Introduction

The secondary survey is a rapid but thorough head-to-toe examination assessment to identify all
potential injuries. It is helpful to determine the priorities for continued evaluation and management. It
should be performed after the primary survey, and initial stabilization is complete. The purpose of the
secondary survey is to obtain pertinent historical data about the patient and his or her injury, as well as
to evaluate and treat injuries not found during the primary survey.[1][2][3][4][5]

Indications

Evaluate trauma patients for whom no life-threatening injuries were identified during the primary
survey.

Contraindications

Contraindications include the presence of life-threatening conditions identified during the primary
survey.

Personnel

Personnel would include trauma team members if trauma team activation was conducted.

Preparation

Observe standard precautions for blood or fluid-borne infection.

Technique

As stated earlier, the secondary survey should not be performed until:

The primary survey has been completed

Resuscitation has been initiated

Normalization of vital signs has begun.

Patients who are hemodynamically unstable should be stabilized before they are transferred to the
operating room or angiography suite, unless they need to be transported to a state designated trauma
center.

An attempt should be made to obtain the patient's history regarding the mechanism of injury, since
certain mechanisms can raise the suspicion for certain injuries such as the following:

Blunt trauma (seat belt use, airbag deployment, extent of damage to the automobile, ejection, and
distance ejected)

Penetrating trauma (which firearm and how many gunshots heard).

AMPLE History

This mnemonic device can be used for obtaining a quick, focused history:

Allergy

Medications

Previous medical history or illness/pregnancy

Last Meal

Events/environment related to injury: What happened (example mechanisms such as blunt, penetrating,
burns or any hazardous environment, such as exposure to chemicals, toxins or radiation. These
considerations are important for the following reasons due to exposure to chemical agents can cause
pulmonary, cardiac and other internal organ dysfunction, or hazardous environment can pose a threat to
the health.

Physical Examination

The purpose of the secondary survey is to identify injuries. Throughout the evaluation, standard
precautions for blood or fluid-borne infections should be observed.

Head and Face Examination

Examine the head for scalp hematoma, skull depression, or laceration. The scalp should be palpated,
since scalp lacerations or bony step-offs may be identified only by careful palpation. No nasogastric tube
(NG) should be inserted if there is facial trauma or evidence of basilar skull fracture. Also, the ears should
be evaluated for hemotympanum or retro-auricular ecchymosis (Battle's sign). The presence of blood or
clear drainage from the ear canal indicates basilar skull fracture with cerebrospinal (CSF) leak.

The pupillary size and response, as well as eye movements, should be assessed. The ocular examination
should also include ocular mobility/entrapment, or periorbital ecchymosis (Raccoon eyes).

Neck Examination

The neck should be carefully inspected and palpated. Beware that injuries under the hard collar may not
be obvious. It is assumed that every patient with blunt trauma may have sustained an injury to the
cervical spine, until proven otherwise. C-spine can be cleared either clinically by applying decision rules,
or by obtaining imaging studies, such as plain radiographs or a CT scan.

Examination of the Chest

Palpate the entire chest wall for crepitus (subcutaneous emphysema) and tenderness. The area over the
sternum and clavicles requires special attention as fractures involving these bones may suggest
significant force and need further evaluation for other intrathoracic injuries. Assess any respiratory effort
and work at breathing. Evaluate whether breath sounds are symmetrical and heart sounds are normal
and not muffled.

Examination of the Abdomen

The abdomen should be examined for distension, bowel sounds, bruising or tenderness. The presence of
these findings requires further evaluation. Also, the presence of a seatbelt sign or other marks to the
abdomen should prompt further evaluation. It is important to keep in mind that the absence of
abdominal tenderness does not eliminate the possibility of abdominal injury. In addition, the abdominal
examination may not be reliable in the following cases:
Elderly population

Presence of distracting injuries

Altered mental state

Pregnant patient, especially late pregnancy

Examination of the rectum and the genitalia.

The perineum should be inspected for any evidence of injury. A digital rectal examination should be
performed when there is a suspicion of urethral injury or penetrating rectal injury.

Look for the following:

Gross blood in the rectal vault, which may indicate bowel injury

Displaced or high-riding prostate, which may suggest urethral injury

Abnormal sphincter tone, which may be due to a spinal cord injury.

If blood is present at the meatus, the urethral injury should be suspected. In this situation, retrograde
urethrography should be performed before a Foley catheter is inserted.

Consider vaginal injury in patients with lower abdominal pain, pelvic fracture or perineal laceration. In
such situations, a vaginal examination should be performed.

Examination of the Extremities

The extremities should be assessed for fractures by carefully palpating each extremity over its entire
length for tenderness and decreased the range of motion. Assess the integrity of uninjured joints by both
active and passive movements. Uninjured joints should be immobilized, and radiographs should be
obtained. Injured joints should also be immobilized, and radiographs should be obtained.
The neurovascular status of each extremity should be assessed and documented. Check pulses, the
capillary refill time and evaluate each compartment. The presence of significant pain or tense
compartments. Pain with passive movement may indicate a development of the compartment
syndrome.

Pelvic Examination

The pubis and anterior iliac spines should be evaluated for any signs of pelvic instability. The presence of
ecchymosis over the iliac wings, pubis, labia, or scrotum and tenderness along the pelvic ring also,
requires diagnostic evaluation.

Neurologic Examination

In this evaluation, the sensory and motor functions should be assessed, and the Glasgow Coma Scale
score should be repeated. This is important, since a patient's condition may change rapidly over time.
The neurological assessment should also include an examination of the pupils, including pupils'
responses to light.

Skin Examination

This examination should include the locations of lacerations, abrasions, ecchymosis, hematoma, marks
or bruises. Pay attention to the following areas:

Scalp

Axillary abdominal and gluteal folds

Perineum

Back should be evaluated by log-rolling the patient, and the spine should be palpated for step-offs or
focal tenderness.

Complications
The risk of missed injuries. This risk may be higher for the following injuries:

Abdominal Trauma

Blunt Trauma: Bowel injury, pancreatic and duodenal injuries, diaphragmatic rupture

Penetrating Trauma: Rectal injuries

Thoracic Trauma: Aortic injuries, pericardial tamponade, esophageal perforation

Extremity Trauma: distal extremity fractures, compartment syndrome

Note that to avoid the risk of any missed injuries a tertiary survey should be required in patients with
multisystem trauma.

Clinical Significance

The secondary survey is a systematic head-to-toe evaluation of trauma patients to identify injuries which
were not discovered during primary survey.[6][7][8][9][8]

Enhancing Healthcare Team Outcomes

All healthcare workers who look after trauma patients should be familiar with the ATLS protocol and how
to perform the primary and secondary survey. The key is not to miss any serious injury. The management
of trauma patients is with a multidisciplinary team that includes a surgeon, anesthesiologist, nurses,
intensivist and a trauma team. The secondary survey is more thorough and assesses the entire body
systematically.