The Secondary Survey - Anschutz Medical Campus

The Secondary SurveyThe Secondary Survey

Clay Cothren Burlew, MD FACS

Director, Surgical Intensive Care Unit

Attending Surgeon, Denver Health Medical Center

Associate Professor of Surgery, University of Colorado

Outlining the ResuscitationOutlining the Resuscitation•• ABCs Completed ABCs Completed

–– adjuncts to the 1adjuncts to the 1°°

surveysurvey–– start 2start 2°°

surveysurvey

•• History/Mechanisms of InjuryHistory/Mechanisms of Injury

•• Examination:Examination:•• injury identificationinjury identification•• intervention and treatmentintervention and treatment•• management pitfallsmanagement pitfalls

•• Take Home PointsTake Home Points

Outlining the ResuscitationOutlining the Resuscitation

Primary Survey Secondary Survey Definitive Treatment

Resuscitation

Reassessment

PITFALLPITFALL

Be wary of the Be wary of the transient respondertransient responder……....

Adjuncts to the ABCsAdjuncts to the ABCs

•• ECG monitoringECG monitoring–– tachycardiatachycardia–– dysrhythmiasdysrhythmias–– ST segment changesST segment changes

•• Fetal monitoringFetal monitoring•• > 26 weeks> 26 weeks•• highhigh--risk for 24risk for 24°°


•• CathetersCatheters–– foleyfoley–– NG tubeNG tube

PITFALLPITFALL•• Suspect urethral injurySuspect urethral injury

•• blood at meatusblood at meatus•• perineal bruisingperineal bruising•• highhigh--riding prostateriding prostate•• pelvis fracturepelvis fracture

foleyfoley

PITFALLPITFALL•• Appropriate NG tube use:Appropriate NG tube use:

•• may precipitate gaggingmay precipitate gagging•• emesis/aspirationemesis/aspiration•• avoid nasal route in avoid nasal route in

patients with facial fxpatients with facial fx

Adjuncts to the ABCsAdjuncts to the ABCs•• Portable XPortable X--rays:rays:

–– blunt trauma = blunt trauma = ““Big 3Big 3””•• AP chestAP chest•• AP pelvisAP pelvis•• lateral clateral c--spinespine


•• Portable XPortable X--rays:rays:–– penetrating = penetrating = ““injured space plus 1 injured space plus 1

above/belowabove/below””


•• FAST exam:FAST exam:–– 4 views of abdomen4 views of abdomen–– >200cc of fluid >200cc of fluid

Right Upper Quadrant Left Upper Quadrant Right Upper Quadrant Left Upper Quadrant Pericardial Pericardial PelvisPelvis

CARDIAC CHAMBERSCARDIAC CHAMBERS

LIVERLIVER

PITFALLPITFALL

If persistent or If persistent or recurrent hypotension, recurrent hypotension, remember FAST isnremember FAST isn’’t t

100% accurate! 100% accurate!

Secondary Survey: HistorySecondary Survey: History

•• AA

= = AAllergiesllergies

•• MM

= = MMedicationsedications

•• PP

= = PPast illnesses/ast illnesses/PPregnancyregnancy

•• LL

= = LLast mealast meal

•• EE

= = EEvents around injuryvents around injury


•• Prenatal history:Prenatal history:•• PIH, DM, CHDPIH, DM, CHD•• preterm laborpreterm labor•• placental abruption/previaplacental abruption/previa•• fetal movementfetal movement

•• Fundal height Fundal height fetal agefetal age


•• Blunt Mechanisms:Blunt Mechanisms:–– seat belt/helmet useseat belt/helmet use–– vehicle damagevehicle damage–– steering wheel deformationsteering wheel deformation–– impact directionimpact direction–– passenger ejectionpassenger ejection–– deaths at the scenedeaths at the scene

Secondary Survey: MechanismSecondary Survey: Mechanism

•• Front impact:Front impact:–– CC--sp fx, rib fx sp fx, rib fx

PTX, liver/spleen lacs, PTX, liver/spleen lacs,

post hip dislocationpost hip dislocation

•• Side impact:Side impact:••CC--sp fx, rib fx sp fx, rib fx

PTX, diaphragm PTX, diaphragm

rupture, pelvis fxrupture, pelvis fx

•• Ejection:Ejection:••increased riskincreased risk

Secondary Survey: MechanismSecondary Survey: Mechanism

•• Penetrating trauma:Penetrating trauma:–– body regionbody region

–– GSW: distance from weapon GSW: distance from weapon to wound, velocity, caliber, to wound, velocity, caliber, presumed pathpresumed path

–– SW: length of object, impact SW: length of object, impact directiondirection

–– associated blunt trauma?associated blunt trauma?

