Trauma Service : Primary and secondary survey (2024)

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The primary survey

Thepurpose of the primary survey is to rapidly identify and manage impending oractual life threats to the patient.

Introduction

Always assume all major trauma patients have aninjured spine and maintain spinal immobilisation until spine is cleared.

Priorities are the assessment and management of:

c Catastrophic haemorrhage
A Airway (and C-spine control)
B Breathing
C Circulation
D Disability
E Exposure / Environment

Prior to arrival:

Activate Trauma Team (as per Trauma Team Activation criteria).
Pre-arrival briefing for team with synthesis
Use of Pre-arrival checklist to help with role and task allocation
Estimate the child's weight using the formula:
Prepare age / weight appropriate doses of medication (use the Monash Drug book or other similar resource)
Prepare age appropriate equipment
Ensure personal protective equipment and lead aprons are worn by the trauma team

On arrival:

Obtain a I-MIST-AMBO handover from ambulance staff
Perform a primary survey
Obtain further information from parents / caregivers where possible
Ensure a dedicated member of staff is available to provide support for parents / caregivers

Airway and the cervical spine

The life threat to identify and manage whenassessing the Airway is airway obstruction

This is typically theresponsibility of the "Airway Doctor" although it is a role which maybe shared with the "Assessment Doctor". The Airway Doctor is typicallyresponsible for assessing the airway, the anterior neck and the GCS.Their goal is to ensure and maintain a patentairway, through which the patient can be successfully oxygenated.

When assessing the airway. The airway doctor should start with assessingfor:

Evidenceof facial fractures
Contaminantssuch as blood, vomit or teeth in the mouth / airway
Epistaxis

Where the patient has suffered a burn, the airway doctor should look in particular for:

Singing of facial / nasal hair
Facial burns
Hoarseness or change in voice
Harsh cough
head or neck swelling
Soot in the mouth, nose or saliva

A complete airway assessmentalso requires an assessment of the anterior neck - looking in particular for signs of blunt or penetrating trauma, or an impending airway life threat. This requires the airway doctor to open theC-spine collar whilst an assistant maintains manual in-line stabilization ofthe cervical spine. The Airway doctor shouldthen examine the anterior neck to look / feel for the following (TWELVE-C):

Trachealdeviation
Wounds
Emphysema(subcutaneous)
Laryngealtenderness / crepitus
Venousdistension
oEsophageal injury (injury unlikely ifable to swallow easily)
Carotidhaematoma / bruits / swelling

The airway doctor also needsto assess the GCS

The life threat to identify when assessing the Airway is airway obstruction. Causesof airway obstruction may be due to:

Directtrauma to the airway or surrounding structures (maxilo-facial / laryngeal /tracheal injury / compression due to anterior neck haematoma)
Contaminationof the airway due to debris (vomitus / blood / teeth or other foreign bodies)
Lossof pharygeal tone (due to head injury or intoxication with drugs/alcohol)
Incorrectpositioning (hyperflexion of the infant due to their large occiput)

The management of airway obstruction is to ensure a patent airway through whichthe patient can effectively be oxygenated.This may require some or all of the following techniques:

Ageappropriate positioning of the head into a neutral position (utilising athoracic elevation device if <8yrs old or a towel under the shoulder bladesto provide thoracic elevation)
Gentlesuction of the airway to remove blood / vomitus / secretions
Applicationof high flow oxygen
Jawthrust - avoiding head-tilt or chin lift
Useof an oropharyngeal airway if tolerated, or naso-pharygeal airway (if headinjury is excluded / unlikely)
Intubation- by an experienced operator

The cervical spine should be protected by manual in-line stabilisation, followed by the rapid (gentle)application of a properly fitted hard collar.(see cervical spine assessment clinical practice guideline)

Breathing

The life threats to identify and manage with regards tobreathing include:

Tension pneumothorax
Open pneumothorax
Massive haemothorax
Flail chest

The assessment of breathing, in the spontaneously ventilating child, is the responsibility of the assessment doctor. Where a child requires positive pressure ventilation (either bag-valve-mask ventilation, or intubated) there will be a shared responsibility for the assessment of breathing by the airway and the assessment doctors. At the start of the assessment, ensure all patients who are spontaneously breathinghave high flow oxygen applied – typically 10-15L O₂via a non-rebreathermask. The child’s breathing is then assessed by looking at:

