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Trauma – secondary survey

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  • See also

    Trauma - primary survey

    Key points

    1. The secondary survey allows the identification of injuries that were not detected in the primary survey
    2. The key element is a thorough top to toe and front to back physical examination
    3. Establish a management plan for each injury identified
    4. Refer to the relevant specialty teams and activate relevant retrieval services

    Background

    • The purpose of the secondary survey is the identification of injuries not detected during the primary survey
    • It is commenced after the management of any immediate life threats found in the primary survey

    Assessment

     Preparation

    • Continue to monitor and reassess the child’s ABCD for deterioration and respond as required. Any unexpected deterioration in these parameters requires immediate reassessment for evolving life threats
    • Develop a rapport with the child, offer reassurance and explain what you are doing. Involve the parent or accompanying adult to comfort and distract the child
    • Keep the child warm. Remove clothing as required to complete a full examination, but ensure the child is covered up when you have finished your examination

    Secondary survey

    Head and face
    • Face, scalp and skull: bleeding, lacerations, bruising, swelling, depressions / irregularities in the skull (to suggest skull fracture), bruising behind the ears (Battle’s sign: may indicate base of skull fracture), periorbital bruising (“Racoon eyes”: may indicate base of skull fracture)
    • Eyes: Palpate bony margins of orbit for fracture. Test eye movements, pupillary reflexes and vision. Inspect for penetrating injury (see Penetrating eye injury), irregular iris, foreign bodies, subconjunctival haemorrhage, hyphaema
    • Ears: bleeding, blood behind tympanic membrane (suggestive of base of skull fracture), tympanic membrane perforation (in blast injuries). Assess hearing
    • Nose: bleeding, septal haematoma, CSF leak, palpate for bony crepitus or deformity
    • Mouth: wounds to the lips, gums, tongue or palate
    • Teeth: subluxed, missing or fractured teeth
    • Jaw: identify pain, trismus or malocclusion and palpate for bony step

    Neck

    Inspect neck whilst maintaining manual in-line stabilisation of spine. Open collar to do this
    Examine anterior neck for blunt or penetrating trauma by looking/feeling for the following (TWELVE-C):

    • Tracheal deviation
    • Wounds
    • Emphysema (subcutaneous)
    • Laryngeal tenderness/crepitus
    • Venous distension
    • OEsophageal injury (unlikely if child can swallow easily)
    • Carotid haematoma/bruits/swelling

    Assess c-spine (See C-spine assessment)

    Chest

    • Observe work of breathing and effectiveness of breathing, assess for  any asymmetrical or paradoxical chest wall movement
    • Inspect for signs of injury such as bruising, seatbelt marks, wounds  
      • in cases of stabbing or other assault, look for ‘hidden’ wounds by checking areas such as axillae (assess back and buttocks with log roll)
    • Palpate for bony tenderness over ribs, crepitus (indicating subcutaneous emphysema)

    Abdomen

    • Inspect for bruising (eg from seatbelt or handlebar injury), abdominal distension
    • Palpate for signs of peritonism such as guarding or rigidity
    • Palpate for tenderness over the liver, spleen, kidneys and bladder

    Pelvis and perineum

    • Inspect for grazes over iliac crests, bruising, deformity
    • Feel for pain or crepitus on gentle palpation of bony prominences
    • Assessment for pelvic instability is performed by gentle compression of  the iliac crests
      • Pelvis and perineum
    • stressing/springing the pelvis is not recommended
    • See Early management of pelvic injuries in children
    • Inspect urinary meatus/introitus for blood
    • Examine for priapism, which may indicate a spinal injury

    Limbs

    • Inspect for wounds, bruising, open fractures, burns, abrasions
    • Feel for soft tissue and bony tenderness or swelling, joint movement and stability
    • Examine pulses and perfusion
    • Examine sensory and motor function of any nerve roots or peripheral nerves that may have been injured