PITFALLPITFALL

If the weapon is in the patient, If the weapon is in the patient, allow the surgeon to remove it allow the surgeon to remove it under controlled conditions!under controlled conditions!

Secondary Survey: ExamSecondary Survey: Exam

Head to ToeHead to Toe

““Every Nook and Every Nook and CrannyCranny””

Exam: HEENTExam: HEENT

•• Head:Head:–– scalp lacerations or contusionsscalp lacerations or contusions–– skull fracturesskull fractures


•• Eye:Eye:–– pupil exampupil exam–– globe intact?globe intact?–– visual acuity?visual acuity?

•• Ears:Ears:–– blood? CSF leak?blood? CSF leak?–– intact?intact?


•• Nose/Mouth/Throat:Nose/Mouth/Throat:–– airway issues paramountairway issues paramount–– bony stepbony step--offoff–– bite feels normal?bite feels normal?–– bleeding from nose/mouthbleeding from nose/mouth

PENETRATINGPENETRATINGNECK INJURYNECK INJURY

Hemodynamically UnstableHemodynamically UnstableUncontrolled HemorrhageUncontrolled Hemorrhage

Operative Operative ExplorationExploration

ObserveObserve

Hemodynamically StableHemodynamically StableSymptomatic**Symptomatic**

** symptoms = expanding hematoma** symptoms = expanding hematomaairway compromiseairway compromisedysphagiadysphagiasubcutaneous emphysemasubcutaneous emphysemahoarsenesshoarseness

AsymptomaticAsymptomatic

Zone IZone I

Zone IIZone IIZone IIIZone III AngioAngio

IR emboIR embo++

Zone IZone I

Zone IIZone II

Zone IIIZone III

Transcervical GSWTranscervical GSWAll OthersAll Others

Penetrating Neck InjuriesPenetrating Neck Injuries

CT CT neck/neck/chestchest

++CTA CTA esophagramesophagram

bronchoscopybronchoscopy

CT CT neck/neck/chestchest

++CTA CTA esophagramesophagram

bronchoscopybronchoscopy


•• The Brain!The Brain!–– evaluation part of ABCevaluation part of ABCDDEsEs–– calculate GCS calculate GCS

•• GCS < 8 severe head injury/comaGCS < 8 severe head injury/coma

–– Dx = CT scan, ICP monitorDx = CT scan, ICP monitor

Exam: SpineExam: Spine

•• Cervical/Thoracic/Lumbar:Cervical/Thoracic/Lumbar:–– always protect the spinealways protect the spine–– safely off the backboardsafely off the backboard

•• if one fx, look for another!if one fx, look for another!•• sensory/motor loss = injurysensory/motor loss = injury•• remember steroidsremember steroids•• complication = neurogenic shockcomplication = neurogenic shock

Exam: Thoracic InjuriesExam: Thoracic Injuries

•• 8 Lethal Injuries:8 Lethal Injuries:•• pneumothoraxpneumothorax•• hemothoraxhemothorax•• pulmonary contusionpulmonary contusion•• blunt cardiac injuryblunt cardiac injury•• aortic disruptionaortic disruption•• diaphragm rupturediaphragm rupture•• tracheobronchial injurytracheobronchial injury•• traversing mediastinal woundstraversing mediastinal wounds


•• Simple pneumothoraxSimple pneumothorax•• penetrating and bluntpenetrating and blunt•• lung laceration with air leakagelung laceration with air leakage•• ↓↓

breath soundsbreath sounds

•• hyperresonancehyperresonance

•• Tx = chest tubeTx = chest tube


•• HemothoraxHemothorax•• lung laceration or laceration lung laceration or laceration

of intercostal vesselof intercostal vessel•• bleeding selfbleeding self--limitedlimited•• <10% require thoracotomy<10% require thoracotomy before chest tubebefore chest tube

after chest tubeafter chest tube

•• Tx = chest tubeTx = chest tube•• If > 1500cc out initially If > 1500cc out initially

thoracotomythoracotomy

PITFALLPITFALL

Make sure blood is evacuated Make sure blood is evacuated –– R/O caked hemothorax. R/O caked hemothorax.


