12 Primary and secondary survey

  • The primary survey

    Introduction

    Always assume all major trauma patients have an injured spine and maintain spinal immobilisation until spine is cleared. Priorities in management are:

    • Airway A
    • Breathing B
    • Circulation C
    • Disability D

    Prior to arrival:

    • Ensure senior emergency medical and nursing staff are aware of  all available details of the case.
    • Call Trauma Team.
    • Delegate specific tasks to appropriate individuals.
    • Check the resuscitation equipment and prepare intravenous lines and fluids.
    • If possible, estimate the child's weight using the formula (Age + 4) x 2 (or 3 x Age for those over 9 years) and calculate:
    1. The amount of fluid bolus at 20 ml/kg
    2. The endotracheal tube size (age/ 4) + 4
    3. Any other drugs likely to be needed 

    On arrival:

    • Immediately perform a primary survey by assessing and managing the child's airway, with cervical spine stabilisation, breathing and circulation.
    • Obtain a history, if possible, from the parents or ambulance officers e.g. type of trauma, speed of the vehicle, height of the fall, restraints or safety equipment used, whether other people were injured.
    • Obtain information regarding any treatment or interventions to date.

    Airway and the cervical spine

    • Assess the child's airway whilst protecting the cervical spine. The cervical spine should be immobilised initially by in-line stabilisation, followed by the rapid (gentle) application of a properly fitted hard collar, sandbags and strap. (see cervical spine management chapter 1.12)
    • If the airway is inadequate, apply a jaw thrust manoeuvre, clear any obstruction using suction under direct vision, and consider intubation.
    • An oropharyngeal airway may be used to help maintain an adequate airway.
       

    Breathing

    • Apply oxygen 10 litres/min by face mask.
    • Assess the child's breathing by observing:
    1. The work of breathing (recession, respiratory rate, accessory muscle use);
    2. The effectiveness of breathing (oxygen saturation, chest expansion, breath sounds);
    3. The effects of inadequate respiration (heart rate, mental state)
    • If breathing is inadequate, exclude a tension pneumothorax. Use positive pressure ventilation with bag/valve/mask, and consider intubation.
    • Insert a large oro-gastric tube to treat and prevent gastric dilatation.
       

    Circulation

    • Assess the child's circulatory state by observing:
    1. pulse rate, skin colour, capillary refill time, blood pressure;
    2. the effects of an inadequate circulation (respiratory rate, mental state).
    • Establish intravenous access with two cannulae that are as large as practicable - ideally one situated in each cubital fossa.
    • If an IV cannula cannot be sited rapidly, consider the use of an intra-osseous needle inserted into a non-traumatised leg.
    • As the IV is inserted, take blood for a blood sugar, FBE, cross-match.
    • If circulation is inadequate, give a fluid bolus of 20 ml/kg of normal saline.
    • Tamponade any continuing external haemorrhage.
    • If the circulation continues to be unstable, repeat the fluid bolus using normal saline or a colloid solution. If a third bolus is necessary, consider using packed cells (O negative, group-specific or cross-matched, as available), and arrange early surgical intervention

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    Disability (mental state)

    • Assess mental state by determining the child's best response to a painful stimulus, observing his/her posture, and examining the pupillary reflexes.
    • The response to pain is determined by squeezing one ear lobe hard and observing the best response to that stimulus (e.g. flexion of one arm and extension of legs is recorded as flexion to pain).
    • Note whether the child:
      • A is Alert, or
      • V responds to Voice, or
      • P responds to Pain by localising appropriately, flexing limbs or extending limbs to pain, or
      • U is Unresponsive.

    Monitor

    • Respiratory rate, heart rate, blood pressure, oxygen saturation and rectal temperature.
    • Response to pain and pupillary light reflexes.

    Temperature

    • Minimise hypothermia by limiting exposure of the body during examination, and by warming all ongoing fluids.

    Normal Physiological Values 

    Radiology

    • Arrange for cross-table lateral cervical spine, chest and pelvic X-rays to be done in the resuscitation room.
    • If there is NO clinical suspicion of a pelvic injury AND the child has a normal conscious state, the pelvic X-ray may be omitted.
    • Arrange additional radiology as indicated

    References

    1. Browne GJ, Cocks AJ, McCaskill ME. Current trends in the management of major paediatric trauma. Emergency Medicine (Fremantle, W.A.). 2001;13(4):418-25.
    2. Cantor RM, Leaming JM. Evaluation and management of pediatric major trauma. Emergency Medicine Clinics of North America. 1998;16(1):229-56.
    3. Mackway-Jones K, Molyneux E, Phillips B, Wieteska S, eds. Advanced Paediatric life Support - the Practical Approach. Third ed. London: BMJ Books, 2001.
    4. Rothrock SG, Green SM, Morgan R. Abdominal trauma in infants and children: Prompt identification and early management of serious life-threatening injuries. Part 1: injury patterns and initial assessment. Paediatric Emergency Care 2000;16:106-115.
    5. Royal Children's Hospital Melbourne. Clinical Practice Guidelines

    -Trauma (Major), 2001. www.rch.org.au/clinicalguide/pages/trauma.php

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    Secondary survey  

    Introduction

    The secondary survey is only to be commenced after the primary survey has been completed and the child is stable. Continue to monitor the child's

    • Mental state,
    • Airway, respiratory rate, oxygen saturation,
    • Heart rate, blood pressure, capillary refill time.

