ATLS

ATLS Secondary Survey: Overview

Initial Management Goals

1. General Information
   • Head-to-toe evaluation of trauma patient
     • A complete history, physical examination, and reassessment of all vital signs
   • Used to prioritize treatment plan
   • Epidemiology
     • Global injury mortality by cause
       • 23% Road traffic
       • 21% Smothering, asphyxiation, choking, animals, hypothermia, hyperthermia, and natural disasters
       • 15% Suicide
       • 11% Homicide
       • 8% Falls
       • 7% Drowning
       • 6% Poisoning, Fires
       • 3% War
   • Secondary survey does not begin until:
     • Primary survey (ABCDE) is completed
     • Resuscitative efforts are underway and hemodynamic stability is achieved
     • Vitals are maintained
   • If additional personnel are available
     • Part of the secondary survey may be conducted while the other personnel attend to the primary survey
     • This should NOT interfere with the primary survey which is highest priority
2. History
   • Prehospital personnel and family may assist with the history
     • Note:
       • Allergies
       • Medications used
       • Past illnesses/Pregnancy
       • Last meal
       • Events and environment related to the injury
   • Mechanism of injury
     • Blunt trauma
       • Interpersonal violence
       • Automobile collision, injuries related to transportation, recreation, and occupations:
         • Seat belt use
         • Steering wheel deformity
         • Presence and activation of air-bag devices
         • Direction of impact
         • Damage to the automobile in terms of major deformation or intrusion into the passenger compartment
         • Patient position in the vehicle
     • Penetrating trauma
       • Gunshot wounds, stab wounds, interpersonal violence, blast debris: find out about:
         • Body region that was injured
         • Organs in the path of the penetrating object
         • Velocity of the missile
         • In GSWs
           • Velocity
           • Caliber
           • Presumed path of bullet
           • Distance from weapon to patient
     • Thermal injury
       • Burns:
         • Serious trauma that can occur isolated or in conjunction with blunt and/or penetrating trauma
           • Burning automobile
           • Explosion
           • Falling debris
           • Patients attempt to escape a fire
           • Complications:
             • Inhalation injury
             • Carbon monoxide poisoning
             • Combustion and inhalation of toxic plastic and chemicals
       • Hypothermia
         • Acute/chronic hypothermia without adequate protection can produce local or generalized cold injuries
         • Significant heat loss can occur:
           • At moderate temperatures (15-20°C [59-68°F])
           • Wet clothes
           • Suppressed body activity
           • Vasodilation caused by alcohol or drugs ⇒ decreased ability to conserve heat
           • Temperature extremes
     • Hazardous Environment
       • Exposure to chemicals, toxins, and radiation
         • Variety of pulmonary, cardiac, and internal organ dysfunction
         • Establish immediate contact with a Regional Poison Control Center
3. Physical Examination
   • Head
     • Examine entire scalp
       • Lacerations, contusions
       • Evidence of fractures
     • Examine the eyes
       • Visual acuity- Snellen chart
       • Pupillary reflex/size exam
       • Hemorrhage of conjunctiva and/or fundi
       • Penetrating injury
       • Contact lenses (remove before edema occurs)
       • Dislocation of the lens
       • Ocular entrapment
     • Lateralizing signs
       • Pupil size
       • Symmetry and reaction to light
       • Movement in all four limbs
       • Deep tendon reflexes
       • Plantar responses
     • Glasgow Coma Score (GCS)
       • GCS of ≤ 8: severe head injury
       • GCS of 9-12: moderate head injury
       • GCS of 13-15: minor head injury
   • Maxillofacial structures
     • Palpate bony structures
     • Assess for occlusion
     • Intraoral examination
     • Assess soft tissues
     • Maxillofacial trauma not associated with airway obstruction/major bleeding
       • Treat after vitals stabilization and life-threatening injuries have been managed
     • Fractures of midface may also have associated fracture of the cribriform plate
     • Perform gastric intubation via oral route
   • Cervical Spine and Neck
     • Patients with maxillofacial or head trauma should also be presumed to have a cervical spine injury
       • Immobilize cervical spine
       • If wearing protective helmet, extreme care must be taken when removing the helmet
       • Absence of neurologic injury does not exclude cervical spine injury
       • Obtain radiographic imaging
         • NEXUS
         • Canadian C-Spine Rule
       • Inspect, palpate, and auscultate for
         • Cervical spine tenderness
         • Subcutaneous emphysema
         • Tracheal deviation
         • Laryngeal fractures
