Clinical Practice Guidelines

Major paediatric trauma - the secondary survey

  • See also: Major paediatric trauma - the primary survey
    Cervical spine guidelines

    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.