trauma - secondary survey
DESCRIPTION
PPT for Housemen Teaching 2012 [Surgical Department]TRANSCRIPT
Secondary Survey
Secondary survey does not begin until the primary survey (ABCDEs) is completed, resuscitative efforts are well established, and the patient is demonstrating normalization of vital functions
History
Physical examination: Head-to-toe
Complete neuro exam
Special diagnostic tests
Reevaluation
HISTORY Allergies Medications Past illnesses Last meal Events / Environment
PHYSICAL EXAMINATIONHeadNeckChestAbdomenLimbsSpine
HeadScalp
lacerations
cephalohematoma
skull fracture
Ears
lacerations
CSF otorrhea
blood from ear canal
blood behind TMs
GCS
✤Face
✤lacerations
✤numbness
✤stepoffs
✤pain
✤malocclusion
✤dental injuries
✤nasal injuries (septal hematoma)
Eyes: -foreign body, -subconjunctival haemmorhage, -hyphaema, -irregular iris, -penetrating injury,
-contact lenses.
Indications for Skull X-RaysIt should be done for all patients with GCS 13
and 14, and those with GCS 15 if the following are present:
(1) Mechanism of injury suggests a severe blow.
(2) Full thickness scalp laceration or boggy haematoma.
(3) Loss of consciousness (any period of time).(4) Loss of memory.(5) Vomiting.(6) Inadequate history.(7) Difficulty in clinical assessment, for
example, alcohol intoxication, epilepsy, uncommunicative children.
(8) Depressed fracture or foreign body suspected.
When should CT head scans be done?
(1) All skull fractures.(2) Signs of skull base fracture(3) Deteriorating conscious level.(4) Neurological signs.(5) Seizure.(6) Patients with GCS 15 with a persistent severe
headache, persistent vomiting, and/or neurological signs.(7) Patients with GCS 13 to 14 and who fail to improve
after fourhours of observation.(8) Patients with GCS 13 to 14 who need a general
anaesthetic for another reason, e.g. orthopaedic injury.(9) All patients with GCS 12 or lower.
extradural haematomahigh density of the haematoma. Slight
midline shift is present.
extradural haematomagas within the haematoma - this indicates a
basal skull fractureNote also the dilated lateral ventricle on the opposite side
subdural haematomas
subdural haematomas
Haemorrhagic contusionThere is a focal area of haemorrhagic
contusion in the right frontal lobe, with surrounding low density due to infarction or oedema. This is a frequent location for a contre-coup injury following a blow to the back of the head.
multifocal haemorrhagic contusionThis image demonstrates a small petechial
haemorrhage in a typical location at the grey-white matter interface (arrow). As is often the case, there were multiple such lesions on other slices.
Indications for Neurosurgical ConsultationSkull fracture with confusion or impairment of
conciousness, focal neurological signs, fits or any other neurological symptom and signs
Coma continuing after resuscitation (GCS < 8)Deterioration in the level of conciousnessConfusion or other neurological disturbances
persisting for more 6-8 hours even if there is no skull
Suspected fracture of the base of skull (CSF rhinorrhea or otorrhea, bilateral orbital hematoma, mastoid hematoma) or other penetrating injury
Necktracheal
deviation
bruits
crepitus
swelling
lacerations
seat belt stripe
bony tenderness, stepoffs
Protection of the spine
Any injury above the clavicle
-Unconscious polytrauma
-Neck pain-Localizing signs
ChestChest wall:
bruising, lacerations, penetrating injury, tenderness, flail segment.
reevaluate breath soundschest wall motioncrepitanceareas of tendernesscontusionpreviously missed penetrating
injuriestake another look at your chest xray
Chest X-Ray✤evaluate ribs✤mediastinum✤apices✤small effusion (hemothorax
Tension PneumothoraxCommonly due to Commonly due to positive-pressure positive-pressure
ventilationventilation in patients with in patients with visceral pleural visceral pleural injuryinjury
Unilateral limited chest excursions and Unilateral limited chest excursions and absence of breath sounds, deviated tracheaabsence of breath sounds, deviated trachea
Hyper-resonance on percussionHyper-resonance on percussion
Clinical diagnosisClinical diagnosis; treatment should not be ; treatment should not be delayed awaiting radiological confirmationdelayed awaiting radiological confirmation
TENSION PT IS A CLINICAL DIAGNOSIS – NOT A RADIOGRAPHIC DIAGNOSIS
AbdomenInspect for bruising, movement and woundsPalpate the abdomenAuscultate for bowel soundSqueeze the pelvis for tendernessCheck the perineum and genitaliaPerform rectal examination
Associated ConditionsLiver LacerationSplenic RuptureRenal InjuryHollow viscus (bowel perforation) or Lumbar
Spine InjurySeat BeltDeceleration injury
Rectum or other bowel injuryGastrointestinal BleedingPelvic FractureUrethral InjuryVaginal InjuryBladder rupture
FAST ScanFocused assessment using sonography in
trauma
Four Quadrants :1)Subxiphoid : Pericardium2)RUQ : Morrison’s pouch (potential space between the liver and kidney)3)LUQ : Splenorenal recess and between the spleen and diaphragm4)Pelvis : Pouch of Douglas
AssessmentCT Abdomen or CT Pelvis, as indicated
If patient is unstable and intra-abdominal injury is suspected, should proceed with laparatomy
Indications for immediate laparatomyEvisceration, stab wounds with implement in-
situ and gunshot wounds traversing the abdominal cavity
Any penetrating injury to the abdomen with haemodynamic instability or peritoneal irritation
Obvious/strongly suspected Intra-Abd Injury with shock or difficulty to stabilize haemodynamics
Obvious signs of peritoneal irritationRectal exam reveals fresh bloodX-ray evidence of pneumoperitoneum or
diaphragmatic rupture
PelvisPain on palpationSymphysis width Leg length unequalInstabilityX-rays as needed
PitfallsPelvic fracturesPelvic organ
trauma
•Check for blood at the urethral meatus•Any scrotal hematoma•PR : high riding prostate?
Limbs
pulsessites of tendernesscontusionsdeformitieslacerationsrange of motion at jointsneurologic functionPelvis stability
Compartment syndromePainPressure (pain on palpation)ParesthesiaParesis (late sign)Pallor (late sign)Pulseless (last sign to occur)
SpineSpinal injuries can be partial or completeTest for sensory and motor deficitsIf there is evidence of spinal injury the
patient should not be movedX-ray of the affected site is requiredIf there is no neurological deficit, the
patient can be log rolled and the whole of the back examinedlacerations, contusions, penetrating wounds
missed previously
Spinal cord injury should be suspected and cervical immobilization maintained from the time of injury in the following :Unconcious trauma patientSurvivors of high velocity accidentPresence of associated injuries
Significant head or facial traumaScapular contusionSeat belt injuriesInjury to feet/ankle from a fall from height