Trauma basis 4
Remember - Hypoxia and hypotension kill head-injured patients.
Secondary survey
This is the definitive examination of the patient and comprises physical examination, X-rays, pathology tests and special diagnostic procedures. It is performed by the team leader once the patient has been initially stabilised.
If at any time the patient becomes unstable, the primary survey must be repeated.
Physical Examination
This should be done 'head to toe' in a methodical and systematic manner.
Neurological
Glasgow Coma Score
- Assessment of spinal function - 'can you wiggle your toes for me'
Head and Neck
- Check scalp and cranium for lacerations, depressed or compound fractures.
- Check eyes including pupils (unequal pupils are of prognostic significance only if the patient is unconscious).
- Look in ears for local trauma or haemotympanum (indicating # base of skull). Manipulate the maxilla to exclude # middle third of face. Palpate zygoma and orbital margins. Assess infraorbital nerve.
- Check inside mouth for tongue or other trauma and note the state of the dentition and ease of intubation.
- Inspect the neck and palpate both carotid arteries. Assess the degree of filling of the jugular veins.
- Remove the collar, having an assistant stabilise the head, and palpate the cervical spine for tenderness.
Chest
- Inspect for contusions, lacerations, entry and exit sites.
- Palpate clavicles, sternum, ribs and scapulae.
- Palpate for subcutaneous emphysema including supraclavicular fossae.
- Assess adequacy and symmetry of air entry and listen for crackles or wheezes.
subcutaneous emphysema
Abdomen and pelvis
- Inspect for bruising, penetrating injuries and degree of distension (serial measurements).
- Palpate abdomen for generalised or local tenderness.
- Palpate the pelvis for bony tenderness. If the pelvis is obviously unstable, do not repeat examination.
Back/ rectal examination
If not performed as part of the Exposure part of the primary survey, the patient should be log rolled onto their side.
This allows
- examination of the back.
- palpation of the thoracolumbar spine for steps/ pain.
- rectal examination for anal tone, blood and high-riding prostate.
Log roll
The log roll is a technique where the patient is rolled keeping their spine immobile.
Genitalia
- Inspect for presence of meatal bleeding. If present suspect ruptured urethra and DO NOT CATHETERISE.
- Consider vaginal examination in women especially if any possibility of pregnancy.
Limbs
- Assess for soft tissue and bony injuries. Consider compartment syndromes.
- Major joint dislocations (hip/knee/ankle/shoulder/elbow) should be looked for and reduced as soon as possible.
- Check peripheral circulation and motor and sensory function.
