While resuscitation continues, a secondary survey should be undertaken. The secondary survey is a rapid but thorough physical examination for the purpose of identifying as many injuries as possible. With this information, the resuscitating physician and his or her surgical colleague can set logical priorities for evaluation and management. Frequent assessments of the patient's blood pressure, pulse rate, and central venous pressure should continue.
The examination is conducted in a head-to-toe fashion, beginning with the scalp. Scalp lacerations can bleed profusely. This bleeding can be controlled with plastic Raney clips that grasp the full thickness of the scalp and galea. The tympanic membranes should be visualized to detect hemotympanum, and the pupil examination should be repeated. if epistaxis is a problem, a Foley catheter or a nasal balloon should be inserted to provide posterior tamponade. The examination continues over the neck and thorax. A lateral cervical spine x-ray (if not already obtained), a chest x-ray, and an anteroposterior pelvic x-ray should be obtained while the secondary survey continues. A 32-Fr gastric tube should be inserted into the stomach and connected to suction. When there is facial trauma or basilar skull fracture, the gastric tube should be inserted through the mouth rather than the nose. The urinary meatus, scrotum, and perineum are inspected for the presence of blood, hematoma, or laceration.
A rectal examination is done, noting sphincter function and whether the prostate is boggy or displaced. Rectal blood should be noted. If the prostate is normal and there is no blood at the urethral meatus, a Foley catheter can be placed in the bladder. If a urethral injury is suspected (meatal blood present), a urethrogram should be obtained prior to passing the catheter. If the prostate is displaced, it should be assumed that the urethra is disrupted. Catheterization should not be attempted if the urethra is injured. The urine should be examined for blood. If the patient is a woman of childbearing age, a pregnancy test should be obtained. A bimanual vaginal examination should be performed. If blood is present, a speculum examination will be necessary to identify a possible vaginal laceration in the presence of a pelvic fracture. Palpate all peripheral pulses. The patient should be logrolled to either side while keeping the neck immobilized so that every inch of the patient's body is seen and felt. The extremities should be evaluated for fracture and soft tissue injury. Peripheral pulses should be felt. A more thorough neurologic examination can now be done, carefully checking motor and sensory function.
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