The work of breathing (recession, respiratory rate, accessorymuscle use)
The effectiveness of breathing (oxygen saturation, symmetry anddegree of chest expansion)
The effects of inadequate respiration (heart rate, mental state)
Signs of injury (seat belt marks, bruising, wounds)

Assessment of the thoracic cage requires feeling for:

Emphysema / crepitus
Clavicle / chest wall tenderness
Request a chest X-ray – this is an important addition to theprimary survey

Assessment also requires listening for:

Breath sounds or added sounds

The life threats to identify with regards to breathing include:

Tension pneumothorax
Open pneumothorax
Massive haemothorax
Flail chest

The management of these life threatsis typically carried out by the procedure doctor under direction from the TeamLeader. Once a life threat has been identified, the assessment doctor should communicate this to the Team Leader, and then continue on with the primary survey allowing the procedure doctor to carry out any interventions. Typical interventions include:

Chest decompression (by needle decompression / fingerthoracostomy) for a tension pneumothorax - followed immediately by insertion ofa chest drain
Chest drain insertion for a massive hameothorax
Closure of an open pneumothorax, and insertion of a chest drain
Positive pressure ventilation and insertion of a chest drain fora flail chest.

Intubated children may also benefit from the early insertion of a largeoro-gastric tube to treat and prevent gastric dilatation which in infants andyoung children especially, can impair effective ventilation.

Circulation

The major life threat to identify and manage with regards to circulation ishaemorrhagicshock. However, obstructive shock does also occur, and causes for this should also be actively sought and managed.

The assessment of the circulation isthe responsibility of the “Assessment” Doctor. They should assess the child’s circulatorystate by:

checking the pulse rate, skin colour, capillary refill time, blood pressure
lookingfor other effects of an inadequate circulation (increased respiratory rate, decreasedmental state).

It is useful for the assessment doctor to calling outthe patients vital signs at this stage of the assessment - so the team is aware of them. The assessment doctor should continue with a focused assessment that involves looking for sites of potential bleeding. These include the following sites:

Externalbleeding – assess by exposing wounds and look for ongoing bleeding - do not remove penetrating foreign bodies
Intra-thoracicbleeding – assess for massive haemothorax (as per breathing above)
Intra-abdominalbleeding – inspect for abdominal distension, bruising, and palpation fortenderness / guarding
Intra-pelvicbleeding – gently assess the pelvis for stability by by compressing the iliaccrests
Longbone fractures – in particular assess the femurs as a site for major bleeding
Retroperitonealbleeding – this can be hard to identify – but maintain a high level ofsuspicion in those with signs of haemorrhagic shock and no obvious signs ofbleeding elsewhere or flank tenderness

The assessment doctor should, in consultation with the Trauma Team Leader, consider the need for a pelvic x-ray (see also Pelvic Injury CPG).

The major life threat to identifywith regards to circulation is haemorrhagic shock

However,care should be taken to actively look and exclude:

obstructive cause forshock - for example tension pneumothorax or cardiac tamponade)
neurogenic shock - associated with spinal injury above the level of T6

The management of haemorrhagicshock is to identify and stop the source(s) of bleeding whilst concurrently resuscitatingthe patient. The management of these life threats may need multiple team members and is co-ordinated by the Trauma Team Leader. Once the assessment doctor has identified these life threats, they must communicate their findings to the Trauma Team Leader, then continue with the primary survey. The management of haemorrhagic shock may include:

Inexternal haemorrhage bleeding may be stopped through the use of directpressure, or in some cases the judicious use of a tourniquet.
Insertinga chest drain into a patient with a massive haemothorax may improveventilation, but stopping ongoing bleeding can only be done in theatre.
Similarlylife threatening bleeding into the abdomen / pelvis or retroperitoneum that is not otherwise controlledwill require surgery or interventional radiology to stop the bleeding. Early consultation with a senior paediatricsurgeon +/- an interventional radiologist is required. Rapid transit to theatre, prior to completionof the secondary survey, may be required to manage patients with ongoingbleeding that cannot be controlled in the emergency department.
Applicationof the pelvic binder is a haemostatic adjunct
Bleedingfrom bone fractures may be reduced through traction
Resuscitationof shock requires intravenous access with two cannulae that are as large aspracticable - ideally one situated in each cubital fossa.
- Ifan IV cannula cannot be sited rapidly (within 90 seconds), consider the use ofan intra-osseous needle inserted into a non-traumatised leg or humerus in theolder child.
- Asthe IV is inserted, take blood for a VBG, FBE, cross-match, UEC, LFTs, lipaseand coagulation screen
- If circulation is inadequate, give an initialfluid bolus. If there is ongoingbleeding this may be packed red blood cells (10ml/kg), if bleeding iscontrolled and blood loss is not thought to be major, you may opt to give of 10-20 ml/kg of crystalloid however careneeds to be given to avoid contributing to coagulopathy, acidosis and hypothermia that can occur with excessive crystalloid administration

