Secondary Survey

Principles

The secondary survey begins after completion of the primary survey and initial resuscitation once the patient is hemodynamically stable.
Its purpose is to perform a head-to-toe evaluation, identify all injuries, and initiate definitive management.
If deterioration occurs at any point, return immediately to the primary survey (ABCDE).

Preparation

Confirm that vital signs are stable and resuscitation is ongoing.
Ensure analgesia and sedation are adequate.
Maintain spinal precautions throughout.
Continue monitoring: ECG, SpO₂, BP, temperature, and urine output.
Warm the patient and maintain a normothermic environment.

History and Mechanism of Injury

AMPLE History

A – Allergies
M – Medications (including anticoagulants, insulin, beta-blockers, etc.)
P – Past medical history (comorbidities, pregnancy status, tetanus immunization)
L – Last meal (important for anesthesia)
E – Events / Environment leading to injury (mechanism, time, extrication, associated hazards)

Mechanism of Injury (MOI)

Evaluate for energy transfer and injury pattern correlation: - Blunt trauma: MVC, fall, assault, blast.
- Penetrating trauma: knife, firearm — note trajectory and object characteristics.
- Blast injuries: consider primary (barotrauma), secondary (shrapnel), tertiary (impact), and quaternary (burn/inhalation) effects.
Understanding mechanism predicts hidden injuries and guides imaging.

Systematic Head-to-Toe Examination

Head and Scalp

Inspect and palpate for lacerations, hematomas, deformities, depression, or CSF leak.
Examine eyes: pupils (size/reactivity), conjunctiva, orbital integrity.
Assess ears: hemotympanum, CSF otorrhea.
Examine nose: septal hematoma, CSF rhinorrhea.
Evaluate mouth and jaw: loose teeth, malocclusion, facial fractures, bleeding.
Control scalp bleeding with direct pressure; avoid blind clamping.

Neck

Maintain cervical immobilization during exam.
Inspect for bruising, seatbelt marks, hematoma, or tracheal deviation.
Palpate for subcutaneous emphysema, laryngeal crepitus, tenderness.
Assess JVD (tamponade vs. tension physiology).
Evaluate for neurologic deficit or hoarseness suggesting laryngeal/tracheal injury.
Do not remove cervical collar until cleared by clinical and radiographic criteria.

Chest

Inspect for abrasions, contusions, penetrating wounds, or flail segments.
Palpate for tenderness, deformity, subcutaneous emphysema, rib instability.
Percuss for dullness or hyperresonance.
Auscultate both lungs and heart.
Reassess chest tube function if present.
Obtain portable chest x-ray and monitor oxygenation.

Abdomen

Inspect for ecchymosis (seatbelt sign), distension, penetrating wounds.
Palpate gently for tenderness, guarding, rigidity, masses.
Percuss for dullness or tympany; auscultate for bowel sounds.
Evaluate for pelvic stability with gentle pressure once.
Perform FAST; if positive and unstable → laparotomy.
Consider CT abdomen/pelvis with contrast if stable.

Pelvis and Perineum

Inspect for lacerations, ecchymosis, bleeding from urethra, vagina, or rectum.
Check pelvic stability once only; if unstable, apply pelvic binder immediately.
Examine perineum for hematoma or laceration.
Rectal exam: assess tone, presence of blood, bony fragments, high-riding prostate.
Vaginal exam in females with pelvic fractures or suspected vaginal injury.

Extremities

Inspect for deformity, wounds, bleeding, or amputation.
Palpate for tenderness, crepitus, distal pulses, and capillary refill.
Assess motor, sensory, and perfusion status (5 P’s: pain, pallor, paresthesia, paralysis, pulselessness).
Immobilize fractures and dislocations with splints.
Control external bleeding with pressure or tourniquet if necessary.
Consider compartment syndrome in crush or long-bone injuries.

Back and Posterior Surface

Logroll with four-person technique maintaining spinal alignment.
Inspect the entire back, buttocks, and posterior thighs.
Palpate spine for tenderness, step-offs, or deformity.
Examine posterior wounds carefully before re-positioning.

Adjuncts to the Secondary Survey

Diagnostic imaging as indicated: CT head/neck/chest/abdomen/pelvis, spine films.
Laboratory evaluation: CBC, electrolytes, renal function, coagulation, lactate, ABG.
Urinalysis: check for hematuria.
Toxicology screen if indicated.
Foley catheter (unless urethral injury suspected).
NG/OG tube for gastric decompression (OG if facial trauma).
Pain control and tetanus prophylaxis as required.

Special Considerations

Pediatric Patients

Use weight-based resuscitation (Broselow tape).
Pediatric anatomy increases risk of airway obstruction and intra-abdominal injury without external signs.

Geriatric Patients

Limited physiologic reserve; normal vitals may mask shock.
High risk for intracranial hemorrhage on anticoagulants.

Pregnant Patients

Evaluate both mother and fetus.
Use left lateral uterine displacement after 20 weeks to relieve IVC compression.
Fetal monitoring if viable gestational age.
Administer Rh immunoglobulin to all Rh-negative mothers with torso trauma.

Reevaluation

Continuously reassess vital signs and mental status.
Repeat focused exams after every intervention or if condition changes.
Any deterioration requires immediate return to primary survey.

Definitive Care and Disposition

Identify injuries requiring operative intervention or specialist consultation.
Coordinate transfer or admission based on injury pattern and facility capability.
Provide clear handoff using SBAR or MIST format.
Continue resuscitation, monitoring, and warming measures during transfer.
Document all findings, diagnostics, and interventions performed.

Documentation

Record all examination findings, imaging results, and interventions.
Note vital trends, neurologic status, wound locations, and definitive management plans.
Document tetanus status, analgesia given, and consultations obtained.

References

Advanced Trauma Life Support (ATLS®) 10th Edition, American College of Surgeons Committee on Trauma.
Vanderbilt University Medical Center Trauma PMG Format.