    If there is any deterioration detected in these parameters, the primary survey MUST be repeated immediately and measures taken to rectify the problem.

    Preparation:

    Before commencing the examination,

    • develop a rapport with the child , offer reassurance and explain what you are doing.
    • involve the parents or other adults accompanying the child by telling them what you are doing and using them to comfort or distract the child.
    • keep the child warm and - as far as possible - covered.
    • remove clothing judiciously; a child may be upset by the sudden and unexplained disappearance of their favorite trousers.

    Performing the examination:

    Head and face

    • Inspect the face and scalp.
    • Look in the eyes, ears, nose and mouth.
    • Palpate the bony margins of the orbit, the maxilla, the nose and jaw.
    • Palpate the scalp.
    • Test eye movements, pupillary reflexes, vision and hearing.

    Neck

    • Inspect the neck through the hard collar. Palpate the cervical vertebrae. (To clear the cervical spine, see Cervical spine guidelines chapter 1.12)
    • Complete examination of the neck by observing the neck veins and palpating the trachea and the carotid pulse.

    Chest

    • Inspect the chest, observe the chest movements ,
    • Palpate for clavicular and rib tenderness and auscultate the lung fields and heart sounds.
       

    Abdomen

    • Inspect the abdomen, palpate for areas of tenderness especially over the liver, spleen, kidneys and bladder, and auscultate bowel sounds.
    • Inspect the perineum and external genitalia.

    Limbs

    • Inspect all the limbs and joints, palpate for bony and soft tissue tenderness and check joint movements, stability and muscular power.
    • Examine sensory and motor function of any nerve roots or peripheral nerves that may have been injured. 

    Back

    • Log roll the child. Inspect the entire length of the back and buttocks and palpate the spine for tenderness.
    • Inspect the anus. Digital examination of the anus is rarely needed; however, if indicated should be performed by one person.

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    Secondary Survey Checklist:

    Head

    • Scalp: lacerations, bruising, depressions or irregularities in the skull, Battles sign (bruising behind the ear indicative of a base of skull fracture).
    • Mouth: lacerations to the lips, gums, tongue or palate.
    • Teeth: subluxed, loose, missing or fractured.
    • Nose: deformities, bleeding, nasal septal haematoma, CSF leak
    • Ears: bleeding, blood behind tympanic membrane.
    • Eyes: foreign body, subconjunctival haemmorhage, hyphaema, irregular iris, penetrating injury, contact lenses.
    • Jaw: pain, trismus, malocclusion.

    Neck

    • Cervical spine: pain, tenderness, deformity, inability to move neck;
    • Soft tissues: bruising, pain and tenderness;
    • Trachea: deviation, crepitus;
    • Neck veins: distention.

    Chest

    • Chest wall: bruising, lacerations, penetrating injury, tenderness, flail segment.
    • Lung fields: percussion note, lack of breath sounds, wheezing, crepitations.
    • Heart: Apex beat, presence and quality of heart sounds.

    Abdomen

    • Abdo wall: bruising, lacerations, penetrating injury, tenderness.
    • Viscera: splenic, hepatic or renal tenderness, bladder tenderness or enlargement.
    • Bowel: abdominal tenderness or rebound, absent bowel sounds.
    • Pelvis: pain on springing.
       

    Limbs

    • Soft tissues: bruising, lacerations, muscle, nerve or tendon damage.
    • Bones: tenderness, deformities, open fractures.
    • Joints: penetrating injuries, ligament injuries.

    Back

    • Soft tissues: bruising, lacerations
    • Bones: tenderness, steps between vertebrae.
       

    Buttocks

    • Soft tissues: bruising, lacerations. 

    Perineum

    • Soft tissues: bruising, lacerations. 

    Genitalia

    • Soft tissues: bruising, lacerations.
    • Urethra: bleeding.
    • Introitus: bleeding.
       

    Urinalysis

    • Blood.

    During the examination, any injuries detected should be accurately documented, and any urgent treatment required should occur, such as covering wounds, tamponading bleeding and splinting fractures.
    Appropriate analgesia, antibiotics or tetanus immunisation should be ordered. The priorities for further investigation and treatment may now be considered and a plan for definitive care established 

    References

    1. Browne GJ, Cocks AJ, McCaskill ME. Current trends in the management of major paediatric trauma. Emergency Medicine (Fremantle, W.A.). 2001;13(4):418-25.
    2. Cantor RM, Leaming JM. Evaluation and management of pediatric major trauma. Emergency Medicine Clinics of North America. 1998;16(1):229-56.
    3. Mackway-Jones K, Molyneux E, Phillips B, Wieteska S, eds. Advanced Paediatric life Support - the Practical Approach. Third ed. London: BMJ Books, 2001.
    4. Royal Children's Hospital Melbourne. Clinical Practice Guidelines

    -Trauma (Major), 2001. www.rch.org.au/clinicalguide/pages/trauma.php