Assess the child's circulatory state by observing:

Disability (mental state)

The life threat to identify is traumatic brain injury

The assessment of 'Disability' is typically the responsibility of the airway doctor - although the assessment doctor may add and complement to this by assessing peripheral function. Initial assessmentof the level of consciousness may be done using the AVPU assessment:

A= Alert
V = responds to Voice
P= responds to Pain
U= Unresponsive

Anyimpairment on detected on the AVPU scale should prompt a formal assessment ofthe patient’s GCS (link to GCS-level of consciousness in Head Injury CPG). Pupilresponse to light should be noted, as should movement in all four limbs. The assessment doctor should check for this as well as reflexes if the prior to intubation where possible. Theblood glucose level should be measured on arrival and periodically during themanagement of the trauma patient.

Thelife threat to identify is traumatic brain injury- whilst the primary brain injury cannot be reversed, secondary brain injurycan be minimised by the prevention of hypoxia/hypotension and instigation of neuroprotectivestrategies to minimise intracranial pressure, along with the expedited progressof the patient to CT imaging of the brain, and then to a site capable of anynecessary neurosurgical intervention.

Exposure and environmental control

Remove clothing initially andlook for any other obvious life threatening injury. Avoidhypothermia by limiting exposure of the body, and by warming all ongoingfluids.

Radiology

Arrangefor chest to be done in the resuscitation room as part of the primary survey.
Pelvic injury is rare in children, the pelvic x-ray does not always need to be requested in paediatric trauma. However, it is done where there are risk factors for pelvic injury and the patient is unlikely to need CT imaging of the abdomen and pelvis. The risk factors for pelvic injury include:
- high risk mechanisms - these include:
  - high speed / rollover or lateral impact motor vehicle accidents
  - Pedestrian vs car
  - Cyclist vs car
  - MVA where another person has died
- Abnormal pelvis examination
- Significant lower limb injury (eg femur fracture)
- Intubated or unable to assess pelvis
Ifthere is no high risk mechanism, no clinical suspicion of a pelvic injury AND the child is haemodynamically stable withhas a normalconscious state, the pelvic X-ray may be omitted.
Arrange additional radiology as indicated

References

Browne GJ, co*cks AJ, McCaskill ME. Current trends in the management of major paediatric trauma. Emergency Medicine (Fremantle, W.A.). 2001;13(4):418-25.
Cantor RM, Leaming JM. Evaluation and management of pediatric major trauma. Emergency Medicine Clinics of North America. 1998;16(1):229-56.
Mackway-Jones K, Molyneux E, Phillips B, Wieteska S, eds. Advanced Paediatric life Support - the Practical Approach. Third ed. London: BMJ Books, 2001.
Rothrock SG, Green SM, Morgan R. Abdominal trauma in infants and children: Prompt identification and early management of serious life-threatening injuries. Part 1: injury patterns and initial assessment. Paediatric Emergency Care 2000;16:106-115.
Royal Children's Hospital Melbourne. Clinical Practice Guidelines

-Trauma (Major)

Secondary survey

Introduction

Thesecondary survey is commenced after the primary survey has been completed,immediate life threats identified and managed, and the child is stable.Continue to monitor the child’s:

Mental state
Airway, respiratory rate, oxygensaturation
Heart rate, blood pressure,capillary refill time.

Any unexpected deteriorationin these parameters require reassessment and management of evolving lifethreats.

Preparation:

Before commencing theexamination:

develop a rapport with thechild, offer reassurance and explain what you are doing
involve the parents orother adults accompanying the child by telling them what you are doing andusing them to comfort or distract the child
keep the child warm and -as far as possible - covered
remove clothingjudiciously - a full examination is necessary, but ensure the child is covered up following examination

Performingthe examination:

Headand face

Inspect the face and scalp. Lookfor:

Bleeding,lacerations, bruising, depressions orirregularities in the skull, Battles sign (bruising behind the ear indicativeof a base of skull fracture).

