ECAT paediatric assessment

Secondary survey

Published: December 2023. Printed on 25 Jun 2024.

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  • 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 carer. Explain the steps of the secondary survey.
  • Use age-appropriate communication techniques.
  • Involve play or distraction.
  • Uncover the child only as needed. Always maintain warmth and privacy.


  • 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.


  • Upper cervical spine injuries are more common in younger children due to their relatively larger heads and underdeveloped neck and head muscles.
  • If a spinal injury is suspected, ensure in-line immobilisation is in place with foam collar (appendix).
  • Children with spinal injuries will commonly prefer to remain still, however reducing movement is of priority until medical clearance is sort.
  • Utilise distraction where possible.


  • Isolated head injuries are more common in younger children due to their relatively larger heads and underdeveloped neck and head muscles.
  • Look at the scalp for signs of injury. Feel for skull depression, irregularities and lumps. Look behind the ear for bruising, i.e. Battle's sign.


  • 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).


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


  • 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.


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


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


  • Assess extremities for deformity, pain, bruising, swelling, lacerations or dislocations.
  • Complete neurovascular assessment for each limb.
  • 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.
    • 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.

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