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Secondary Surveys in paediatric trauma patients

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What is it?

Secondary surveys are a top-to-toe and back-to-front examination. The aim is to identify all important injuries.

Why do we do it?

Paediatric trauma can be complex and managing it can be stressful. The secondary survey ensures that nothing is missed once the time-critical and lifesaving interventions have been done.

A brief literature review of available data highlights a couple of interesting points.

  • We’re not brilliant at doing it, but practice does make perfect. Education and simulation around the paediatric secondary survey improve clinician confidence and accuracy of the process
  • Without a dedicated secondary survey, non-immediate non-life threatening injuries (i.e those not up on the primary survey) can be frequently missed and diagnosis delayed.
  • There is no substitute for a thorough clinical examination.

When should it be done?

The secondary survey should happen as soon as the primary survey (and relevant life-saving interventions) has taken place. During the secondary survey, it’s still important to keep an eye on the observations and mental state of the child. If something life or limb-threatening develops, then it needs to be dealt with there and then, as long as you return to complete the rest of the secondary survey.

The great thing about us paediatric types doing the secondary survey is that we get to do our ‘paeds bits’. It’s (hopefully) not as dramatic as the primary survey and there are fewer people getting in the way. We can concentrate on building rapport with the child, making sure they are comfortable and warm, and taking a slightly more detailed history whilst including parents/carers in the process. Ideally, it should be done BEFORE the child leaves the emergency department. This will improve continuity of care, and enable a logical and thorough assessment before they leave your care. Of course, there are situations where the child needs to proceed directly to theatre or PICU for life/limb-saving interventions. In this case, it needs to be made clear to the receiving team that a secondary survey has NOT been completed and still needs completion.

It is how slowly evolving or smaller injuries and complications are at risk of being missed.

How do we do it?

It’s the bread and butter of what we do in paediatrics. It is history and Examination in a detailed and logical manner.  Which other speciality examines so many different systems so regularly? No need to worry, this is your jam.

History (AMPLE)

What about the unconscious, sedated or feisty child? 

Fully assessing the unconscious patient can be challenging – feedback on tenderness will be limited, for example. However, this should just be taken into consideration and documented. It should not prevent the secondary survey from taking place.

Technically speaking, you should have limited/no imaging. Interventions from the primary survey do not require them. The secondary survey shouldn’t really take any longer than 5 mins and so shouldn’t delay imaging but it may help with making sure you get the right areas imaged with the correct modalities. However, we all know things can go in a bit of a skewiff way, so make sure you take into account any imaging and test results you may already have whilst doing the secondary survey.

What’s next?

On the basis of the secondary survey, think, what can you do? What do you need to do? What more information do you need?

  • Can you clear the C-Spine?
  • Can you clear the thoracic/lumbar spine?
  • Do you need to call other specialist teams? (e.g. MaxFax or ophthalmology)
  • Do you need to get more/different imaging?
  • Do you need to organise a transfer to another unit?
  • Do you need any further/repeat investigations? (i.e. bloods/toxicology)

References

Excellence in Communication and Emergency Leadership (ExCEL): Pediatric Primary and Secondary Survey in Trauma Workshop for Residents. Kelley MN, Mercurio L, Tsao HS, Toomey V, Carillo M, Brown L, Wing R. Mededportal Publications. 17:11079, 2021 01 22.

https://trauma.reach.vic.gov.au/guidelines/early-trauma-care/secondary-survey

https://www.rch.org.au/clinicalguide/guideline_index/Major_paediatric_trauma_the_secondary_survey/

Incidence of Delayed Diagnosis of Orthopaedic Injury in Pediatric Trauma Patients. Podolnick JD, Donovan DS, Atanda AW Jr. Journal of Orthopaedic Trauma. 31(9):e281-e287, 2017 Sep

Missed foot fractures in multiple trauma patients. Stefanie Fitschen-Oestern, Sebastian Lippross, Rolf Lefering , Lutz Besch , Tim Klüter , Elke Schenzer-Hoffmann,  Andreas Seekamp  TraumaRegister Dgu . PMID: 30909889 DOI: 10.1186/s12891-019-2501-8

Performance in Trauma Resuscitation at an Urban Tertiary Level I Pediatric Trauma Centre. Gala PK, Osterhoudt K, Myers SR, Colella M, Donoghue A,. Pediatric Emergency Care. 32(11):756-762, 2016 Nov

‘Using rapid cycle deliberate practice to improve primary and secondary survey in pediatric trauma’. Yan DH,  Slidell MB, McQueen A BMC Medical Education. 20(1):131, 2020 Apr 28. UI: 32345288

About the authors

  • A Wessex Paeds trainee hoping to sub-specialise in PEM. Mother of 2, fuelled mostly by coffee and cake.

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