    Back and spine

    • A log roll should be performed, but only once
    • Inspect entire length of back and buttocks
    • Inspect anus when indicated
    • Palpate then percuss spine for tenderness
    • Palpate scapulae and sacroiliac joints for tenderness
    • Digital rectal examination should be limited to children with neurological deficits concerning for spinal injury, and should only be performed once if required   

    Investigations

    Imaging:

    • Request a portable chest X-ray if not already done
    • Consider the need for pelvic X-ray
    • eFAST (extended Focussed Assessment using Sonography in Trauma) has a limited role in paediatric trauma
      • it may be useful in diagnosing acute haemo/pneumothorax and haemopericardium when used by an appropriately credentialed clinician
      • FAST abdominal assessment will not necessarily change management, especially in a younger child

    Urinalysis/urine microscopy:

    • Frank haematuria is highly suggestive of a urinary tract injury and should be further investigated
    • Isolated microscopic haematuria, without any signs or symptoms concerning for urinary system injury, is not a clear sign of renal injury and should not be considered an absolute indication for additional imaging

    Management and disposition planning

    • Document all injuries that have been identified
    • Dress wounds and splint fractures
    • Ensure adequate analgesia
    • Prescribe antibiotics if appropriate and determine if a tetanus booster is required
    • Establish a plan for ongoing care of all injuries identified
    • Further imaging, such as CT, should be considered if indicated
    • Determine patient disposition to ICU, theatre, ward (or hospital transfer)
    • Where possible, the trauma team leader should remain responsible for a child until completion of advanced imaging and transfer of care
    • Formal and thorough handover of patient care is important and documentation should be complete

    Consider transfer when

    • All children with major trauma should be transferred to a major trauma service for definitive management. This should be done in consultation with the local inter-hospital transfer guidelines 
    • The child requires care beyond the comfort level of the hospital

    For emergency advice and paediatric or neonatal ICU transfers, call Retrieval Services

    Additional Resources

    RCH Paediatric Trauma Manual
    NSW Institute of Trauma and Injury Management – NSW Trauma App 
    NSW Inter-hospital Major Trauma Transfer

    Trauma Victoria Inter-hospital Major Trauma Transfer


    Last Updated June 2022

  • Reference List

    • Avarello JT and Cantor RM. Pediatric major trauma: an approach to evaluation and management. Emergency Medicine Clinics of North America. 2007. 25(3):803-36.
    • Calder BW et al. Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis. Journal of Trauma and Acute Care Surgery. 2017. 83(2):218-24.
    • Casson C et al. Does microsopic haematuria after paediatric blunt trauma indicate clinically significant injury? Journal of Surgical Research. 2019. 241: 317-322.
    • Fox JC et al. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Academic Emergency Medicine. 2011. 18:477– 482.
    • Holmes JF et al. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. Journal of Pediatric Surgery. 2007. 42(9):1588-94.
    • Holmes, JF et al. Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children with Blunt Torso Trauma. JAMA. 2017. 317(22):2290-2296.
    • Kenefake ME et al. Nuances in Pediatric trauma. Emergency Medicine Clinics of North America. 2013. 31(3):627-52.
    • Menaker J et al. Intra-abdominal Injury Study Group of the Pediatric Emergency Care Applied Research Network (PECARN). Use of the focused assessment with sonography for trauma (FAST) examination and its impact on abdominal computed tomography use in hemodynamically stable children with blunt torso trauma. Journal of Trauma and Acute Care Surgery. 2014. 77(3):427-32.
    • Samuels, M. and Wieteska S. Advanced Paediatric Life Support - A Practical Approach to Emergencies, 6th ed. 2016. John Wiley & Sons. UK.
    • Scaife ER et al. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. Journal of Pediatric Surgery. 2013. 48(6):1377-83.
    • Trauma Victoria, Major Trauma Guidelines and Education, https://trauma.reach.vic.gov.au/
    • Vassallo J et al. (Paediatric Emergency Research in the UK and Ireland). Paediatric traumatic cardiac arrest: the development of an algorithm to guide recognition, management and decisions to terminate resuscitation.  Emergency Medicine Journal. 2018. 35:669-674.