II. Precautions

  1. Repeat the sevcondary survey after initial management (and again as needed)
  2. Reevaluation of Trauma patients is paramount
    1. Management of initial life-threatening concerns may unmask previously undiagnosed injuries
    2. Progression of injury (e.g. intraabdominal bleeding) may result in gradually developing physical findings

III. Evaluation: Head

  1. See Head Injury
  2. See Eye Injury
  3. See Head Injury CT Indications in Adults
  4. See Head Injury CT Indications in Children
  5. Assessment
    1. See Trauma Neurologic Exam
    2. See below under neurologic evaluation
    3. 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
  6. Pitfalls
    1. Eye Injury masked by overlying Facial Edema
    2. Head Injury
      1. Epidural Hematoma
      2. Subdural Hematoma
      3. Intracerebral Hemorrhage
      4. Basilar Skull Fracture
    3. Posterior Scalp Laceration
      1. Risk of occult significant blood loss (best identified in Primary Survey)

IV. 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 on initial presentation
      1. Orbital Blow Out Fracture
      2. Maxillary Fracture (Le Fort Fractures)
      3. Mandibular Fracture (mal-Occlusion)
    4. Facial Fractures with delayed presentation (reassess)
      1. Nasal Fracture
      2. Nondisplaced zygomatic Fracture
      3. Orbital Rim Fracture
  2. Pitfalls
    1. Pending airway obstruction or airway status changes
    2. Exsanguination from mid-face Fracture
    3. Lacrimal duct Laceration
    4. Facial Nerve injury
    5. Cervical Spine Injury

V. Evaluation: Neck and Cervical Spine

  1. See Cervical Spine Injury
  2. Precautions
    1. Blunt neck injury may result in occult and initially masked major neck vascular injury
      1. Risk of Carotid Artery Dissection and thrombosis
      2. May be initially asymptomatic with subsequent vessel thrombosis and hemispheric stroke within 72 hours
      3. See Neck Vascular Injury in Blunt Force Trauma for CT Angiography criteria
    2. Assume unstable Cervical Spine Injury in Maxillofacial Trauma or Head Trauma
    3. Prolonged Spine Immobilization risks complications (e.g. Decubitus Ulcers, Propofol Infusion Syndrome)
      1. Remove the spine longboard during the Primary Survey or Secondary Survey in most cases
      2. However, Long Spine Board must be maintained in uncooperative patients to ensure Spine Immobilization
  3. Assessment
    1. Cervical Spine Injury
      1. CT Cervical Spine (preferred)
        1. Typically performed at the same time as CT Head
      2. Cervical Spine XRay (inadequate in most Trauma patients)
        1. Cross Table Lateral XRay followed by Open Mouth Odontoid and AP C-Spine
        2. Adequate views are obtained in only 30% of Trauma patients
          1. However, if adequate, has high Negative Predictive Value
    2. Tracheal Deviation
    3. Subcutaneous Emphysema
    4. Carotid Bruits
    5. Respiratory accessory Muscle use
    6. Penetrating Neck Trauma (deep to the platysma)
    7. Distended neck veins
  4. Pitfalls
    1. Cervical Spine Injury
    2. Laryngel Fracture
    3. Tracheal Tear
    4. Esophageal Tear
    5. Carotid Artery injury

VI. Evaluation: Chest and Lung

  1. Precautions
    1. Trauma in the Elderly
      1. Seemingly mild Chest Trauma may result in serious respiratory compromise and acute distress
    2. Trauma in Children
      1. Intrathoracic injury is common without signs of external thoracic Trauma
  2. Assessment
    1. Asymmetric breath sounds
    2. Hypertympanic or chest dull to percussion
    3. Parodoxical chest wall movement (Flail Chest)
    4. Palpate thorax for Fractures (Clavicle Fracture, Scapula Fracture, Rib Fracture, Fractured Sternum)
  3. Diagnostics
    1. Portable Chest XRay
      1. Preferred first-line study
    2. Chest CT
      1. Indicated for suspected Great Vessel injury (e.g. high velocity accident)
    3. Bedside Ultrasound
      1. See FAST Exam
      2. Perform FAST Exam as part of Primary Survey
  4. 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. Sternal Fracture
    8. Cardiac Tamponade
    9. Aortic Rupture
    10. Diaphragmatic Rupture

VII. Evaluation: Heart

  1. Assessment
    1. See Neck above for distended neck veins
    2. Cardiac auscultation (e.g. Distant heart sounds)
    3. Pulses in all extremities (assess for asymmetry and pulseless extremity)
  2. Diagnostics
    1. Electrocardiogram
    2. FAST Exam (evaluate for Pericardial Effusion or Cardiac Tamponade)
  3. Pitfalls
    1. Cardiac Tamponade
    2. Aortic Rupture
    3. Myocardial Contusion

VIII. Evaluation: Abdomen

  1. See Abdominal Trauma
  2. Precautions
    1. Initial abdominal exams may be benign despite serious intraabdominal injury (especially retroperitoneal injury)
    2. Although distracting injury may theoretically hide abdominal findings on exam, it still has 90% Test Sensitivity
      1. Rostas (2015) J Trauma Acute Care Surg 78(6):1095-100 +PMID:26151507 [PubMed]
    3. Aggressively evaluate the Abdomen
      1. Unexplained Hypotension
      2. Trauma patients with Altered Mental Status
  3. Assessment
    1. Serial abdominal exams
  4. Diagnostics
    1. CT Abdomen and CT Pelvis
    2. FAST Exam
  5. 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
  6. Precautions
    1. Do not delay emergent exploratory laparotomy when indicated

