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 informing them of 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 ü a child may be upset by the sudden and unexplained disappearance of their favorite trousers.
Performing the examination:
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 pupiliary reflexes, vision and hearing.
Inspect the neck through the hard collar. Palpate the cervical vertebrae. To clear the cervical spine see Cervical spine guidelines. Complete examination of the neck by observing the neck veins and palpating the trachea and the carotid pulse.
Inspect the chest, observe the chest movements , palpate for clavicular and rib tenderness and auscultate the lung fields and heart sounds.
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.
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.
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.
Specifically during the secondary survey the examiner must look for the following.
| 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 and 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 |
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During the examination any injuries that are detected should be
accurately documented and any urgent treatment such as covering
wounds, tamponading bleeding and splinting fracture should occur.
Appropriate analgesia, antibiotics or tetanus immunization should
be ordered. The priorities for further investigation and treatment
may now be considered and a plan for definitive care
established.