We’ve done the primary survey
and you may actually repeat the
primary survey several times.
Now, we’re going to move one
to the secondary survey.
The patient is stable.
You solved the problem, maybe you’re
planning on going to the OR in a bit,
but we really want to do a head-to-toe
history and physical exam
once the patient is stable.
So we have done the primary survey,
we’re on to the secondary.
Here’s an overview of
your secondary survey.
Head and neck:
we’re going to look intraorally
for any evidence of trauma.
We will inspect the eyes, ears and nose
for evidence of blood or CSF
drainage from ears and the nose.
We will assess for things like
raccoon’s eyes or battle sign
which are evidence of
significant head trauma.
We need to assess for C-spine tenderness.
If the patient is awake, they can
report it hurts or it doesn’t,
but you want to palpate every
single cervical vertebrae
and make sure there is no
deformity or no tenderness there.
If they are awake, they
can report that to you.
It’s always important to
assess for tracheal deviation.
Hopefully, you would have noticed
that during the primary survey
because this patient will
have a circulatory problem
as well as a breathing problem that you
will auscultate no lung sounds on one side,
but certainly you want
to assess the trachea
and make sure there is no deviation and
look anteriorly to the entire neck.
Next the chest:
assess where there is
accessory muscle use,
that will give you a sign if there is
intraparenchymal problems in the lungs
and also listen to
heart and lung sounds
and report those out to the person who
is taking the notes from the trauma.
Next is the abdomen and pelvic exam.
Assess for guarding,
rebound, and tenderness.
It’s also important to
assess for pelvic stability
by pushing on the anterior superior iliac
crest and what we call rocking the pelvis,
but do it gently and just assess
for any pelvic instability.
If there is pelvic instability,
that’s important to know about
because that could be a major
source of internal bleeding.
Next, the urogenital exam is important.
You should inspect everywhere down there
and also, we will do a rectal exam.
When we do the rectal exam,
there's two things we're noting.
We are noting whether
there is good rectal tone
which is a sign of spinal
injury if there is low tone.
And also, we’re going to
send a stool for guaiac test
to verify that there is no
Next, the extremities and the spine.
You’re going to palpate every joint
and every bone in this patient
to make sure there are no abnormalities
in the extremity or the spine.
Palpate the spine also with a log roll for
tenderness or step-off all the way down,
every single vertebrae must
be palpated one after another
and you’re going to
assess all pulses.
I would recommend the
dorsalis pedis pulse
as the lowest pulse there
and also the wrist pulses.
Generally, if you got those,
you’re in good shape.
The easiest to feel is the femoral pulse,
unless it’s a newborn baby in which
case it's the umbilical pulse,
but that’s usually not a trauma.
Last is neurologic.
This is where we can do that AVPU.
AVPU is a quick way of remembering
what can we say about this
patient’s awakeness status.
A is awake.
V is responds to verbal.
P is responds to pain
and U is unresponsive.
Get their baseline neurologic status.
If they are awake and compliant,
check the cranial nerves.
Even if they’re not, you can
still check some cranial nerves
like pupillary response or
whether there is a facial palsy.
Next, check strength.
If they are awake and compliant, you can
check strength in all the extremities
and looking for a generalized sense
of strength and also sensation.
You don’t need to do a super
careful neurologic sensation exam.
We are not so worried about the
finer details like whether
it’s light touch or pinprick.
We want to just get a general sense
of can they feel up and down the body
in the most of the major areas.
And then also, don’t forget to
check the deep tendon reflexes,
looking for things like
clonus at the ankles
or if they’re having any brisk reflexes
implies that there may be some CNS damage.
So when we see these patients, we’ve
done the primary and secondary survey,
we often will get labs and we may just
get something called a trauma panel.
I don’t actually mind that.
I think that’s a good idea.
I don’t like the shotgun approach
for most disease processes.
I don’t think it’s indicated
to do a shotgun labs approach.
For example, the patient with pneumonia.
But in a patient with a trauma
it’s generally beneficial because you
don’t have time really to think about
things very carefully before they whisked
off to the OR in all circumstances.
So what are the labs that are
part of the trauma panel?
We get a type and screen.
This is for obvious reasons,
if they need blood either now
or during the operating room.
We get a CBC.
Again, we can assess for loss of
red blood cells and acute anemia
and we can also see if there
is an underlying problem.
We will check LFTs and lipase
as that’s a reasonable way
of assessing for hepatic
and pancreatic damage.
We will get a basic metabolic panel.
That’s important to assess the acid base
and the hydration status of a patient.
If it’s applicable, we’ll get a tox screen.
So any infant who is found
with altered mental status
or anybody who has been in an MVA
certainly, we want to check a tox screen
because it’s important to know
whether there is underlying
chemicals that may be
affecting their vital signs.
And lastly, we’ll check a pregnancy test.
If it’s any girl who is
over about 13 years of age,
you want to check a pregnancy test
because we need to know whether
there is a fetus involved
in terms of issues
around end-organ damage.
So that’s my quick review of the
primary and secondary survey
and the labs we get in
patients with trauma.
Thanks for your time.