repair |
| Hard sign — the bruit or the thrill | The arterio-venous fistula | Operative or the endovascular repair |
| Hard sign — the active or the pulsatile haemorrhage | The arterial transection | The immediate haemorrhage control |
| Hard sign — the expanding haematoma | The ongoing arterial bleed | The immediate operative control |
| Soft sign — the stable haematoma | The contained bleed | The CT angiography and the observation |
| Soft sign — the proximity wound | The vessel at risk | The CT angiography and the serial examination |
| Soft sign — the asymmetric ankle-brachial index (the ABI < 0.9) | The reduced distal perfusion | The CT angiography |
Skin and soft tissue
The skin is the last region of the secondary survey, and it is examined in its entirety — the front and (on the log roll) the back — for the lacerations, the abrasions, the contusions, the burns, the degloving injuries, and the entry and exit wounds of the penetrating injury. The pattern of the skin injury often reveals the mechanism and the deeper injury: the seat-belt contusion, the tyre-mark abrasion, the patterned bruise of the blow, and the small circular wound of the low-velocity penetrating injury. The burns are assessed for the depth and the total body surface area (the rule of nines in the adult, the Lund-Browder chart in the child), and the circumferential burns are identified for the escharotomy decision. The entry and the exit wounds are marked before the imaging so the trajectory can be reconstructed. [1]
Neurological examination and the decision rules
The Glasgow Coma Score is rechecked, the pupils are re-examined, and the motor and the sensory examination is performed for the lateralising signs, the spinal-cord level and the peripheral nerve deficit. The Canadian CT Head Rule guides the CT of the head in the minor head injury: the CT is indicated for any one of the high-risk criteria (the signs of a basal-skull fracture, a GCS below 15 at two hours, the suspected open or depressed skull fracture, the vomiting, the age 65 or older, or the dangerous mechanism), validated in the clinical studies.[1] The NEXUS criteria or the Canadian C-Spine Rule guide the cervical-spine imaging.[2][1]
The Canadian CT Head Rule
The Canadian CT Head Rule (the Stiell group, the Lancet 2001) is the validated decision rule for the adult patient with the minor head injury — defined as the GCS of 13 to 15 with the loss of consciousness, the amnesia, or the confusion. It lists the high-risk criteria (any one of which mandates the CT — the sign of a basal-skull fracture, the GCS below 15 at two hours, the suspected open or the depressed skull fracture, the vomiting two or more episodes, the age 65 or older, and the dangerous mechanism — the pedestrian struck, the fall from over three feet or five stairs, the ejection from the motor vehicle) and the medium-risk criteria (any one of which supports the CT — the amnesia before the impact of over 30 minutes, and the dangerous mechanism, the focal neuro deficit, the seizure).[3] The rule is 100% sensitive for the neurosurgically-relevant injury in the derivation and the validation cohorts, and it outperforms the New Orleans Criteria in the comparative studies.[1][6]
Stiell — Canadian CT Head Rule (Lancet 2001)
Design
Prospective cohort — 3121 adults with the minor head injury (the GCS 13–15, the loss of consciousness, the amnesia, the confusion), 10 Canadian emergency departments
Derivation
Five high-risk criteria and two medium-risk criteria derived; the rule then validated in a separate cohort of 828 patients
Primary result
The rule was 100% sensitive (no neurosurgically-relevant injuries missed) and 76% specific for the need for the neurological intervention; it would have reduced the CT rate
Bottom line
The Canadian CT Head Rule is the validated, sensitive rule for the adult minor head injury — and the foundation of the modern practice of the selective (not the routine) head CT.
Papa — CCHR vs the New Orleans Criteria (Acad Emerg Med 2012)
Design
Prospective comparison of the two rules in 445 adult patients with the minor head injury and the GCS of 15
Intervention
The Canadian CT Head Rule vs the New Orleans Criteria for the prediction of the intracranial injury on the CT
Primary result
Both rules were 100% sensitive; the Canadian rule was more specific (51% vs 13%), and would have led to fewer CT scans
Bottom line
In the GCS-15 patient, the Canadian CT Head Rule is the more specific — it safely reduces the CT rate more than the New Orleans Criteria, with the same sensitivity.
