Secondary Trauma Evaluation

Aka: Secondary Trauma Evaluation, Trauma Secondary Survey, Secondary Survey in Trauma

1. Evaluation: Head
   1. See Head Injury
   2. Assess Eyes early (may be difficult after face edema)
      1. Visual Acuity
      2. Pupil size and pupil reactivity
      3. Conjunctival Hemorrhage
      4. Retinal Hemorrhage
      5. Hyphema
      6. Penetrating injury
      7. Contact lenses
      8. Lens Dislocation
   3. Pitfalls
      1. Eye Injury as above
      2. Head Injury
      3. Posterior scalp Laceration
2. Evaluation: Maxillofacial
   1. Assessment
      1. Airway compromise risks
         1. See Primary Survey Airway Evaluation
         2. Example: Loose teeth or dentures
      2. Basilar Skull Fracture
         1. Raccoon's Eyes
         2. Battle Sign
         3. Ear or nose clear drainage (CSF)
      3. Facial Fractures
         1. Orbital blow out Fracture
         2. Maxillary Fracture (Le Fort Fractures)
         3. Mandibular Fracture (mal-Occlusion)
   2. Pitfalls
      1. Pending airway obstruction or airway status changes
      2. Cervical Spine Injury
      3. Exsanguination from mid-face Fracture
      4. Lacrimal duct Laceration
      5. Facial Nerve injury
3. Evaluation: Neck and Cervical Spine
   1. Assessment
      1. Cervical Spine Injury
         1. Cross Table Lateral XRay followed by Open Mouth Odontoid and AP C-Spine
      2. Tracheal Deviation
      3. Subcutaneous Emphysema
      4. Carotid Bruits
      5. Respiratory accessory muscle use
      6. Penetrating Neck Trauma
      7. Distended neck veins
   2. Pitfalls
      1. Cervical Spine Injury
      2. Laryngel Fracture
      3. Tracheal Tear
      4. Esophageal Tear
      5. Carotid injury
4. Evaluation: Chest and Lung
   1. Assessment
      1. Asymmetric breath sounds
      2. Hypertympanic or chest dull to percussion
      3. Parodoxical chest wall movement (Flail Chest)
   2. Pitfalls
      1. Tension Pneumothorax
      2. Massive Hemothorax
      3. Pulmonary Contusion
      4. Open chest wound (Open Pneumothorax, Sucking Chest Wound)
      5. Rib Fractures (especially ribs 1-3 associated with serious thoracic trauma)
      6. Flail Chest
      7. Cardiac Tamponade
      8. Aortic Rupture
      9. Diaphragmatic Rupture
5. Evaluation: Heart
   1. Assessment
      1. Distant heart sounds
      2. See Neck above for distended neck veins
   2. Pitfalls
      1. Cardiac Tamponade
      2. Aortic Rupture
      3. Myocardial Contusion
6. Evaluation: Abdomen
   1. See Abdominal Trauma
   2. Assessment
      1. CT Abdomen and CT Pelvis
   3. Pitfalls
      1. Liver Laceration
      2. Splenic rupture
      3. Renal trauma
      4. Pancreatic injury
      5. Hollow viscus (bowel perforation) or Lumbar Spine Injury
         1. Seat Belt
         2. Deceleration injury
   4. Precautions
      1. Do not delay emergent exploratory laparotomy when indicated
7. Evaluation: Genitourinary
   1. See Genitourinary Trauma
   2. Assessment
      1. Pelvic stability
      2. Perineum exam
      3. Vagina or scrotal exam
      4. Blood at Urethral meatus
   3. Pitfalls
      1. Pelvic Fracture
      2. Urethral Injury
      3. Vaginal Injury
      4. Bladder rupture
   4. Precautions
      1. Do not insert Foley Catheter if Urethral blood, scrotal hematoma or high riding Prostate
8. Evaluation: Rectum
   1. See Abdominal Trauma
   2. Assessment: Rectal exam
      1. Decreased rectal tone (spinal injury)
      2. High riding Prostate (Urethral transection)
      3. Bloody stool on rectal exam
   3. Pitfalls
      1. Rectum or other bowel injury
      2. Gastrointestinal Bleeding
9. Evaluation: Musculoskeletal - Thoracic and Lumbar Spine
   1. Log-Roll patient for this examination
      1. Backboard may be discontinued during log-roll if no contraindication
   2. See Lumbar Spine Trauma or Thoracic Spine Trauma
   3. Diagnostics
      1. CT Thoracic Spine can be reconstituted from CT chest
      2. CT Lumbar Spine can be reconstituted from CT Abdomen and Pelvis
   4. Assessment
      1. Vertebral tenderness
      2. Midline spine deformity
      3. Neurologic Exam correlated to spinal levels and dermatomes
         1. Motor Exam
         2. Sensory Exam
         3. Reflex Exam
   5. Pitfalls
      1. Vertebral Fracture
      2. Vertebral dislocation
      3. Vertebral instability
      4. Paraplegia
      5. Quadriplegia
      6. Nerve root injury
10. Evaluation: Musculoskeletal - Extremities
    1. See Musculoskeletal Trauma
    2. Diagnostics
       1. Consider angiography
       2. Consider compartment pressures
    3. Examination
       1. Vascular exam
          1. Pulses
          2. Capillary Refill
       2. Neurologic Exam
          1. Motor Exam
          2. Sensory Exam
          3. Reflex Exam
    4. Pitfalls
       1. Digital Fracture
       2. Compartment Syndrome
       3. Fracture with vascular compromise
          1. Posterior knee dislocation
          2. Supracondylar femoral Fracture
          3. Suprecondylar humeral Fracture
11. Evaluation: Neurologic
    1. See Head Injury
    2. Assessment
       1. Assign Glasgow Coma Scale score
       2. Increased Intracranial Pressure
       3. Subdural Hematoma
       4. Epidural Hematoma
       5. Depressed skull Fracture
       6. Spine injury
       7. Check Sensory Levels affected
          1. Use syringe filled with Alcohol
          2. Spray skin at each dermatome level
          3. Patient should feel cold sensation
       8. Steroid Indications
          1. Spinal Trauma
          2. Not indicated for intracranial swelling
12. Evaluation: Skin
    1. See Skin Trauma
    2. Pitfalls
       1. Burn Injury
       2. Laceration with heavy bleeding
       3. Puncture Wound
       4. Embedded foreign body
13. Reference
    1. (2008) Advanced Trauma Life Support (ATLS) Student Manual, American College of Surgeons