Survey Flashcards
◦ Vital signs
◦ Does the patient have a fever?
◦ Is the patient bradycardic or tacycardic?
◦ Is the patient bradypneic or tachypneic?
◦ Is the patient hypotensive or severely hypertensive?
◦ Neurologic status
◦ Level of alertness
◦ GCS score or AVPU scale (A=alert, V=responds to verbal stimuli, P=responds to painful stimuli, U=unresponsive). A verbal description is helpful
◦ How difficult is it to keep the patient awake?
◦ Content of thought and speech
◦ Does the patient stay focused?
◦ Is their speech tangential?
◦ Is the patient appropriately oriented?
◦ Does the patient keep asking the same questions over and over (perseveration)?
◦ Are they reacting to internal stimuli?
◦ Assess for focal motor findings
◦ Is there weakness or pronator drift?
◦ Cranial nerve exam (especially pupils)
◦ Remember, the brainstem is where isolated structural or ischemic lesions can cause decreased arousal. Decreased level of consciousness with cranial nerve findings is a brainstem lesion until proven otherwise.
◦ Evaluate for tremulousness or abnormal reflexes
◦ Common in withdrawal states or metabolic derangements
Chest
Inspect for obvious injuries with consideration for mechanism.
Palpate for subcutaneous emphysema, chest wall stability.
Percuss for dullness or hyperressonance.
Auscultate for diminished breath sounds (pneumo- or hemothorax)
Some life threatening conditions:
◦ A tracheobronchial tree disruption will present on physical as subcutaneous emphysema. You may notice that after placing a chest tube, the lung refuses to inflate. There may be a persistent air leak. You may need to place a second chest tube, and if this fails, the patient needs to go to the OR.
◦ A pulmonary contusion may initially present as mild hypoxia but after fluid
resuscitation, the corresponding pulmonary edema worsens and so does the
hypoxia. This can be diagnosed on chest x-ray (or CT) and is treated by
proper oxygenation and ventilation (often with intubation), and maintaining
normovolemia.
◦ A blunt cardiac injury is difficult to diagnosis. Often the only sign may be an abnormal ECG or tracing on the cardiac waveform. Echocardiography may show a hypokinetic heart. Treatment consists of medicating dysrhythmias that effect hemodynamics.
◦ A traumatic aortic disruption is caused by a rapid acceleration (or
deceleration) causing a tear in the aorta. Normally this is immediately fatal,
but those who survive may show a widened mediastinum on CXR. This can
be confirmed with CT scan or angiography of the aorta and requires prompt
surgical correction.
◦ A flail chest is caused by two or more fractures in 2+ contiguous ribs creating a free-floating segment of chest wall. This segment will move in the opposite direction of the rest of the chest wall during inspiration and expiration and disrupts the normal negative-pressure ventilatory mechanics.
• Chest x-ray is performed in between the primary survey and the secondary
survey.
◦ Blunt: < 10% of patients require surgery
◦ Penetrating: 15-30% require surgery
◦ Majority: Require simple procedures
◦ Most life-threatening injuries are identified during the primary survey
◦ Cardiovascular exam
◦ Are there arrhythmias (a-fib) that predispose to embolic strokes?
◦ Is there a murmur? endocarditis?
◦ Is there evidence of good peripheral circulation?
◦ Are there pulmonary findings that indicate pneumonia (sepsis) or pulmonary edema (hypoxia)?
◦ Are there bruits over the carotid arteries?
Abdomen
Inspect for bruising patterns (Cullen’s sign of periumbilical bruising or Grey-
Turner’s sign of flank bruising, both associated with retroperitoneal hemorrhage) or a seat belt sign.
Auscultate for absent or tympanic bowel sounds.
Palpate and percuss for rebound tenderness, guarding or diffuse dullness
(peritoneal signs).
Frequent re-evaluations are important since the process may progress.
◦ Abdominal exam
◦ Is there ascites, caput medusa, liver enlargement or tenderness (hepatic encephalopathy)?
◦ Is the abdomen tender (appendicitis, intussusception, abdominal sepsis source, mesenteric ischemia)?
