Skill Station F

SECONDARY SURVEY

LEARNING OBJECTIVES

1. Assess a simulated multiply injured patient by using
the correct sequence of priorities and management
techniques for the secondary survey assessment of
the patient.
2. Reevaluate a patient who is not responding
appropriately to resuscitation and management.
3. Demonstrate fracture reduction in a simulated
trauma patient scenario.
4. Demonstrate splinting a fracture in a simulated
trauma patient scenario.
5. Evaluate a simulated trauma patient for evidence of
compartment syndrome.
6. Recognize the patient who will require transfer to
definitive care.
7. Apply a cervical collar.

Sk ill s Inc luded in this •• L—last meal

Sk ill S tation •• E—environment and exposure

•• Perform a Secondary Survey in a Simulated STEP 2. Obtain history of injury-producing event

Trauma Patient and identify injury mechanisms.
•• Reduce and Splint a Fracture in a Simulated
Trauma Patient HEAD AND MAXILLOFACIAL
•• Apply a Cervical Collar in a Simulated Trauma
Patient STEP 3. Assess the head and maxillofacial area.
•• Evaluate for the Presence of Compartment A. Inspect and palpate entire head and face
Syndrome for lacerations, contusions, fractures, and
thermal injury.

Per for m Secondary B. Reevaluate pupils.

Surv e y in a Simul ated
Traum a Patient C. Reevaluate level of consciousness and
Glasgow Coma Scale (GCS) score.

STEP 1. Obtain AMPLE history from patient, family, D. Assess eyes for hemorrhage, penetrating
or prehospital personnel. injury, visual acuity, dislocation of lens, and
presence of contact lenses.
•• A—allergies
E. Evaluate cranial nerve function.
•• M—medications
F. Inspect ears and nose for cerebrospinal
•• P—past history, illnesses, and pregnancies fluid leakage.

