Pediatric Secondary Survey

00:01 Okay.

00:02 We’ve done the primary survey and you may actually repeat the primary survey several times.

00:08 Now, we’re going to move one to the secondary survey.

00:11 The patient is stable.

00:13 You solved the problem, maybe you’re planning on going to the OR in a bit, but we really want to do a head-to-toe history and physical exam once the patient is stable.

00:23 So we have done the primary survey, we’re on to the secondary.

00:28 Here’s an overview of your secondary survey.

00:31 Head and neck: we’re going to look intraorally for any evidence of trauma.

00:37 We will inspect the eyes, ears and nose for evidence of blood or CSF drainage from ears and the nose.

00:46 We will assess for things like raccoon’s eyes or battle sign which are evidence of significant head trauma.

00:54 We need to assess for C-spine tenderness.

00:57 If the patient is awake, they can report it hurts or it doesn’t, but you want to palpate every single cervical vertebrae and make sure there is no deformity or no tenderness there.

01:07 If they are awake, they can report that to you.

01:10 It’s always important to assess for tracheal deviation.

01:13 Hopefully, you would have noticed that during the primary survey because this patient will have a circulatory problem as well as a breathing problem that you will auscultate no lung sounds on one side, but certainly you want to assess the trachea and make sure there is no deviation and look anteriorly to the entire neck.

01:33 Next the chest: assess where there is accessory muscle use, that will give you a sign if there is intraparenchymal problems in the lungs and also listen to heart and lung sounds and report those out to the person who is taking the notes from the trauma.

01:48 Next is the abdomen and pelvic exam.

01:51 Assess for guarding, rebound, and tenderness.

01:54 It’s also important to assess for pelvic stability by pushing on the anterior superior iliac crest and what we call rocking the pelvis, but do it gently and just assess for any pelvic instability.

02:07 If there is pelvic instability, that’s important to know about because that could be a major source of internal bleeding.

02:14 Next, the urogenital exam is important.

02:17 You should inspect everywhere down there and also, we will do a rectal exam.

02:22 When we do the rectal exam, there's two things we're noting.

02:25 We are noting whether there is good rectal tone which is a sign of spinal injury if there is low tone.

02:30 And also, we’re going to send a stool for guaiac test to verify that there is no intraintestinal bleeding.

02:39 Next, the extremities and the spine.

02:41 You’re going to palpate every joint and every bone in this patient to make sure there are no abnormalities in the extremity or the spine.

02:49 Palpate the spine also with a log roll for tenderness or step-off all the way down, every single vertebrae must be palpated one after another and you’re going to assess all pulses.

03:02 I would recommend the dorsalis pedis pulse as the lowest pulse there and also the wrist pulses.

03:08 Generally, if you got those, you’re in good shape.

03:10 The easiest to feel is the femoral pulse, unless it’s a newborn baby in which case it's the umbilical pulse, but that’s usually not a trauma.

03:20 Last is neurologic.

03:22 This is where we can do that AVPU.

03:24 AVPU is a quick way of remembering what can we say about this patient’s awakeness status.

03:30 A is awake.

03:31 V is responds to verbal.

03:33 P is responds to pain and U is unresponsive.

03:36 Get their baseline neurologic status.

03:39 If they are awake and compliant, check the cranial nerves.

03:42 Even if they’re not, you can still check some cranial nerves like pupillary response or whether there is a facial palsy.

03:50 Next, check strength.

03:52 If they are awake and compliant, you can check strength in all the extremities and looking for a generalized sense of strength and also sensation.

04:01 You don’t need to do a super careful neurologic sensation exam.

04:06 We are not so worried about the finer details like whether it’s light touch or pinprick.

04:11 We want to just get a general sense of can they feel up and down the body in the most of the major areas.

04:17 And then also, don’t forget to check the deep tendon reflexes, looking for things like clonus at the ankles or if they’re having any brisk reflexes implies that there may be some CNS damage.

04:30 So when we see these patients, we’ve done the primary and secondary survey, we often will get labs and we may just get something called a trauma panel.

04:42 I don’t actually mind that.

04:44 I think that’s a good idea.

04:45 I don’t like the shotgun approach for most disease processes.

04:49 I don’t think it’s indicated to do a shotgun labs approach.

04:52 For example, the patient with pneumonia.

04:54 But in a patient with a trauma it’s generally beneficial because you don’t have time really to think about things very carefully before they whisked off to the OR in all circumstances.

05:04 So what are the labs that are part of the trauma panel? We get a type and screen.

05:10 This is for obvious reasons, if they need blood either now or during the operating room.

05:15 We get a CBC.

05:16 Again, we can assess for loss of red blood cells and acute anemia and we can also see if there is an underlying problem.

05:24 We will check LFTs and lipase as that’s a reasonable way of assessing for hepatic and pancreatic damage.

05:31 We will get a basic metabolic panel.

05:33 That’s important to assess the acid base and the hydration status of a patient.

05:39 If it’s applicable, we’ll get a tox screen.

05:41 So any infant who is found with altered mental status or anybody who has been in an MVA certainly, we want to check a tox screen because it’s important to know whether there is underlying chemicals that may be affecting their vital signs.

05:55 And lastly, we’ll check a pregnancy test.

05:58 If it’s any girl who is over about 13 years of age, you want to check a pregnancy test because we need to know whether there is a fetus involved in terms of issues around end-organ damage.

06:11 So that’s my quick review of the primary and secondary survey and the labs we get in patients with trauma.

06:18 Thanks for your time.