◦ Genitourinary and rectal exam
◦ Is the patient making urine (uremic encephalopathy)?
◦ Are there signs or urinary, vaginal, prostatic or perineal infection?
◦ Is there melena or blood in the stool?
◦ Skin, extremity, musculoskeletal exam
◦ Are there petechiae (meningococcemia)?
◦ Is there a dialysis graft (uremic encephalopathy)?
◦ Are there track marks from injection drug abuse?
◦ Are there transdermal drug patches?
◦ Is the skin jaundiced (hepatic encephalopathy)?
◦ Is there nuchal rigidity or meningismus (CNS infection)?
◦ Are there signs of trauma (raccoon’s eyes, Battle ‘s sign, hemotympanum)?
◦ Are there infectious sources noted (decubitus ulcers, cellulitis, abscesses)?
◦ Are there masses or lymphadenopathy that might indicate cancer (paraneoplastic syndromes)?
Head/ CNS
Trauma
looking for skull fractures, axonal injuries, contusion, concussion, or
hemorrhage. Look for Battle’s sign (left, ecchymosis behind ear indicative of
basilar skull fracture) or Raccoon’s eyes (right, periorbital ecchymosis without
edema indicative of basilar skull fracture.
Motor/ Strength
Grading
◦ 0: Total paralysis
◦ 1: Palpable/visible contraction
◦ 2: FROM w/gravity eliminated
◦ 3: FROM against gravity
◦ 4: FROM, less than normal strength
◦ 5: Normal strength
Cervical Spine /
Neck Exam
Blunt Trauma may result in crushed larynx, tracheal disruption, expanding
hematoma, esophageal leak.
Penetrating trauma may result in injury to major vascular structures, pharynx, larynx, trachea, esophagus
Flexion, extension, rotational injuries may injure spine
Obstruction secondary to trauma may be due to direct trauma to larynx or neck. The presentation may be of inspiratory stridor (supraglottic) or expiratory stridor (subglottic), muffled voice, difficulty handling secretions. Exam may be misleading as neck trauma may show subtle symptoms and signs prior to obstruction.
In order to clear the cervical spine and remove the patient’s collar, they must
have the following findings:
◦ Alert, not intoxicated
◦ Absence of neck pain
◦ Absence of midline neck tenderness
◦ Absence of distracting injury
◦ Absence of sensory or motor complaint
Cervical spine pearls
◦ 5% of brain injuries have associated C-spine injury
◦ 55% spinal injuries are cervical
◦ 10% of patients with C-spine fx will have a second noncontiguous vertebral
fracture
Pelvis
Presents with pain/instability on palpation or unequal leg lengths. If the pelvic
ring is disrupted, it may shear blood vessels such as the pelvic venous plexus or internal iliac arterial system. This can lead to severe hemorrhage, and the pelvis can hide a lot of blood (5 L).
Treatment involves stabilizing the pelvis by wrapping a sheet around it (to
compress) , longitudinal traction, pelvic binders, MAST trousers (falling out of
favor) [external fixation].
Perineum,
Rectum, and
Genital Exam
Examine perineum for contusions, scrotal hematomas, lacerations, or blood at
the urethral meatus which can be sign of urethral disruption. On the rectal exam,
look for diminished sphincter tone which can be a sign of a spinal cord injury.
Exam prostate to check position as a high-riding prostate can be sign of a pelvic
fracture or urethral injury. Finally, assess for rectal wall integrity and gross
blood.
Musculoskeletal
Always check for distal perfusion and neurovascular status. Be sure to document that each extremity is “neurvascularly intact.” The worrisome diagnosis of the extremity is a compartment syndrome (an increased pressure is a closed fascial space). This presents eventually with the five P’s (Pallor, Pain, Paresthesia, Poikilothermic, Pulseless (late finding)). Injuries prone to developing compartment syndrome include forearm and tibial injuries, tight dressings with underlying increasing swelling, prolonged external pressure, crush injuries, or circumferential burns. The treatment is a a fasciotomy versus escharotomy.
