Secondary survey

• The secondary survey follows the completion of the primary survey, after immediate threats to life have been managed and the patient is stable.
• Continuous assessment of ABCD should occur during the secondary survey.
• Give appropriate analgesia before the examination.
• Develop a rapport with the patient and explain the steps of the secondary survey.
• Uncover the patient only as needed. Always maintain warmth and privacy.

Unconsciousness

• Causes of unconsciousness can be classified into broad groups:
  • low oxygen levels to the brain
  • circulatory
  • metabolic
  • neurological problems.
• Consider all the following for assessment as diagnosis of exclusions (AEIOU TIPS):
  • A alcohol, acidosis (metabolic disorders), ammonia (hepatic encephalopathy, arrhythmia)
  • E endocrine, electrolytes or encephalopathy
  • I infection
  • O oxygen, overdose or opiates
  • U uraemia
  • T trauma, temperature or thrombus
  • I insulin, intoxication
  • P poisoning or psychiatric
  • S seizure, syncope, stroke, space-occupying lesion or shunt.

C-spine

• If a spinal injury is suspected, ensure in-line immobilisation is in place with foam collar (appendix).

Head

• Look at the scalp for signs of injury. Feel for skull depressions, irregularities and lumps
• Look behind the ear for bruising, i.e. Battle's sign.

Face

• Look for maxillofacial trauma, including facial injuries, fractures and eye injuries.
• Proptosis (bulging eye), loss of vision or orbital pain may indicate a retrobulbar haemorrhage. Escalate urgently as per local CERS protocol.
• Look for bruising around the eyes and injury to the eye itself, including penetrating injuries, haemorrhage or hyphaema.
• Assess extraocular movement and pupillary response and size.
• Look for facial symmetry.
• Palpate the facial bones, assessing for movement and pain.
• Instruct the patient to open their mouth. Assess for jaw pain and malalignment.
• Look inside the mouth for oral injuries, including dental trauma, lacerations, bruising or lip lacerations.
• Look at the nose, check for symmetry, deformity, epistaxis and patency of nares.
• Look at the ears for discharge, bruising to the mastoid (behind the ears).

Neck

• Look at the anterior neck observing for tracheal deviation, signs of injury, distension of the neck veins, carotid pulsation, pain, difficulty swallowing or hoarse voice.

Chest

• Look for signs of injury.
• Observe for chest expansion, asymmetrical or paradoxical movement, short, shallow breaths, pain on inspiration and/or expiration.
• Palpate the sternum, ribs and clavicles.
• Auscultate heart and lung sounds.
• Listen for clarity of heart sounds. Muffled sounds may indicate a cardiac tamponade.
• Perform E-FAST if accredited.

Abdomen

• Assess the abdomen for injury.
• Bruising or injury to the abdomen increases the likeliness of an internal abdominal injury.
• Perform E-FAST if accredited.
• Gently palpate all four quadrants, assessing for pain or mass. See abdominal focused assessment, if required.
• Inspect the external genitalia.

Pelvis

• Look for external genitourinary injuries.
• Check for pain on movement or palpation of the hips.
• If a pelvic binder or sheet is in situ, do not remove it.
• Apply pelvic binder (appendix) if required.

Extremities

• Assess extremities for deformity, pain, bruising, swelling, lacerations or dislocations.
• Complete neurovascular assessment for each limb and palpate peripheral pulses.
• Provide elevation or splinting, where required.

Log roll

• If adequate staff are available, a log roll can be completed to assess for posterior injuries:
  • Ensure C-spine precautions are maintained.
  • Log roll the patient.
  • Assess posterior surfaces for obvious signs of injury.
  • Remove any wet or soiled clothing and bedding.
• Log roll should be avoided if there is risk of worsening an unstable pelvis.