Secondary Survey

Hi guys, time to learn again with Dr. Oli! If you haven't checked out our brand new Facebook page, please do so and "like" us at www.facebook.com/drolimedonthego/. As usual, this post is available in podcast form; Med On The Go is downloadable on iTunes, Google Play, and Podbean, where our podcast site is at www.medonthego.podbean.com. If you enjoy our podcast and access to the free medical notes here, please also consider supporting us by becoming a patron--there are lots of exclusive bonus materials available to our patrons!

Without further ado, this week's topic and notes:

After last week's post about conducting rapid primary survey and resuscitation, it is time for secondary survey. The point of secondary survey is to identify major injuries or areas of concern, so a full physical examination should be conducted.

Secondary survey

·      History (SAMPLE): signs and symptoms, events related to injury, past medical history, allergies, medications, and the last time patient ate something

·      Physical examination

o   Head—check for scalp lacerations, contusions, fractures, or burns

o   Ears—check for heamotympanum or CSF leakage

o   Eyes*

§  Assess pupils equality, size, symmetry, reactivity to light

·      Inequality à local eye problem or lateralizing CNS lesion

·      Relative afferent pupillary defect (swinging light test) à optic nerve damage

·      Reactive pupils + decreased LOC à systemic cause

·      Non-reactive pupils + decreased LOC à structural cause

·      Unilateral, dilated, non-reactive pupil à focal mass lesion, epidural hematoma, or subdural hematoma

§  Fundoscopy (papilledema, hemorrhages)

§  Extraocular movements and nystagmus

§  If intracranial lesion suspected NON-CONTRAST CT HEAD is the best imaging

o   Face

§  Check for lacerations, contusions, or burns

§  Palpation of facial bone for fracture

§  Assess GCS

§  Full cranial nerve exam

§  Check inside mouth for bleeding, loose teeth, and soft tissue injury

o   Cervical spine and neck

§  Assess for tenderness, bruising, swelling, deformity, subcutaneous emphysema, and tracheal deviation.

§  BEWARE CAROTID DISSECTION

§  C-spine X-ray

o   Chest

§  Assess trachea to see if it’s midline

§  Flail segment indicates 2 or more rib fractures in 2 or more places

§  Assess for evidence of open wounds, pneumothorax, haemothorax

§  Check for evidence of myocardial injury

§  Auscultate lung fields

§  Palpate for subcutaneous emphysema

§  ECG monitoring

§  CXR

o   Abdomen

§  Assess for bruising of anterior abdominal wall, distention, tenderness and guarding, rebound

§  Palpate iliac crests and pubic symphysis, pelvic stability (lateral, AP, vertical)

§  Vaginal examination if female

§  FAST (rapid ultrasound which assess the subxiphoid pericardial window for pericardial effusion, perisplenic window for free fluid around the spleen and kidney, hepatorenal window for blood around liver or kidney, and pelvic/retrovesical window for free fluid around bladder) or CT if stable

§  Pelvic X-ray

o   Back

§  Logroll and examine entire length of spine for tenderness, bruising, or deformity

§  Rectal examination, high-riding prostate (contraindication of Foley catheter insertion), and anal tone

o   Limbs—all limbs should be examined for fractures, lacerations, hematomas, peripheral pulses, and neurological deficits (spinal cord integrity).

·      X-rays

o   C-spine, chest, pelvis combo must be done for trauma

o   Consider T or L spine as indicated

Signs of Increase intracranial pressure

·      Deteriorating LOC (hallmark)

·      Deteriorating respiratory pattern

·      Cushing reflex—high BP, low heart rate, irregular respirations

·      Lateralizing CNS signs such as cranial nerve palsies, hemiparesis

·      Seizures

·      Papilledema (occurs late)

·      Nausea and vomiting and headache

*Toronto Notes 2016 puts the eye examination during primary survey.