History

The secondary survey is only to be commenced once the primary survey has been completed and any life-threatening injuries have been treated. If during the examination any deterioration is detected, go back and reassess the primary survey.

Taking an adequate history from the patient, family members, bystanders, or emergency personnel of the preceding events can assist with predicting possible injuries.

Older patients may need longer to divulge all elements of the history—be patient, listen, and engage. It is also important to involve family members as well as the General Practitioner and the patient’s local pharmacist in determining an accurate and comprehensive medical, medication, and social history. Note any history of drugs or alcohol prior to and at the time of injury.

Use the AMPLE acronym to assist with gathering pertinent information:

Allergies
Medication (especially anticoagulants, antiplatelet agents, and cardiac medications)
Past medical history (include normal functional status)
Last meal (important if general anesthesia and surgery is being considered)
Events leading to injury¹²

Medications

• Antihypertensive medications are associated with an increased risk of serious falls, particularly in patients with previous falls.²²
• Anti-arrhythmic and beta-blockers may further blunt an already reduced physiological response.
• Oral anticoagulants are prescribed for several conditions and their use is associated with higher mortality in older persons following major trauma.²³
• DOACs are increasingly prescribed in older patients.
• Warfarin is still widely used and increases the risk of catastrophic bleeding in head trauma.
• Multiple treatments exist to reverse anticoagulation including prothrombin precipitate complex, fresh frozen plasma, cryoprecipitate, and vitamin K. Local policies should be followed.
• Limitation of treatment orders

It is vital to consider the patient’s requests in relation to resuscitation and escalation of treatment. This should be a collaborative discussion with the patient and family. Proactive and early resuscitation discussions integrated into a broader escalation of care review lead to greater clarity and aligned expectations about goals of care.²⁴

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Head-to-toe examination

The purpose of this examination is to identify injuries potentially overlooked in the initial assessment. Clinicians should take their time in performing this assessment and any injuries detected should be accurately documented.

Older patients have a reduced pain sensation and may not be able to localize pain or tenderness to the same extent as a younger patient.

Head and face

• Inspect the scalp. Look for any bleeding or lacerations. Do not probe the scalp and be cautious when examining as bone fragments and fractures may be present. Gently palpate for any depressions or irregularities in the skull. If a penetrating object remains lodged, do not remove it.

Lacerations can bleed profusely in anticoagulated patients; control bleeding with direct pressure and bandaging. If this is unsuccessful, consider temporary closure with preferably a continuous interlocking suture or staples as an alternative. The wound may need to be thoroughly irrigated at a later stage, this can be managed on a case-by-case basis.

• Inspect the face. Look for any lacerations or bruising. Periorbital bruising and/or mastoid bruising or a haemotympanum is indicative of a base of skull fracture; however, mastoid bruising will only occur 12–24 hours post-injury and therefore has limited use in the acute setting.^{25, 26}
• Look in the eyes for any foreign body, subconjunctival hemorrhage with no posterior limit, hyphema, irregular iris, penetrating injury, or contact lenses. Assess the ears for any bleeding or blood behind the tympanic membrane, as well as any cerebrospinal fluid (CSF) leak. Check the nose for any deformities, bleeding, nasal septal hematoma, or CSF leak. If a CSF leak is present, do not pack the nose; apply a bolster. To determine whether any clear fluid is CSF, the easiest method is to sample the fluid onto filter paper: if there is a formation of two rings (the ‘halo’ sign) this indicates the presence of CSF. Glucose should also be detected in the fluid, helping to differentiate it from mucus. Look in the mouth for any lacerations to the gums, lips, tongue, or palate. Inspect the teeth, noting if any are loose, missing, or fractured. Test eye movements, vision, and hearing. Palpate the bony margins of the orbit, maxilla, nose, and jaw. Inspect the jaw for any pain or trismus.

Neck

• Inspect the neck. Ensure another colleague maintains manual in-line stabilization while the hard collar is removed and throughout the examination.
• Gently palpate the cervical vertebrae. Note any cervical spine pain, tenderness, or deformity.
• Check the soft tissues for bruising, pain, and tenderness.
• Complete the examination of the neck by observing the neck veins for distension and by palpating the trachea and the carotid pulse; note any tracheal deviation or crepitus.

The patient will need to be log rolled to complete the full examination. This can be combined with the back examination. Older patients are at higher risk of pressure ulcers as a result of immobilization in hard collars and may have difficulty tolerating lying flat. Those with severe degenerative neck problems may not tolerate standard rigid collars due to their postural alignment and should be held in the most comfortable position with soft padding and tape.¹⁹

If able, replace a hard collar with a correctly fitted, longer-term, padded cervical collar, e.g. Philadelphia collar.

Chest

Blunt thoracic trauma carries a significant risk of complications and mortality, even with isolated rib fractures due to pneumonia and pulmonary contusions.

• Inspect the chest, observing movements. Look for any bruising, lacerations, penetrating injury, or tenderness.
• Palpate for clavicle or rib tenderness. Even isolated rib fractures in the older population carry a significant risk of complications and mortality.
• Auscultate the lung fields; note any percussion, lack of breath sounds, wheezing, or crepitations.
• Check the heart sounds: apex beat and the presence and quality of heart sounds.

Abdomen

The abdominal examination may be unreliable due to decreased perception of pain and cognitive decline.

• Inspect the abdomen. Palpate for areas of tenderness, especially over the liver, spleen, kidneys, and bladder. Look for any bruising, lacerations, or penetrating injuries. A seatbelt sign indicates a higher risk of intraabdominal injury and warrants further investigation.
• Check the pelvis. Gently palpate for any tenderness. Do not spring the pelvis.
• Pelvic fractures are common in older persons and carry an increased risk of clinically significant hemorrhage compared to younger patients.²⁷
• Apply a binder if a pelvic fracture is suspected.
• Auscultate bowel sounds.
• Inspect the perineum and external genitalia.

Limbs

Musculoskeletal injuries are very common in the older population and often result from low-impact mechanisms such as falls from standing height. Older patients have a high mortality following a hip fracture, and it is essential that these patients receive timely care with early surgical repair.

• Note any inequalities with limb response to stimulation and observe any shortening/rotation of lower limbs which may indicate a fracture to the hip.
• Inspect all the limbs and joints; palpate for bony and soft-tissue tenderness and check joint movements, stability, and muscular power. Note any bruising, lacerations, muscle, and nerve or tendon damage. Look for any deformities, penetrating injuries, or open fractures.
• Examine sensory and motor function of any nerve roots or peripheral nerves that may have been injured.

Back

• Log roll the patient. Maintain in-line stabilization throughout. Inspect the entire length of the back and buttocks noting any bruising and lacerations.
• Palpate the spine for any tenderness or steps between the vertebrae.
• Digital examination should be performed only if a spinal injury is suspected. Note any loss of tone.

Buttocks and perineum

• Look for any soft-tissue injuries such as bruising or lacerations.

Genitalia

• Inspect for soft tissue injuries such as bruising or lacerations. Check the urethra for any bleeding.

The priorities for further investigation and treatment may now be considered, and a plan for definitive care can be established in conjunction with Adult Retrieval Victoria (ARV).