•• Pulmonary contusionPulmonary contusion•• most common injurymost common injury•• develops over timedevelops over time•• present without rib fx in present without rib fx in

childrenchildren admitadmit

12 hrs12 hrs

•• Tx = intubation ifTx = intubation ifsignificant hypoxiasignificant hypoxia


•• Blunt cardiac injuryBlunt cardiac injury•• contusion to any chambercontusion to any chamber•• occasional ruptureoccasional rupture•• clinical symptoms:clinical symptoms:

•• tachycardiatachycardia•• arrhythmiasarrhythmias•• abnormal ECHOabnormal ECHO

•• Tx = 24Tx = 24˚̊

of Telemetryof TelemetrySwan if ECHO abnormal, patient unstableSwan if ECHO abnormal, patient unstable


•• Aortic disruptionAortic disruption•• complete transection complete transection ––

typically DOAtypically DOA

•• incomplete tear incomplete tear ––

potentially salvageablepotentially salvageable•• injury near ligamentum arteriosuminjury near ligamentum arteriosum•• contained hematomacontained hematoma


•• Aortic disruptionAortic disruption•• few symptomsfew symptoms•• XX--ray findings:ray findings:

•• wide mediastinumwide mediastinum•• obliterated aortic knobobliterated aortic knob•• deviation of tracheadeviation of trachea•• depressed left bronchusdepressed left bronchus•• deviation of esophagusdeviation of esophagus•• apical cappingapical capping


•• Aortic disruptionAortic disruption•• empiric treatment in trauma empiric treatment in trauma

baybay•• esmolol SBP < 100, HR < 100esmolol SBP < 100, HR < 100

•• screening helical CT scanscreening helical CT scan•• angiography is the gold angiography is the gold

standardstandard

•• Tx = operative repair Tx = operative repair vs.vs.stent graftstent graft


•• Diaphragm ruptureDiaphragm rupture•• more common on leftmore common on left•• blunt = radial tear blunt = radial tear •• penetrating = linear lacpenetrating = linear lac

left diaphragm ruptureleft diaphragm rupture

right diaphragm ruptureright diaphragm rupture

•• DiagnosisDiagnosis•• gastric bubble in chestgastric bubble in chest•• liver in the chestliver in the chest•• NGT coiled in chestNGT coiled in chest


•• Dx = CT scan can be Dx = CT scan can be confirmatoryconfirmatory

•• Tx = operative repair via Tx = operative repair via the abdomenthe abdomen


•• Tracheobronchial InjuryTracheobronchial Injury•• within 1 inch of carinawithin 1 inch of carina•• often lethaloften lethal•• hemoptysis, subQ emphysema, hemoptysis, subQ emphysema,

tension pneumothoraxtension pneumothorax•• persistent air leakpersistent air leak•• bronchoscopybronchoscopy

•• Tx = watch Tx = watch vs.vs. glue glue vs.vs. operateoperate

http://content.nejm.org/content/vol342/issue18/images/large/05f1.jpeg


•• Transmediastinal WoundsTransmediastinal Wounds•• external wounds + Xray external wounds + Xray

•• Tx = determined by hemodynamicsTx = determined by hemodynamics•• stable stable ––

CT, triple evalCT, triple eval

•• unstable unstable ––

OROR

•• Mortality > 20Mortality > 20--40%40%

KEY POINTKEY POINT

Rule out the Rule out the 8 lethal 8 lethal

chest injuries.chest injuries.

Exam: Abdominal InjuriesExam: Abdominal Injuries

•• Blunt trauma = crushing injuryBlunt trauma = crushing injury•• Penetrating = lacerationPenetrating = laceration•• Organ injuriesOrgan injuries

•• blunt = spleen blunt = spleen liver liver bowelbowel•• SW = liver SW = liver bowel bowel diaphragmdiaphragm•• GSW = bowel GSW = bowel colon colon liverliver


•• Diagnostic tools:Diagnostic tools:•• FAST exam FAST exam blood in the abdomen?blood in the abdomen?•• Plain film Plain film retained bullet?retained bullet?

