Trauma Resuscitation — Secondary Survey: Organized Evaluation — Clinical Pathway: Emergency

Trauma Resuscitation Clinical Pathway — Emergency Department

Secondary Survey: Organized Evaluation

Secondary Survey Goal: Perform an Organized Evaluation to identify all injuries.

Any unexpected deterioration in ABCDE status requires re-assessment and intervention.

History
  • A Allergies
  • M Medications currently used
  • P Past illness, pregnancy
  • L Last meal
  • E Events/Environment related to injury
Physical Exam by System Exam Example Script
Negative/Normal Findings Positive findings
Head, Maxillofacial, ENT
  • Inspect and Palpate
  • Head
    • Wounds - abrasions, lacerations, hematomas
    • Skull tenderness, depression, step-offs or midface instability
  • Eyes
    • FBs, subconjunctival hemorrhage, hyphema, irregular iris, penetrating injury, contact lenses, EOMs, pupil response
  • Ears
    • Signs of basilar skull fracture:
      • Bleeding, hemotympanum, Battle's sign (bruising over mastoid)
    • CSF leak
  • Nose
    • Deformities, bleeding, tenderness, septal hematoma, CSF leak
  • Mouth
    • Lacerations to lips, gums, tongue or palate, bleeding
  • Teeth
    • Subluxed, loose, missing, fractured
  • Maxilla/Mandible
    • Abrasions, lacerations, contusions, pain, trismus, malocclusion
  • “Head with no visible wounds, no palpable tenderness, hematoma, or step-off”
  • “No midface instability”
  • “Eyes without signs of trauma”
  • “No hemotympanum”
  • “Nares clear. No septal hematoma”
  • “Oropharynx clear. Mouth without signs of trauma”
  • “Hematoma/step-off noted on __ side over __ (skull bone)”
  • “Midface instability at ___”
  • “Pupils unequal, R __mm, L__mm”
  • “Hyphema present in ___”
  • “Periorbital contusion to ___”
  • “Hemotympanum present in ___”
  • “Clear drainage noted from ___ nare”
  • “Septal hematoma present ___ nare”
  • “Oropharynx with blood/vomitus”
  • “Upper central incisors loose”
  • “Mandible with abrasion, laceration, contusion, wounds on ___ side”
  • “Trismus noted”
C-spine & Neck
  • Inspect and Palpate, Open C-collar, maintain immobilization
    • Tracheal deviation
    • Posterior, anterior cervical tenderness
    • Wounds, seatbelt mark
    • Subcutaneous emphysema
    • Neck vein distention
    • Carotid pulses, hematoma
  • If no immobilization was deemed necessary:
    • “Neck is supple, moves freely, no pain”
  • If not already done in log roll:
    • “No posterior C-spine tenderness.
      • No step-offs or wounds”
    • “No tracheal deviation. No anterior neck tenderness or wounds.”
    • “No subcutaneous emphysema”
  • “C-spine with c-collar in place”
  • “Trachea deviated to the ___”
  • “C-spine with mid-line tenderness”
  • “Step-off palpated at ___”
  • “Subcutaneous emphysema on __(location)”
  • “Neck veins are distended on the ___”
  • “Pulsating hematoma is present on ___”
Chest
  • Inspect, Auscultate and Palpate
    • Wounds
    • Asymmetric or paradoxical chest wall movement
    • Breath sounds & heart sounds
    • Pain (clavicular/rib tenderness) or crepitus on palpation
  • “Chest wall stable – no visible wounds”
  • “Breath sounds and chest wall movement equal”
  • “No labored breathing or tachypnea”
  • “No tenderness or crepitus on palpation”
  • “Chest wall with abrasion on ___”
  • “Breath sounds decreased on ___ side”
  • “Chest wall movement asymmetric, decreased on ___ side”
  • “Retractions and abdominal breathing with tachypnea”
  • “Tender to palpation over __”
  • “Crepitus on palpation over ___”
Abdomen
  • Inspect, Auscultate and Palpate
    • Softness/Rigidity, tenderness
    • Distended/Non-distended
    • Wounds
      • Seat belt sign, handle-bar injuries
    • Bowel sounds
  • “Abdomen soft, non-distended, non-tender”
  • “No visible wounds”
  • “Normal bowel sounds”
  • “Abdomen rigid/firm, distended, tender to palpation in ___”
  • “Contusion, hematoma in ___”
Pelvis
  • Inspect and Palpate
    • Stability - minimize number of exams to avoid further injury
    • Wounds
    • Tenderness of iliac crest
      • Apply gentle pressure with heels of hands
  • “Pelvis stable”
  • “No visible wounds”
  • “No tenderness on palpation”
  • “Pelvis unstable – binder placed”
  • “Abrasion/contusion,/laceration/puncture to ___”
  • “Tenderness with palpation to ___”
Perineum, Rectum, Vagina
  • Inspect and Palpate
    • Wounds — injury to inguinal area increases concern for pelvic fracture
    • Blood at the urethral meatus
    • If not already done during logroll: inspect rectum for signs of injury
    • Digital rectal exam to evaluate tone only if concerned for spinal cord injury
  • “Perineum clear”
  • “No visible wounds”
  • “Abrasion, contusion, laceration, puncture to ___”
  • “Blood at ___”
Musculoskeletal
  • Inspect and Palpate
    • Swelling or deformities
    • Wounds
    • Tenderness on palpation
    • Sensory and motor function
    • Pulses and capillary refill
    • ROM
  • “Upper/lower extremities without tenderness, deformity or visible wounds”
  • “2+ radial pulses”
  • “2+ DP pulses”
  • If not already done in logroll: “No visible wounds or palpable step-off along spine”
  • “Deformity/swelling to ___”
  • “Unequal/thready /absent pulse ___”
  • “Tenderness to palpation of ___”
  • “Limited ROM to ___”
  • "If not done in logroll: “Step-off over ___ (spine)”
Neurologic
  • “Pt is alert – GCS 15”
  • “Cranial nerve exam grossly normal”
  • “Moving all extremities equally, sensation grossly intact”
  • “Altered mental status – GCS ___. Points off for ____”
  • “No verbal response - ___ to pain”
  • “Cranial nerve exam with no ___”
  • “Weakness/no movement of ___”
  • “Altered/limited sensation to ___”
Skin
  • Inspect
    • Wounds (abrasions/contusions/lacerations/punctures)
  • “No additional wounds identified”
  • “Abrasion/contusion/laceration/puncture to ___”
Adjuncts to consider: Radiographs (C-spine, CXR, Pelvis), CT scan as indicated, Laboratory studies, OG/NG tube and/or Foley catheter placement
Imaging Considerations
Re-evaluate as indicated after each resuscitative intervention