IX. Evaluation: Genitourinary

  1. See Genitourinary Trauma
  2. Precautions
    1. Pelvic instability on compression
      1. Hold initial position of compression and apply Pelvic Binder
      2. Avoid excessive manipulation of the Pelvis
    2. Do not insert Foley Catheter if Urethral blood, scrotal Hematoma or high riding Prostate
      1. Retrograde Cystourethrogram may be performed bedside in the Emergency Department
  3. Diagnostics
    1. Pregnancy Test in all women of child-bearing age
    2. FAST Exam
    3. Portable AP Pelvic XRay
    4. CT Abdomen and Pelvis
      1. May miss significant retroperitoneal injuries (e.g. injury to the duodenum or Pancreas)
  4. Assessment
    1. Pelvic stability
      1. Also evaluate for other Pelvic Fracture signs (Ecchymosis over the iliac wing, pubis, labia or Scrotum)
    2. Perineum exam
    3. Vagina or scrotal exam
      1. Perform a vaginal exam in all women with Pelvic Fracture or other vaginal injury risks
    4. Blood at Urethral meatus
      1. Urethral injury is more common in men
      2. Women can experience Urethral injury with Pelvic Fractures or straddle injuries
  5. Pitfalls
    1. Pelvic Fracture
      1. Associated with significant risk of Hemorrhage (act rapidly)
    2. Bladder rupture
    3. Urethral Injury
    4. Vaginal Injury

X. Evaluation: Rectum

  1. See Abdominal Trauma
  2. Indications: Rectal Exam
    1. Not routinely indicated in all Trauma patients (change based on 2014 ATLS and Trauma literature)
    2. Weakness or paralysis suggestive of Spinal Cord Injury (record Rectal Tone as monitoring parameter)
    3. Suspected bowel injury in Penetrating Trauma
  3. Efficacy: Rectal Exam
    1. Does not offer additional information beyond what can be found with other exam findings
      1. However, see specific indications as above
      2. Esposito (2005) J Trauma 59(6): 1314-9 [PubMed]
  4. Assessment: Rectal Exam
    1. Decreased Rectal Tone (Spinal Injury)
    2. Bloody stool on Rectal Exam
    3. High riding Prostate is a sign of Urethral transection
      1. Poor Test Sensitivity
      2. Rarely identified by even experienced clinicians at high volume Level I Trauma Centers
      3. Replaced by other findings of Urethral transection (e.g. unable to void, blood at meatus)
  5. Pitfalls
    1. Rectal Injury or other bowel injury
    2. Gastrointestinal Bleeding
    3. Spinal Cord Injury
  6. References
    1. Herbert and Inaba in Herbert (2014) EM:Rap 14(3): 5-6

XI. Evaluation: Musculoskeletal - Thoracic and Lumbar Spine

  1. See Lumbar Spine Trauma
  2. See Thoracic Spine Trauma
  3. Log-Roll patient for this examination
    1. Backboard may be discontinued during log-roll if no contraindication
  4. Diagnostics
    1. CT Thoracic Spine can be reconstituted from CT chest
    2. CT Lumbar Spine can be reconstituted from CT Abdomen and Pelvis
  5. Assessment
    1. Vertebral tenderness
    2. Midline spine deformity
    3. Priapism
    4. Neurologic Exam correlated to spinal levels and Dermatomes
      1. Motor Exam
      2. Sensory Exam
      3. Reflex Exam
  6. Pitfalls
    1. Vertebral Fracture
    2. Vertebral dislocation
    3. Vertebral instability
    4. Paraplegia
    5. Quadriplegia
    6. Nerve root injury
    7. Finger and Hand Fractures
      1. Not life-threatening and commonly missed on initial Secondary Survey
      2. However, missed finger and Hand Fractures confer a high degree of longterm Disability

XII. Evaluation: Musculoskeletal - Extremities

  1. See Musculoskeletal Trauma
  2. Diagnostics
    1. Consider angiography
    2. Consider Compartment Pressures
  3. Examination
    1. Skin
      1. Contusions
      2. Extremity deformities
    2. Vascular exam
      1. Pulses
      2. Capillary Refill
    3. Neurologic Exam
      1. Motor Exam
      2. Sensory Exam
      3. Reflex Exam
  4. Pitfalls
    1. Compartment Syndrome
    2. Fracture with vascular compromise
      1. Posterior Knee Dislocation
      2. Supracondylar Femoral Fracture
      3. Suprecondylar Humeral Fracture
    3. Fractures frequently missed on initial Secondary Survey
      1. Hand Fracture and digital Fracture
      2. Wrist Fracture
      3. Foot Fracture

XIII. Evaluation: Neurologic

  1. See Head Injury
  2. See Emergency Neurologic Exam
  3. See Head Injury CT Indications in Adults
  4. See Head Injury CT Indications in Children
  5. Assessment
    1. Assign Glasgow Coma Scale score
    2. Increased Intracranial Pressure
      1. Ensure efficient and expedited procedures to minimize increase in ICP
      2. Example: Avoid multiple intubation attempts
    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

XIV. Evaluation: Skin

  1. See Skin Trauma
  2. Pitfalls
    1. Burn Injury
    2. Laceration with heavy bleeding
    3. Puncture Wound
    4. Embedded foreign body

XV. Reference

  1. (2008) Advanced Trauma Life Support (ATLS) Student Manual, American College of Surgeons
  2. (2012) ATLS Manual, 9th ed, American College of Surgeons

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