Secondary survey

Meet the patient

A 30-year-old man is brought in after a high-speed motorbike crash, having been worked through the primary survey in the bay next door — airway protected, bilateral chest tubes for haemopneumothoraces, two large-bore cannulae, pelvis bound, and now stable enough to be transferred to your trolley. He is the patient the secondary survey was built for: the life threats are addressed, and your job is the head-to-toe hunt for everything else.[1]

Two questions frame every secondary survey: is he truly stable, or about to deteriorate? (reassess the vitals and the response to resuscitation continuously) and have I examined every region systematically, or have I stopped at the obvious injury? (the missed injury is the classic preventable harm). The obvious fracture is the distraction; the systematic survey is the safety net.[1]

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1. [1]Papa L, Stiell IG, Clement CM, et al. Performance of the Canadian CT Head Rule and the New Orleans Criteria for predicting any traumatic intracranial injury on computed tomography in a United States Level I trauma center Acad Emerg Med, 2012.PMID 22251188
2. [2]Touger M, Gennis P, Nathanson N, et al. Validity of a decision rule to reduce cervical spine radiography in elderly patients with blunt trauma Ann Emerg Med, 2002.PMID 12192352
3. [3]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury Lancet, 2001.PMID 11356436
4. [4]Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group N Engl J Med, 2000.PMID 10891516
5. [5]Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma N Engl J Med, 2003.PMID 14695411
6. [6]Haydel MJ, Preston CA, Mills TJ, et al. Indications for computed tomography in patients with minor head injury N Engl J Med, 2000.PMID 10891517
7. [7]Huber-Wagner S, Lefering R, Qvick LM, et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study Lancet, 2009.PMID 19321199
8. [8]Sierink JC, Treskes K, Edwards MJR, et al. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial Lancet, 2016.PMID 27371185
9. [9]Stengel D, Rademacher G, Ekkernkamp A, et al. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma Cochrane Database Syst Rev, 2015.PMID 26368505
10. [10]Brown CV, Foulkrod KH, Reifsnyder A, et al. Computed tomography versus magnetic resonance imaging for evaluation of the cervical spine: how many slices do you need? Am Surg, 2010.PMID 20420244
11. [11]Pfeifer R, Pape HC. Missed injuries in trauma patients: A literature review Patient Saf Surg, 2008.PMID 18721480
12. [12]Keijzers GB, Giannakopoulos GF, Del Mar C, et al. The effect of tertiary surveys on missed injuries in trauma: a systematic review Scand J Trauma Resusc Emerg Med, 2012.PMID 23190504
13. [13]Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study Lancet, 2009.PMID 19758692