The NEXUS and the Canadian C-Spine Rule
The cervical spine is cleared clinically by one of the two rules, or imaged (by the CT in the modern practice) when the rule fails or the patient is intubated. The NEXUS criteria (the Hoffman group, the NEJM 2000) clear the cervical spine without the imaging if all five of the low-risk criteria are met: no midline tenderness, no focal neurological deficit, a normal level of alertness, no intoxication, and no painful distracting injury.[4] The Canadian C-Spine Rule (the Stiell group, the NEJM 2003) applies to the alert and the stable trauma patient, and it clears the cervical spine when the patient has no high-risk factor (the age 65 or older, the dangerous mechanism, the paraesthesia in the extremities), and can rotate the head 45 degrees to the left and the right.[5]
| The NEXUS criteria vs the Canadian C-Spine Rule | NEXUS | Canadian C-Spine Rule |
|---|---|---|
| The population | Any blunt-trauma patient | The alert (GCS 15) and the stable trauma patient |
| The clearance requires | All five low-risk criteria met | No high-risk factor AND the ability to rotate the neck 45° each way |
| The high-risk flags | The intoxication, the distracting injury, the focal deficit | The age 65, the dangerous mechanism, the limb paraesthesia |
| The sensitivity | High but not as high as the CCR | Higher sensitivity than the NEXUS in the head-to-head comparison |
| The specificity | Lower (more imaging) | Higher (more clearances, fewer CT scans) |
| The elderly patient | The age is not a flag | The age 65 is the high-risk flag — the CT is done |
Hoffman — the NEXUS criteria (NEJM 2000)
Design
Prospective, multicentre — 34,069 patients with the blunt trauma who underwent the cervical-spine imaging, 21 US centres
Intervention
The five low-risk criteria applied prospectively to identify the patients who did not need the cervical-spine imaging
Primary result
The criteria were 99.0% sensitive (missed 8 of the 818 clinically-significant injuries) and would have reduced the imaging rate by 12.6%
Bottom line
The NEXUS rule is the validated cervical-spine clearance — the five criteria, all met, clear the spine. The sensitivity is high but not perfect, and the head-to-head study showed the Canadian rule is the more sensitive.
Stiell — the Canadian C-Spine Rule vs NEXUS (NEJM 2003)
Design
Prospective — 8283 alert and stable blunt-trauma patients, 9 Canadian centres, with both rules applied and the imaging as the reference
Intervention
The Canadian C-Spine Rule vs the NEXUS low-risk criteria, head-to-head
Primary result
The Canadian rule was more sensitive (99.4% vs 90.7%) and more specific (45.1% vs 36.8%) than the NEXUS; the Canadian rule missed one clinically-important injury, the NEXUS missed 16
Bottom line
In the head-to-head comparison, the Canadian C-Spine Rule is the more sensitive and the more specific rule — fewer missed injuries and fewer unnecessary CT scans. The NEXUS is the simpler rule (five criteria) and the more widely applied.
