Abdomen: the abdomen must be inspected for signs of injury and the presence of free intra -peritoneal fluid. Penetrating wounds should be examined at laparotomy if they breach muscle. Eviscerated bowel must be covered with packs soaked in warm saline and replaced under general anaesthesia. Pelvic injury may be diagnosed by clinical examination, but an X- ray should always be performed. Blood at the urethral meatus, scrotal haematoma or on a high prostate on rectal examination indicate urethral injury in the male. In these situations a supra-pubic catheter should be inserted. Otherwise a urethral catheter should be inserted, and the presence of any obvious or microscopic haematuria sought. The rectal examination may also reveal blood or pelvic fractures, and an assessment of anal tone can be made. A lax anal sphincter may indicate that spinal cord injury has occurred. The stomach may dilate acutely in trauma patients, and may need decompression using a nasogastric tube (or an oro-gastric tube if a basal skull or mid face fracture is suspected). Vaginal examination may show a pelvic fracture or breach of the vaginal vault.

If assessment is difficult or equivocal, then diagnostic peritoneal lavage is indicated. It should not be performed if there is a need for urgent laparotomy i.e. penetrating trauma, unexplained hypovolaemia, extruded bowel or radiological evidence of intra-abdominal trauma.

Limbs: Fractures, wounds and discoloration must be noted. Check pulses in all limbs even if no fracture is suspected. Fractures compromising circulation must be reduced to prevent distal ischaemia. If possible, sensation in the limbs is assessed. Fractures should be splinted to reduce pain and the risk of fat emboli. Swabs should be taken from open wounds, which can then be covered with a sterile dressing.

Contaminants and devitalised tissue should be removed. Large blood losses may be associated with long bone and particularly pelvic fractures, but in a shocked patient they must not be assumed to be the only cause. Early fixation of these fractures may reduce blood loss, accelerate mobilisation of the patient and reduce the severity of fat embolism. Signs such as increased limb swelling, pain and disordered sensation suggest compartment syndrome and urgent decompression by surgical fasciotomy is required.

Spine: hypotension with bradycardia is unusual in hypovolaemia but, if present, does not exclude haemorrhage, especially in elderly patients. It is, however, more likely to be due to spinal cord damage in a patient with a history suggestive of spinal injury. Fluid replacement should be guided by careful cardiovascular monitoring to prevent circulatory overload. Other indicators of cord damage are acute urinary retention, diaphragmatic respiration, priapism (persistent abnormal penile erection), lax anal sphincter and flaccid paralysis of the limbs.

The cervical and thoracolumbar regions are most commonly affected by trauma, and appropriate radiographs should be taken. The patient must be log rolled (figure 8) and the entire spine examined for deformities or injuries. The rest of the back should also be examined at this point to exclude other injuries.

 
Definitive treatment

The further treatment of the patient will depend on the injuries detected during the preceding examination. The highest priority is given to those that are life threatening. Thoracic and abdominal conditions may warrant surgery at this stage.

Key point:

During the secondary survey, a reassessment of the primary survey (airway, breathing and circulation) is often indicated. This takes priority over any other procedure being carried out. Once the secondary survey has been completed, the primary survey should be repeated to prevent any new complications from occurring during the course of the definitive treatment.

Case History

Following initial assessment and resuscitation, a 21 year old road traffic accident victim still had the signs of class 3 hypovolaemia after 6 litres of saline and 2 units of O negative blood had been given. Her abdomen was distended and the hospital had run out of blood that morning. The anaesthetist asked for the autotransfusion bottles to be made ready in theatre, and moved the patient into the operating theatre. A number of sterilised 500ml bottles containing 2g of sodium citrate and 3g of dextrose made up to 120ml with sterile water were ready. Anaesthesia was induced once the surgeon was scrubbed and the patient draped for laparotomy. This revealed a free intraperitoneal rupture of the spleen with over 2 litres of intraperitoneal blood. There was no obvious bowel injury and the blood appeared to be uncontaminated. The blood was collected 500ml at a time into a kidney dish and the splenic vessels clamped. The scrub nurse poured the anticoagulant from the first of the prepared bottles into the kidney dish with the blood and mixed well. The nurse then filtered the mixture of blood and anticoagulant through 4 layers of sterile gauze back into the bottle, replacing the stopper, discarding any clots, and handing it to the anaesthetist before repeating the process with the next bottle. The anaesthetist then transfused the blood via a blood giving set (all of which have a 120micron filter). Four bottles of blood were returned to the patient who survived and made a good recovery. Autotransfusion is effective but needs preparation. If you cannot prepare your own anticoagulant as described, use the anticoagulant from purpose designed venisection bags available in your local blood bank.

Transfer of the patient with multiple trauma can be hazardous. In all but the most desperate situations, the condition of the patient should be stabilised prior to transfer. The level of monitoring must be maintained during transport, adequate resuscitation equipment and drugs should be available, hypothermia avoided and the receiving area must be warned of the condition of the patient. The staff who accompany the patient should be experienced in transport of the critically ill.

(Continued...)

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