         • Carotid bruits
         • Seatbelt marks- common sign for potential underlying injury
     • Blunt force to neck/traction injury from shoulder harness restraint
       • Intimal disruption, dissection, and/or thrombosis of carotid arteries
       • Blunt carotid injury can present with coma or without neurologic finding
       • Obtain CT angiography, angiography, duplex U/S
         • Rule out major vascular injury
     • Penetrating injuries to the neck
       • Can injure several organs
       • Wounds that extend through the platysma
         • Requires experienced personnel
         • Active arterial bleeding, expanding hematomas, arterial bruit, or airway compromise requires surgery consult
       • Unexplained/isolated paralysis of an upper extremity should raise suspicion of cervical nerve root injury
   • Chest
     • Inspection, palpation, auscultation, percussion, and chest x-ray (anterior and posterior chest walls)
       • Palpate entire chest cage including the clavicles, ribs, and sternum
         • Tenderness may indicate fracture or costochondral separation
       • Significant chest injury can present with pain, dyspnea, and hypoxia
     • Identify:
       • Tension pneumothorax
         • Hyperresonance of affected side, JVD
         • Chest x-ray or eFAST can confirm hemothorax or simple pneumothorax
       • Pericardial tamponade
         • Distant heart sounds, decreased pulse pressure, JVD
       • Aortic rupture
         • Widened mediastinum, hypotension
   • Abdomen and Pelvis
     • Abdominal injuries:
       • Determine if surgical intervention is necessary as opposed to exact etiology on initial inspection
       • A normal initial exam of the abdomen DOES NOT exclude significant intrabdominal injury
         • Therefore, close observation and frequent reevaluation of the abdomen by the same observer is pertinent
         • Early involvement of a surgeon is beneficial
         • Consider DPL, abdominal ultrasonography, or CT in patients with:
           • Unexplained hypotension
           • Neurologic injury
           • Impaired sensorium secondary to alcohol and/or other drugs
     • Pelvic fractures:
       • Ecchymosis over iliac wings, pubis, labia, or scrotum
       • Pain on palpation of pelvic ring
       • Assess peripheral pulses for vascular lesions
       • Apply a pelvic binder to limit blood loss from pelvic fractures
   • Perineum, Rectum, and Vagina
     • Examine perineum
       • Contusions
       • Hematomas
       • Lacerations
       • Urethral bleeding
     • Rectal examination
       • Blood
       • Rectal wall integrity
       • Sphincter tone
     • Perform vaginal inspection in patients who are at high risk of vaginal injury
       • Assess for vaginal lacerations or the presence of blood in the vaginal vault
       • Perform pregnancy tests in females of childbearing age
   • Musculoskeletal System
     • Inspect extremities for contusions and deformities
     • Palpation of bones and examination for tenderness may help with identification of occult fractures
     • Significant extremity injuries may be present without fractures e.g., ligament ruptures, tendon injuries
     • MSK evaluation is NOT complete without examination of the back
   • Neurological system
     • Perform a motor and sensory evaluation of the extremities
     • Always protect the spinal cord until a spine injury is excluded
     • Assess patients' level of consciousness, pupillary size, and response
     • The GCS score
       • Detects early changes and trends in patient's neurological status
       • GCS of ≤ 8: severe head injury
       • GCS of 9-12: moderate head injury
       • GCS of 13-15: minor head injury
     • Consult neurosurgery for traumatic brain injury or spinal cord injury
     • Monitor patients frequently for deterioration or for changes in neurologic function
       • If deterioration ⇒ reassess oxygenation, adequacy of ventilation, and perfusion of the brain
     • Depressed skull fractures and hematomas may require neurosurgical evacuation
4. Adjuvants to Secondary Survey
   • Draw trauma labs
     • CBC
     • Blood type and match
     • ABG
     • Electrolytes
     • BUN/Cr
     • Glucose
     • Urinalysis
     • PT/PTT
     • Pregnancy test
     • Lactate
     • DIC
     • Drug/EtOH screen as needed
   • Imaging (e.g., C-spine, CXR, pelvis X-rays)
   • Tetanus prophylaxis for any lacerations or penetrating injuries
   • Prophylactic IV antibiotics for all open fractures or abdominal penetration
   • If hypotensive despite fluid and blood replacement
     • Immediate abdominal or thoracic exploration

Related Topics

• Head and Neck
• Chest
• Abdomen and Pelvis
• Extremities
• Laboratory

References

1. In: Stewart RM, Rotondo MF, Henry SM, et al; (eds). ATLS - Advanced Trauma Life Support Student Course Manual 10th ed. American College of Surgeons, 2018. ISBN 78-0-9968262-3-5

Contributor(s)

1. Bruner, David, MD, FAAEM
2. Cherian, Geo, MD

Updated/Reviewed: July 2023