•• CT scan CT scan specific injury?specific injury?•• DPA/DPL DPA/DPL blood? bowel contents?blood? bowel contents?

Hemodynamically Stable

Peritonitis?

FAST +

Indications for CT:-Altered mental status-Confounding injury-Gross hematuria-Pelvic fracture-Abdominal tenderness-Unexplained Hct<35%

Repeat FASTin 30 minutes

FAST +

LAPAROTOMY

Abdominal CT

Yes

Yes

Yes

Yes

Yes No

No

No

DPA

Equivocal

+

No

Blunt Abdominal TraumaBlunt Abdominal Trauma

PenetratingPenetratingAbdominalAbdominal

TraumaTrauma

HemodynamicallyHemodynamicallyUnstableUnstable

HemodynamicallyHemodynamicallyStableStable

Operating Operating RoomRoom

GSWGSW

SWSW

AnteriorAnteriorAbdomenAbdomen

RUQRUQ

Tangential Tangential Back/FlankBack/Flank CTCT

Scan Scan

AASWAASWwithwith

+ LWE + LWE

Back/FlankBack/Flank

SerialSerialExamsExams

++

++

Penetrating Abdominal TraumaPenetrating Abdominal Trauma


Blunt liver injury:Blunt liver injury:

Penetrating liver injury:Penetrating liver injury:


Blunt spleen injury:Blunt spleen injury:


Blunt pancreatic/duodenal injury:Blunt pancreatic/duodenal injury:


Blunt bowel injury:Blunt bowel injury:


Penetrating vascular injury:Penetrating vascular injury:

SW to inferior vena cavaSW to inferior vena cava

GSW to left externalGSW to left externaliliac arteryiliac artery

Exam: Pelvic InjuriesExam: Pelvic Injuries

•• ExamExam•• stable pelvic ring? stable pelvic ring?

•• Pelvis filmPelvis film•• intact circle?intact circle?•• rami intact?rami intact?•• acetabulum smooth?acetabulum smooth?

Exam: Pelvic InjuriesExam: Pelvic Injuries

•• If patient has a pelvic fractureIf patient has a pelvic fracture•• rectal exam rectal exam bony fragments?bony fragments?•• vaginal exam vaginal exam lacerations?lacerations?•• GU exam GU exam bladder/urethral injury?bladder/urethral injury?•• perineal exam perineal exam degloving?degloving?

Pelvic Fracture KCPPelvic Fracture KCP

FAST ExamFAST Exam

PositivePositive NegativeNegative

2 units PRBCs/ED trauma bay2 units PRBCs/ED trauma bay

HD StableHD Stable

SICU +/SICU +/--

CT scans**CT scans**

Laparotomy, Pelvic Fixation,Laparotomy, Pelvic Fixation,Pelvic PackingPelvic Packing

Operating RoomOperating Room

Hemodynamically Stable?Hemodynamically Stable?

YesYes

AngiographyAngiography

SICUSICU

Pelvic Fixation and Pelvic PackingPelvic Fixation and Pelvic Packing

HD UnstableHD Unstable

Operating RoomOperating Room

Ongoing Transfusion Requirements?Ongoing Transfusion Requirements?

NoNo

AngiographyAngiography

SICUSICU

YesYes

NoNo

** normalize coagulation status,** normalize coagulation status,abdominal CT scan if no laparotomy done.abdominal CT scan if no laparotomy done.

Exam: Extremity InjuriesExam: Extremity Injuries

•• ExamExam•• deformity?deformity?•• open fracture?open fracture?•• intact motor/sensory exam?intact motor/sensory exam?•• pulses? pulses?

•• Stop bleeding with pressureStop bleeding with pressure•• Measure AMeasure A--A gradientA gradient•• Traction/splintsTraction/splints

22ºº

SurveySurvey: Take Home Points: Take Home Points

•• Systematic evaluationSystematic evaluation

•• Recognize and treat life threatening Recognize and treat life threatening injuriesinjuries

•• Ongoing resuscitationOngoing resuscitation

•• Diagnostic testsDiagnostic tests

•• Watch for pitfallsWatch for pitfalls

The Secondary SurveyThe Secondary Survey

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The Secondary Survey - Anschutz Medical Campus

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