Special investigations — the FAST, the eFAST, the CT pan-scan and the pelvic film
The special investigations of the secondary survey are the adjuncts that confirm or exclude the injuries suspected on the examination. They run in parallel with the head-to-toe assessment, they are the bedside (the FAST and the radiographs) or the radiology-department (the CT) investigations, and they follow the principle that the unstable patient is not sent to the scanner — the unstable patient is resuscitated and taken to the operating theatre or the angiography suite on the clinical and the bedside evidence.[1][1]
The FAST and the extended FAST
The FAST (the focused assessment with sonography in trauma) is the bedside ultrasound that looks for the free fluid in the four classical views: the right upper quadrant (the Morrison pouch — the hepatorenal recess), the left upper quadrant (the splenorenal recess), the subxiphoid (the pericardium), and the suprapubic (the pouch of Douglas). The extended FAST (the eFAST) adds the bilateral thoracic views for the pneumothorax and the pleural fluid. The FAST is the triage tool: a positive FAST in the shocked patient is the indication for the immediate laparotomy; a positive FAST in the stable patient is the indication for the CT; a negative FAST does not exclude the intra-abdominal injury — the stable patient with the negative FAST still gets the CT, and the unstable patient with the negative FAST gets the repeat FAST or the alternative source search.[9]
| The four FAST views | The window | The target fluid |
|---|---|---|
| The right upper quadrant (the Morrison pouch) | The 7th–9th intercostal space, the mid-to-posterior axillary line | The hepatorenal recess — the most sensitive view for the intra-abdominal blood |
| The left upper quadrant (the splenorenal recess) | The 6th–8th intercostal space, the posterior axillary line | The splenorenal recess — the splenic injury |
| The subxiphoid (the pericardium) | The subxiphoid, angled up under the sternum | The pericardial effusion — the cardiac tamponade |
| The suprapubic (the pouch of Douglas) | The suprapubic, angled into the pelvis | The dependent pelvic fluid |
The CT pan-scan (the whole-body CT)
The whole-body trauma CT (the CT from the vertex to the symphysis, with the intravenous contrast and the CT-angiogram phase) is the definitive imaging of the stable major-trauma patient. It identifies the intracranial, the cervical-spine, the thoracic, the abdominal, and the pelvic injury in a single acquisition, and it changed the trauma practice from the selective imaging (the chest film, the pelvic film, the FAST, and the focused CT) to the near-routine whole-body CT in the high-energy mechanism. The mortality and the diagnostic benefit of the early whole-body CT was demonstrated in the Huber-Wagner retrospective multicentre study of the German trauma registry.[7]
Huber-Wagner — whole-body CT and survival (Lancet 2009)
Design
Retrospective, multicentre registry analysis — 4621 major-trauma patients in the German Trauma Registry, with the propensity-score adjustment for the injury severity
Intervention
The whole-body CT during the trauma resuscitation vs the selective imaging and the focused CT
Primary result
The whole-body CT was associated with a significant survival benefit (the odds ratio for the death 0.75, a 25% relative reduction), greatest in the high-injury-severity patient
Bottom line
The whole-body CT during the resuscitation is associated with the improved survival in the major-trauma patient — the retrospective design is the limitation, and the REACT-2 RCT tested the question prospectively.
REACT-2 — the immediate total-body CT RCT (Sierink, Lancet 2016)
Design
Pragmatic, multicentre, randomised controlled trial — 1403 adult major-trauma patients across 4 Dutch trauma centres
Intervention
The immediate total-body CT vs the standard radiography with the selective CT (the conventional imaging strategy)
Primary result
No difference in the in-hospital mortality (16% vs 16%) — the immediate total-body CT did not improve the survival over the selective strategy
Key secondary
The total-body CT did not reduce the ICU or the hospital length of stay; the trial excluded the patients in the extremis
Bottom line
In the haemodynamically-stable major-trauma patient, the immediate total-body CT is not superior to the selective strategy for the survival — the Huber-Wagner survival signal was the confounding of the retrospective design. The total-body CT remains the standard in the polytrauma patient for the diagnostic certainty, not the proven mortality benefit.
