The secondary survey is a comprehensive, methodical evaluation of a trauma patient, designed to uncover injuries not immediately apparent or life-threatening. This systematic assessment follows the rapid primary survey, which focuses solely on identifying and managing immediate threats to life, such as airway obstruction or uncontrolled hemorrhage. The goal is to perform a detailed inspection to identify occult injuries, which can contribute to long-term disability or become life-threatening if missed. The information gathered during this phase guides subsequent diagnostic steps and the ultimate treatment plan.
The Transition to Secondary Survey
Initiating the secondary survey is a deliberate step taken only once the patient’s condition is stable and immediate life-threatening issues are addressed. It requires completing the primary survey and initiating all necessary resuscitation measures, including securing a stable airway, ensuring adequate breathing, and controlling significant external bleeding. Stabilization of vital signs is a prerequisite. If the patient’s condition deteriorates at any point during the secondary assessment, clinicians must immediately revert to the primary survey to re-evaluate for a newly developed or worsening life threat.
The Systematic Head-to-Toe Physical Assessment
The most extensive component of the secondary survey is a physical examination that moves sequentially through every region of the body. This head-to-toe approach ensures no injury is overlooked. The process involves inspection, palpation, and sometimes auscultation, looking for signs of trauma like lacerations, swelling, or deformity.
The examination begins with the head and face, where clinicians look for scalp hematomas, skull depressions, and signs of a basilar skull fracture, such as bruising behind the ears or around the eyes. Moving to the neck, the cervical collar is briefly and carefully opened while maintaining manual in-line stabilization to check for tracheal deviation, tenderness, and obvious wounds. The chest is inspected for paradoxical movement or bruising, and palpated for rib tenderness or crepitus, which suggests air has escaped into the soft tissues.
The abdomen is examined for distension, tenderness, and the presence of bruising that could indicate internal organ damage. A gentle but firm assessment of the pelvis is performed to check for instability, as an unstable pelvic fracture can lead to massive blood loss. All four extremities are then checked for deformity, fractures, and circulatory status by assessing pulses and capillary refill. Finally, the patient is carefully log-rolled to inspect the entire back and flanks for any posterior wounds or tenderness along the spine that might suggest a vertebral injury.
Gathering the Essential Patient History
The collection of pertinent patient information is an important part of the secondary survey, often utilizing the mnemonic AMPLE to structure the inquiry. This history is critical because pre-existing conditions or certain medications can alter a patient’s response to trauma and subsequent treatment.
The AMPLE mnemonic covers five key areas:
- Allergies: Identifying substances or medications that must be avoided during treatment.
- Medications: Noting current prescriptions, particularly anticoagulants, which increase the risk of hemorrhage, or beta-blockers, which can mask a patient’s typical physiological response to shock.
- Past medical history: Covering previous illnesses, surgeries, or chronic conditions that may affect recovery.
- Last meal or oral intake: Essential information when planning for potential emergency surgery or anesthesia.
- Events surrounding the injury: Providing context about the mechanism of trauma, such as the speed of a vehicle collision or the height of a fall, which helps predict potential injury patterns.
Ongoing Monitoring and Preparation for Definitive Care
The completion of the secondary survey initiates a period of continuous reassessment and preparation for definitive care. Trauma is a dynamic process, and patients must be monitored for signs of clinical deterioration, such as changes in consciousness level or a drop in blood pressure. Any worsening of the patient’s status necessitates an immediate return to the primary survey to look for a newly developed life-threatening condition.
Findings from the physical assessment and history directly inform the need for subsequent diagnostic imaging, which often includes X-rays, ultrasound, or computed tomography (CT) scans. The secondary survey provides the comprehensive data needed for the trauma team to formulate the final treatment plan, which may involve specialized surgical intervention, transfer to a dedicated trauma center, or admission to an intensive care unit.