Surgical Critical Care,  Trauma Surgery

The Five Letters on Which Trauma Stands – Part 6

The Secondary Survey

Now you can start breathing again and relax… or not?

The secondary survey can be conducted only once the patient has been completely assessed with the primary survey and is stable enough. 

It is nothing more than a complete and meticulous medical examination. It is divided into two parts:

  1. History: use the acronym AMPLE to remember what to ask (Allergies, Medications, Past illness/Pregnancy, Last meal, Events related to the trauma).
  2. Clinical examination: this is a head-to-toe front-to-back evaluation. During the examination, you have to touch the patient, palpate for pain, search for suspected fractures, etc…

As per the primary survey, the secondary survey has adjuncts too. They include everything not done during the primary survey (e.g. additional x-rays, CT scans, angiography, bronchoscopy, etc…).

This is it. We have finished our journey through the magical world of ATLS. It was long and complex, but we made it.

However, didn’t we forget about something? Someone, maybe?

Oh yeah… Our dear Kenny… Let’s go back to our clinical scenario…

Put It All Together

As you have learned, you begin your primary survey from the airway. Meanwhile, the two nurses undress the patient, monitor him, give him low flow oxygen supply through an oxygen mask, and draw blood.

A – You ask Kenny if he knows what happened, and he tells you about the accident and how he blacked out after the impact. His voice is perfectly normal, without any sign of hoarseness or stridor. While someone is holding his C- spine you touch it, he does not complain about pain. However, you decide to leave the Philadelphia collar in place.

B – His chest is expanding bilaterally and symmetrically. The lung sounds are normal on both sides. Saturation is 100% on a low-flow oxygen mask, respiratory rate is 14 bpm.

C – Kenny has no external sources of bleeding. You have already excluded a massive hemothorax during the B evaluation. The abdomen is soft diffusely, and the pelvis seems stable at pressure. However, Kenny has an open mid-shaft fracture to the right femur, already splinted. Blood pressure is 110/60, and the heart rate 115 bpm. Skin seems slightly pale, with a capillary refill of 2 sec.

D – First thing you assess the GCS: Kenny is awake with both eyes open (E4), he answered your previous questions normally (V5), and he obeys when you ask him to touch his nose (M6). His GCS is 15/15, great. You evaluate his pupils, which appear equal and reactive to light. Kenny can move both arms and feet.

E – He has some superficial excoriations on both legs and arms and the forehead. Afterward, while the orthopod and the two nurses log-roll him, you assess the spine. However, when you ask the patient if he feels pain, he does not answer properly. 

Something is wrong. It seems the neurologic status is precipitating. Why is it happening? What to do next? The only correct answer is to start again from the beginning.

A – Airways are patent, and the patient is still breathing on his own. Though now he is tachypneic, and saturation is 97% with the oxygen mask on. Do you need to tube him? We would say that you do not have enough information to decide yet, but there is a high chance you must. Therefore, you ask the nurses to prepare everything for intubation. Meanwhile, you don’t have to lose time, and you must continue with the primary survey.

B – Lung sounds are still normal and bilateral.

C – Nothing new. However, blood pressure now is 90/70 mmHg and heart rate 110 bpm. You start a 500 mL crystalloid fluid bolus.

D – GCS has dropped to 6/15. Pupils are unequal, more dilated than before, and less reactive to light. 

Now you have the indication, you needed to tube him, and to do so you have to start everything once again.

A – You perform endotracheal intubation and set up the ventilator.

B – You listen to his chest to confirm that the lung sounds are present and bilateral.

C – Blood pressure is still around 85/65 with a heart rate of 105 bpm. The fluid bolus you gave him previously is finished, but it did not sort any effect. So, you start a blood transfusion (O neg) and obtain a good response.

D – At this point is no more possible to evaluate GCS because the patient is sedated. Pupils are the same as before, meaning possible intracranial hypertension. Therefore, you start slightly tilting the bed (head up) and continue the “C” resuscitation.

E – Nothing new has emerged from the evaluation.

As you noticed, starting over and over again from the beginning seems quite redundant, but it is fundamental to obtain a complete and accurate assessment of the patient, reducing the risk to miss something. Remember that nothing is straightforward in trauma. Sudden impairment of the neurological status may be secondary to hypoxia (e.g. airway obstruction, pneumothorax, hemothorax…), hypovolemic shock (i.e. unknown internal hemorrhage), traumatic brain injury, intoxication, etc… 

Nothing can be underestimated… Always suspect everything…

The only way to avoid stupid mistakes is having a method… and the primary survey is this method.

  1. Advanced Trauma Life Support: Student Course Manual. 10th Ed. Chicago, IL: American College of Surgeons; 2018.
  2. Peitzman AB, et al. The Trauma Manual: trauma and acute care surgery; 4th Ed. Philadelphia, PA: Lippincott; 2013.
  3. European resuscitation Council and European Society for Trauma and Emergency Surgery. European Trauma Course: the team approach.
How to Cite This Post

Marrano E, Bellio G. The Five Letters on Which Trauma Stands – Secondary Survey. Surgical Pizza. Published on August 10, 2020. Accessed on October 22, 2021. Available at [].

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