- 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.
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
- 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.
Head
- 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.
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 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.
Abdomen
- 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.
Pelvis
- 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.
Extremities
- 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.
Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/paediatric/assessment/secondary-survey