Lookspecifically at the:

Eyes:for foreign bodies, subconjunctival haemmorhage, hyphaema, irregular iris,penetrating injury, contact lenses.
Ears:for bleeding, blood behind tympanic membrane (suggestive of base of skullfracture)
Nose:for deformities, bleeding, nasal septal haematoma, CSF leak
Mouth:for lacerations to the lips, gums, tongue or palate.
Teeth:for subluxed, loose, missing or fractured teeth
Jaw:for pain, trismus, malocclusion suggestive of fracture.

Palpate the:

bony margins of theorbit, the maxilla, the nose and jaw.
the scalp / skull looking for evidence of fracture

Test eye movements, pupillaryreflexes, vision and hearing

Neck

Inspectthe neck - it is necessary to open the collar to do this - whilst maintaining manualin-line stabilisation of the neck. Examine the anterior neck (as per theprimary survey) checking for:

trachealdeviation
wounds/ bruising to the neck
subcutaneous emphysema
laryngealtenderness
distensionof the neck veins
carotid pulsation and the presence of a haematoma, listen for a bruit

Asses the c-spine by palpation of the cervical vertebrae (see Cervical spine assessment CPG)

Chest

Inspectthe chest, observe the chest movements. Lookin particular for:

bruising (from seat-belts)
asymmetric or paradoxical chest wall movement
penetratingwounds are rare in children, but in cases where there is a stabbing or otherassault look for "hidden" wounds - checking areas such as the axillaand back

Palpatefor clavicular and rib tenderness and auscultate the lung fields and heartsounds.

Abdomen

Inspect the abdomen, the perineum and external genitalia. Look for in particular for:

seat-belt bruising / handle-bar injuries
distension
blood at the urinary meatus / introitus

Palpate for areas of tenderness especially over the liver, spleen, kidneys and bladder, and auscultate bowel sounds.

Pelvis

Inspect the pelvis for grazesover the iliac crest. Examine for bruising, deformity,pain or crepitus on movement.

Limbs

Inspectall the limbs and joints, palpate for bony and soft tissue tenderness and checkjoint movements, stability and muscular power. Examinesensory and motor function of any nerve roots or peripheral nerves that mayhave been injured.

Back

A log roll should be performed either in the primary survey or in the secondary survey.

Inspectthe entire length of the back and buttocks.
Palpate,then percuss, the spine for tenderness,
Palpatethe scapulae and sacroiliac joints for tenderness
Inspect the anus. Digital examination is rarely needed – if itis indicated it should only be performed once.

Urinalysis

Interpretation of theurine dipstick in blunt paediatric trauma suffers from high rates of falsepositive and false negative results – formal microscopy is the better testwhere renal injury is suspected.

Disposition planning

During the examination,any injuries detected should be accurately documented, and any urgent treatmentrequired should occur, such as covering wounds and splinting fractures. Appropriate analgesia,antibiotics or tetanus immunisation should be ordered. Following the secondarysurvey, the priorities for further investigation and treatment may now beconsidered and a plan for definitive care established. At this stage the patient may requireadvanced imaging in CT, or transfer to the ward, intensive care or theatre.

Typically the trauma teamleader will remain responsible for the patient until they have completed theirimaging and arrived at their inpatient destination. Handover of care may occur sooner than this –for example if the anaesthetist is present in the ED and will accompany thepatient to theatre or intensive care. Onthese occasions formal handover where the new team leader and team acknowledgethat responsibility for the patient hasbeen transferred. A departure checklistmade aid in this process.

References

Browne GJ, co*cks AJ, McCaskill ME. Current trends in the management of major paediatric trauma. Emergency Medicine (Fremantle, W.A.). 2001;13(4):418-25.
Cantor RM, Leaming JM. Evaluation and management of pediatric major trauma. Emergency Medicine Clinics of North America. 1998;16(1):229-56.
Mackway-Jones K, Molyneux E, Phillips B, Wieteska S, eds. Advanced Paediatric life Support - the Practical Approach. Third ed. London: BMJ Books, 2001.
Royal Children's Hospital Melbourne. Clinical Practice Guidelines

-Trauma (Major)