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Our previous two Trauma summaries were focused on the Primary Survey; now we move to the Secondary Survey. The secondary survey starts after the primary survey is completed, resuscitation is in process, the ABCDE’s have been reassessed and the vital functions are returning to normal. At this point there should be six tubes in our trauma patient- (2) 14 gu IV’s, chest tube, Foley Catheter, NG tube and ET tube. A Maxim states that there should be a finger and a tube in every orifice. At this time one of the team members is busy getting an AMPLE history from family or friends that were present at the trauma and are aware of the patient’s history. A complete head to toe physical exam is performed along with a complete neurological exam, special diagnostic tests and reevaluation. Mechanism of injury must be ascertained as well as allergies, medications, past illnesses, pregnancy, last meal and events that took place in the trauma scene. Respect all members that were at the scene such as paramedics, as they are the first responders at trauma scenarios.
The mnemonic AMPLE is :
A-Allergies
M-Medications
P-Past illness/pregnancy
L-Last meal
E-Events/environment
Burn Injury- Burns can be married to blunt and perforating injury and are usually present at all terrorist scenes. Burns and smoke inhalation are present in closed and open spaces and are more lethal in closed spaces where materials such as plastics may have changes to other chemicals. In cases where there is a burn or carbonaceous material in the nares, intubation is necessary and should be done before the airway is lost. The Brooke Burn formula is considered reliable as is proper I&O and estimation of TBSA by Rule of nine.
Cold Injury- Significant heat loss occurs at moderate temperatures; therefore, keeping the patient warm is a priority. One should be using warm infusions, patient warming devices and setting the trauma room temperature at a reasonable temperature to prevent patient morbidity and mortality. Special attention is given to frostbite to prevent loss of a limb. Care should be addressed in removing any wet materials and rewarming after demarcation occurs.
Secondary Survey-
Head – Examine face, head, eyes and ears. A total neurological exam should be performed, a GCS score determination should have been acquired and attention should be given to obvious clues such as raccoon eyes, battles sign and FB in any of the airways or the ears.
Maxillofacial – the HCP should be observing for bony crepitus/instability, a palpable deformity, complete oral and dental exam. There needs to be an awareness of potential airway obstruction, cribriform plate fracture and inability to verbalize because of facial injury. Note the function of the facial nerves at this time.
C-spine – Any injury to the clavicles or above requires immobilization which has probably been done by the ambulance team. In any case, never assume unless you have personally examined your patient. Look for altered LOC, reflexes, complete motor and sensory exams and palpate for tenderness. Only a negative C-spine x-ray or CT can definitively R/o a cervical spine fracture and findings should be corroborated by a radiological expert Films should be from C-2 to T-1 to effectively make a diagnosis. If there is penetrating injury, do not remove the object as the patient may esanguinate.
Neck – The neck exam is initiated by inspection, palpation and auscultation. Is the trauma blunt or penetrating, is there any hoarseness or airway problem, is there evidence of a hematoma, crepitus, stridor or bruit. Remember that airway injuries are often progressive which is why reassessment is necessary.
Chest – Inspect, ascultate, palpate and percuss. Perform chest x-rays and revaluate frequently. Are there signs of a pneumothorax, hemopnumothorax or Tension pneumothorax? Are there distant heart sounds? If so, R/O cardiac contusion, which may be reflected on EKG, but also consider a pericardial injury and Cardiac Tamponade. Multiple fracture of the ribs can lead to a diagnosis of flail chest and care should be taken to discover a perforation of the lung and the need to place a chest tube. Ascultate breath sounds bilaterally, listen for heart sounds and also for bowel sounds in the chest which occur when the diaphragm is ruptured and the bowel ascends to the thoracic cavity and creates pressure and impedance of respiration. Look for distend neck veins and a mediastinal shift to R/O tension pneumothorax which is a clinical diagnosis.
This is far from a complete secondary survey of these areas but serve as a preparation for the full TEAM program which will be given at the GAPA conference this spring, the AFPPA meeting in Washington, D.C. this summer and the AFPPA meeting in Colorado Springs in November. This will be a four hour didactic review preparing the registrant for the ATLS course. See you at a future meeting.
Trauma Vl will look at the Secondary Survey and the abdomen, musculoskeletal system, pelvis, Neurologic and all adjuncts.
Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 150 plus articles and is a sought out conference speaker throughout the United States.
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