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­372 APPENDIX G n Skills
G. Inspect mouth for evidence of bleeding and
cerebrospinal fluid, soft-tissue lacerations,
and loose teeth.
CERVICAL SPINE AND NECK
STEP 4. Assess the cervical spine and neck.
A. Inspect for signs of blunt and penetrating
injury, tracheal deviation, and use of
accessory respiratory muscles.
B. Palpate for tenderness, deformity, swelling,
subcutaneous emphysema, tracheal devia-
tion, and symmetry of pulses.
C. Auscultate the carotid arteries for bruits.
D. Restrict cervical spinal motion when injury
is possible.
CHEST
STEP 5. Assess the chest.
A. Inspect the anterior, lateral, and
posterior chest wall for signs of blunt
and penetrating injury, use of accessory
breathing muscles, and bilateral
respiratory excursions.
B. Auscultate the anterior chest wall and pos-
terior bases for bilateral breath sounds and
heart sounds.
C. Palpate the entire chest wall for evidence
of blunt and penetrating injury,
subcutaneous emphysema, tenderness,
and crepitation.
D. Percuss for evidence of hyperresonance
or dullness.
ABDOMEN
STEP 6. Assess the abdomen.
A. Inspect the anterior and posterior abdomen
for signs of blunt and penetrating injury and
internal bleeding.
B. Auscultate for the presence of bowel sounds.
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C. Percuss the abdomen to elicit subtle
rebound tenderness.
D. Palpate the abdomen for tenderness, involun-
tary muscle guarding, unequivocal rebound
tenderness, and a gravid uterus.
PERINEUM/RECTUM/VAGINA
STEP 7. Assess the perineum. Look for
•• Contusions and hematomas
•• Lacerations
•• Urethral bleeding
STEP 8. Perform a rectal assessment in selected
patients to identify the presence of rectal
blood. This includes checking for:
•• Anal sphincter tone
•• Bowel wall integrity
•• Bony fragments
STEP 9. Perform a vaginal assessment in selected
patients. Look for
•• Presence of blood in vaginal vault
•• Vaginal lacerations
MUSCULOSKELETAL
STEP 10. Perform a musculoskeletal assessment.
•• Inspect the upper and lower extremities
for evidence of blunt and penetrating
injury, including contusions, lacerations,
and deformity.
•• Palpate the upper and lower extremities
for tenderness, crepitation, abnormal
movement, and sensation.
•• Palpate all peripheral pulses for presence,
absence, and equality.
•• Assess the pelvis for evidence of fracture
and associated hemorrhage.
•• Inspect and palpate the thoracic and
lumbar spines for evidence of blunt and
penetrating injury, including contusions,
­373 APPENDIX G n Skills
lacerations, tenderness, deformity, and
sensation (while restricting spinal motion
in patients with possible spinal injury).
NEUROLOGICAL
STEP 11. Perform a neurological assessment.
•• Reevaluate the pupils and level of
consciousness.
•• Determine the GCS score.
•• Evaluate the upper and lower extremities
for motor and sensory functions.
•• Observe for lateralizing signs.
R educ e and Splint a
Frac tur e in a Simul ated
Traum a Patient
STEP 1. Ensure that the ABCDEs have been assessed
and life-threatening problems have
been addressed.
STEP 2. Completely expose the extremity and remove
all clothing.
STEP 3. Clean and cover any open wounds.
STEP 4. Perform a neurovascular examination of
the extremity.
STEP 5. Provide analgesia.
STEP 6. Select the appropriate size and type of
splint. Include the joint above and below
the injury.
STEP 7. Pad the bony prominences that will be
covered by the splint.
STEP 8. Manually support the fractured area and
apply distal traction below the fracture and
counter traction just above the joint.
STEP 9. Reevaluate the neurovascular status of
the extremity.
STEP 10. Place the extremity in the splint and secure.
STEP 11. Obtain orthopedic consultation.
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Apply a Cervical Collar in a
Simulated Trauma Patient
STEP 1. Place the patient in the supine position.
STEP 2. Place your extended fingers against the
patient’s neck. Your little finger should
almost be touching the patient’s shoulder.
Count how many of your fingers it takes
to reach the jawline. Remember, sizing a
cervical collar is not an exact science; the
available sizes are limited, so make your
best estimate.
STEP 3. Find the appropriately sized collar or use an
adjustable one, if available.
STEP 4. Have another provider restrict the patient’s
cervical spinal motion by standing at head
of bed and holding either side of the head.
STEP 5. Slide the posterior portion of the collar
behind the patient’s neck, taking care not
to move the neck.
STEP 6. Place the anterior portion of the collar on
while making sure to place the patient’s
chin in the chin holder.
STEP 7. Secure the collar with the hook and loop
fasteners, making it snug enough to prevent
flexion but allowing the patient to open his
or her mouth.
E va luate for Pr e senc e of
Compartment Sy ndrome
STEP 1. Assess the degree of pain — is it greater
than expected and out of proportion to the
stimulus or injury?
STEP 2. Determine if there is pain on passive stretch
of the affected muscle.
STEP 3. Determine if there is altered sensation or
paresthesia distal to the affected compartment.
STEP 4. Determine if there is tense swelling of the
affected compartment.
STEP 5. Palpate the muscular compartments of
the extremity and compare the tension
­374 APPENDIX G n Skills
in the injured extremity with that in the
noninjured extremity. Asymmetry may be
an important finding.
STEP 6. Compartment pressures may be measured,
but the diagnosis is clinical. Pressure
measurements may be useful in unconscious
or neurologically impaired patients.
STEP 7. Frequently reevaluate the patient, because
compartment syndrome can develop
over time.
STEP 8:. Obtain surgical or orthopedic consultation
early.
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Links to Futur e Le arning
Review the secondary survey video on the MyATLS
mobile app.
Post ATLS—Recognize that the secondary survey is
similar to the comprehensive physical examination
learned in medical school. It incorporates the AMPLE
history and takes into account the mechanism
of traumatic injury. It is easy therefore to find
opportunities in one’s practice setting to continue
to practice the skills learned in the secondary survey
skill station.