The pelvic radiograph and the cervical-spine clearance
The two radiographs that remain part of the secondary survey are the chest radiograph and the pelvic radiograph, both done in the resus bay. The chest film identifies the haemothorax, the pneumothorax, the widened mediastinum (the aortic injury), and the rib and the sternal fracture. The pelvic film identifies the pelvic fracture that drives the pelvic-binder and the angiography decision, and it is done in the high-energy blunt-trauma patient regardless of the examination (the pelvic examination is unreliable for the lateral-compression injury). The lateral cervical-spine radiograph is now largely replaced by the CT cervical spine in the modern practice.[1][10]
The tertiary survey and the continuous re-evaluation
The secondary survey is not the end of the examination. The tertiary survey, performed within 24 hours of the admission (and ideally on the morning after), is a complete repeat of the primary and the secondary surveys plus the review of all the imaging and the laboratory results, and it is designed to catch the injuries that were missed in the initial assessment — which occur in a significant minority of the major trauma patients, particularly the multi-injured, the intubated, and the physiologically deranged. The continuous re-evaluation of the vital signs, the perfusion and the conscious level runs throughout the resuscitation and the secondary survey, because the patient who was stable after the primary survey can deteriorate from an occult injury (the expanding intracranial haematoma, the delayed splenic rupture, the missed aortic injury).[1][1]
Common pitfalls
The recurring errors are: performing the secondary survey before the patient is stable; missing the basal-skull-fracture signs; not examining the back (the log roll is forgotten); placing a urinary catheter through a urethral injury; clearing the cervical spine without meeting the full clinical criteria; not applying the Canadian CT Head Rule or the NEXUS criteria; accepting a normal examination without the tertiary survey within 24 hours; and the failure to re-evaluate the vital signs continuously during the secondary survey, allowing the deteriorating patient to go unnoticed. [1]
Exam practice
SAQ — The cervical-spine clearance with the Canadian C-Spine Rule and the NEXUS
10 minutes · 10 marks
A 50-year-old man presents to the emergency department after a low-speed rear-end motor-vehicle collision. He was the restrained driver, the airbags deployed, and he walked out of the car. He reports the neck pain and the midline cervical tenderness on the palpation, but no neurological deficit, no dangerous mechanism, and a GCS of 15. He asks whether he can take the collar off and go home.
SAQ — The missed injuries and the tertiary survey in the polytrauma patient
10 minutes · 10 marks
A 38-year-old man is in the intensive care unit 24 hours after a high-speed motor-vehicle collision in which he sustained the splenic laceration (managed non-operatively), the right femur fracture (the intramedullary nail), the left pulmonary contusion, and the closed head injury (the GCS 14, the CT head with the small subarachnoid haemorrhage). He is intubated and sedated for the respiratory support. On the day-2 review, the nurse reports the left-arm swelling and the new swelling in the left calf.
Red flags
The following features identify the secondary survey that is failing or incomplete, in which the examination is revisited and the tertiary survey is planned: [1]
[1]References
- [1]Papa L, Stiell IG, Clement CM, et al. Performance of the Canadian CT Head Rule and the New Orleans Criteria for predicting any traumatic intracranial injury on computed tomography in a United States Level I trauma center Acad Emerg Med, 2012.PMID 22251188
- [2]Touger M, Gennis P, Nathanson N, et al. Validity of a decision rule to reduce cervical spine radiography in elderly patients with blunt trauma Ann Emerg Med, 2002.PMID 12192352
- [3]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury Lancet, 2001.PMID 11356436
- [4]Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group N Engl J Med, 2000.PMID 10891516
- [5]Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma N Engl J Med, 2003.PMID 14695411
- [6]Haydel MJ, Preston CA, Mills TJ, et al. Indications for computed tomography in patients with minor head injury N Engl J Med, 2000.PMID 10891517
- [7]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.PMID 19321199
- [8]Sierink JC, Treskes K, Edwards MJR, et al. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial Lancet, 2016.PMID 27371185
- [9]Stengel D, Rademacher G, Ekkernkamp A, et al. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma Cochrane Database Syst Rev, 2015.PMID 26368505
- [10]Brown CV, Foulkrod KH, Reifsnyder A, et al. Computed tomography versus magnetic resonance imaging for evaluation of the cervical spine: how many slices do you need? Am Surg, 2010.PMID 20420244
- [11]Pfeifer R, Pape HC. Missed injuries in trauma patients: A literature review Patient Saf Surg, 2008.PMID 18721480
- [12]Keijzers GB, Giannakopoulos GF, Del Mar C, et al. The effect of tertiary surveys on missed injuries in trauma: a systematic review Scand J Trauma Resusc Emerg Med, 2012.PMID 23190504
- [13]Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Lancet, 2009.PMID 19758692