Secondary Survey
■ The secondary survey includes a directed history and a detailed physical
examination.
■ A Focused Assessment with Sonography for Trauma (FAST) exam is a
quick tool that can be used during a secondary survey to evaluate for intra-
abdominal/pelvic and cardiac injuries.
■ A FAST exam showing free fluid in the abdomen in a hypotensive victim
of blunt trauma suggests that the patient has intra-abdominal hemorrhage
and suggests the need for immediate exploratory laparotomy.
TREATMENT
■ Any patient with concern for circulatory compromise needs to have two
large-bore IVs for fluid resuscitation.
■ In the setting of hypovolemia, administer an initial 1–2 L of crystalloid.
■ If the patient remains hypotensive, transfuse with O-negative blood or type-
specific blood if available.
■ This treatment should be provided concurrent with efforts to identify and
treat sources of hemorrhage as well as other possible causes of hypotension
including cardiac, chest, and spinal injury.
A young man arrives in the ED following isolated head trauma with loss
of consciousness (LOC). His mental status has returned to baseline, but
he has been vomiting and complains of persistent headache. What
should you do next?
This patient has a moderate risk for intracranial injury based on his presenting
symptoms. Administer antiemetics and obtain a head CT with or without C-spine
imaging.HEAD TRAUMAThe brain is contained within a fixed volume (the skull). After trauma, bleeding
and swelling can cause an increase in increased intracranial pressure (ICP),
which can lead to herniation of the brain, most commonly along the falx cere-
belli (uncal herniation). The goal of the emergency physician is to support oxy-
genation and BP to prevent secondary brain injury and to identify head injuries
that require intervention or observation (see Table 3.3).
SYMPTOMS
Symptoms depend on severity of injury and range from mild focal headache
to loss of consciousness, amnesia, vomiting, or headache.
EXAM
■ Varies with severity of injury
■ Calculate GCS (Table 3.2).
■ Review vital signs—ICP may cause the Cushing reflex: Hypertension,
bradycardia, and irregular respirations.
■ Pupillary exam
■ A single fixed and dilated pupil may be a sign of ipsilateral uncal hernia-
tion (but in awake patients, is usually indicative of ocular trauma).
■ Bilateral fixed and dilated pupils may indicate complete uncal hernia-
tion, poor brain perfusion, or stimulant use.
TRAUMA