Secondary survey in trauma

secondary survey

1. Secondary survey in trauma Dr Shambhavi Sharma MS 1 st year resident PAHS

2. Secondary survey Complete , head-to-toe physical examination to identify all anatomic injuries Begins after primary survey & resuscitation have been completed and patient is sustaining satisfactory physiology

3. Risk of missed injuries Abdominal Trauma Blunt Trauma: Bowel injury, pancreatic and duodenal injuries, diaphragmatic rupture Penetrating Trauma: Rectal injuries Thoracic Trauma: Aortic injuries, pericardial tamponade , esophageal perforation Extremity Trauma: distal extremity fractures, compartment syndrome

4. History A llergies M edications, particularly cardiac, anticoagulation, and diabetic medications P ast medical history/pregnancy L ast meal eaten

5. E vents/environmental (more detailed mechanism of injury, helps to define injury patterns ) Blunt Motor vehicle Pedestrian Fall Crush Penetrating Gunshot Shotgun Stab

6. In patients who sustain blunt trauma spleen (40% to 55 %) liver (35% to 45 %), small bowel (5% to 10 %) 15% incidence of retroperitoneal hematoma

7. Direct blow: ( contact with the lower rim of a steering wheel, bicycle or motorcycle handlebars,intruded door in a motor vehicle crash) compression and crushing injuries to abdominopelvic viscera and pelvic bones deform solid and hollow organs rupture with secondary hemorrhage contamination by visceral contents leading to associated peritonitis

8. Shearing injuries form of crush injury that can result when a restraint device is worn inappropriately injury in motor vehicle crashes fall from significant heights may sustain deceleration injuries, in which there is a differential movement of fixed and mobile parts of the body Examples: lacerations of the liver and spleen

9. Penetrating injury Stab wounds and low-energy gunshot wounds cause tissue damage by lacerating and tearing liver (40%), small bowel (30%), diaphragm (20%), and colon (15%)

10. Gunshot wounds intra-abdominal injuries based on the trajectory, cavitation effect , possible bullet fragmentation commonly injure the small bowel (50%), colon (40%), liver (30%), and abdominal vascular structures (25 %)

11. Environmental Burn Cold Chemical, radiological, biological

12. bLast injury possibility of combined penetrating and blunt mechanism incur additional injuries to the tympanic membranes, lungs, and bowel related to blast overpressure (have delayed presentation)

13. Physical exam Head Mental status: GCS Scalp Lacerations and avulsions Open skull fractures Depressed fractures No nasogastric tube (NG) inserted if facial trauma or evidence of basilar skull fracture

14. Eyes Visual acuity: the vital sign of the eye Pupil size & reactivity Globe integrity & foreign body assessment Extraocular muscle movement Periorbital echymossis ( racoon eyes)

15. Ears Pinna External auditory canal Hemotympanum and tympanic membrane rupture retro-auricular ecchymosis (Battle's sign ). The presence of blood or clear drainage from the ear canal indicates basilar skull fracture with cerebrospinal (CSF) leak

16. Face Nose Epistaxis Septal hematoma Fracture Mouth Mid-face stability Malocclusion Dental fractures Mandibular fractures Tongue lacerations

17. Neck maintain in-line stabilization as anterior and posterior collar sections are temporarily removed for neck exam Anterior Laryngeal deformity Subcutaneous emphysema Hematoma Bruit Posterior Cervical spine tenderness Paravertebral swelling

18. Chest Breath sounds Hyper-resonance or dullness to percussion Rib, sternal , and clavicular fractures Subcutaneous emphysema Heart sounds

19. Abdomen Scars and open wounds Distention Tenderness Seat belt sign Peritoneal signs absence of abdominal tenderness does  not  eliminate the possibility of abdominal injuries

20. may not be reliable in Elderly population Presence of distracting injuries Altered mental state Pregnant patient, especially late pregnancy

21. Pelvis Bony tenderness and pubis and anterior iliac spines for stability Perineum/genitalia: stigmata of urethral injury and pelvic fracture Hematoma/bruising Blood at urethral meatus Vaginal lacerations Scrotal hematoma Tenderness over pelvic rings discrepancy in limb length rotational deformity of a leg without obvious fracture

22. The mechanically unstable hemipelvis migrates cephalad because of muscular forces and rotates outward secondary to the effect of gravity on the unstable hemipelvis External rotation of the unstable pelvis results in an increased pelvic volume that can accommodate a larger volume of blood

23. Perineum/ Anorectum extends from the iliac crests to the gluteal folds Penetrating injuries to this area are associated with up to a 50% incidence of significant intra-abdominal injuries, including rectal injuries below the peritoneal reflection.

24. penetrating wounds : assess sphincter tone and look for gross blood, which may indicate a bowel perforation sustained blunt trauma: assess sphincter tone and rectal mucosal integrity and to identify any palpable fractures of the pelvis

25. vaginal exam presence of complex perineal laceration, pelvic fracture, or transpelvic gunshot wound In unresponsive menstruating women, examine the vagina for the presence of tampons; can cause delayed sepsis Blood in meatus : urethral injury  retrograde urethrography performed before a Foley catheter inserted

26. Extremities : use symmetry to advantage Deformity and limb length: fracture and dislocation Swelling: fracture, soft tissue (crush) and joint injury Skin integrity: open fracture Pulse,capillary refill time Each compartment The presence of significant pain or tense compartments and p ain with passive movement ; development of the compartment syndrome

27. Neuromuscular function Axillary : shoulder abduction Musculocutaneous : elbow flexion Ulnar : little finger sensation Median: thumb opposition Radial: wrist extension

28. Femoral: knee extension Posterior tibial : ankle plantarflexion Deep peroneal : great toe dorsiflexion Circulation Upper: brachial and radial Lower: femoral, posterior tibial , dorsalis pedis

29. Back: logroll essential (50% of body surface area) Tenderness Deformity Torso neurologic level Shoulder abduction: C5 Elbow flexion: C6 Elbow extension: C7 Grip: C8 Finger spread: T1

30. Nipple level sensation: T4 Umbilical level sensation: T10 Hip flexion: L2 Knee extension: L3,4 Big toe dorsiflexion : L5 Ankle plantarflexion : S1

31. Management principles