Once life-threatening conditions identified in the primary survey are stabilized, perform a timely, directed evaluation of each body area, proceeding from head to toe.11,13 Continuously reassess vital signs and abnormal conditions identified in the primary survey at a minimum of every 15 minutes. The components of the secondary survey include a history, a complete head to toe examination, laboratory studies, radiographic studies, and problem identification. Use an AMPLE history to determine the mechanism of injury, time, status at scene, changes in status, and complaints that the child may have. This includes Allergies, Medications, Past medical and surgical history, Last meal time, and Events preceding the injury. Complete laboratory and radiologic studies that were not done during the initial resuscitation. A decision regarding disposition can probably be made at this point during most resuscitations.
Reevaluate pupil size and reactivity. Perform a conjunctival and fundal examination for hemorrhage or penetrating injury. Assess visual acuity by determining if the patient can read, see faces, recognize movement, and distinguish light versus dark.
Palpate the skull and mandible looking for fractures or dislocations. Although relatively uncommon, infants may become hypotensive from blood loss into either the subgaleal or epidural space. An infant with an open fontanelle is more tolerant of an expanding intracranial mass lesion, and signs of this may be hidden until rapid decompensation occurs. Unlike adults, vomiting and altered mental status, such as amnesia, commonly occur in head-injured children and do not necessarily imply increased ICP. However, persistent vomiting, progressive headache, palpable skull defect, or an inability to observe a patient's mental status (e.g., they are going to the operating room) are some of the indications for an immediate head CT scan. If airway is secure, maxillofacial trauma is a lower priority and the physician should move on quickly.
Injuries of the C-spine are not common in children. In lower-risk injuries, the C-spine can usually be cleared in the ED with a normal examination, and anteroposterior (AP), odontoid, and lateral view radiographs of the C-spine. Before ruling out a cervical injury, the patient should be awake, cooperative, and free of other distracting painful injuries, and the radiographs must show all seven C-spine vertebrae. The child, performing the movements voluntarily, should actively flex, extend, and rotate the neck with no symptoms or signs of spasm, guarding, pain, or tenderness. Patients at higher risk for C-spine injury include those with: altered mental status, focal neurologic deficits, complaint of neck pain, torticollis, substantial injury to the torso, predisposing condition, high-risk MVC, and diving.17 Additional radiographic imaging should be considered, such as a CT for immediate evaluation of fractures and acute injury, and an MRI for a more detailed evaluation of ligamentous and spinal cord injuries.18
Unique characteristics of the pediatric C-spine predispose it to ligamentous disruption and dislocation injuries without radiographic evidence of bone injury. The incomplete development of the bony spine, the relatively large size of the head, and the weakness of the soft tissue of the neck predispose to spinal cord injury without radiographic abnormality (SCIWORA). Patients with altered sensorium cannot be cleared despite negative x-rays, and the cervical collar should remain in place while further testing and imaging studies are completed (see Chapter 24).
Special considerations are required in four situations:
The child who requires immediate intubation because of airway compromise should not have airway management delayed waiting for C-spine film(s). The safety of oral intubation with in-line C-spine immobilization has been demonstrated in multiple studies.
If such a child who is intubated is at high risk for C-spine injury, then a CT scan of the upper cervical vertebrae should be done when a head CT scan is performed.
If an injured patient arrives with a helmet in place and does not require immediate airway intervention, then lateral C-spine can be done before removing the helmet. There should be careful attention to maintaining C-spine immobilization while removing the helmet.
Penetrating injuries to the neck requiring operative intervention should have entry and exit sites noted with opaque markers on anterior–posterior and lateral films of the C-spine.
Expose and visually inspect the chest for wounds requiring immediate attention. Sucking chest wounds require a sterile occlusive dressing. A flail chest component could be splinted but the patient may need intubation to do so. Roll the patient, keeping in-line spine immobilization, and look for posterior wounds. Auscultate the chest and evaluate for pneumothorax, hemothorax, or cardiac tamponade. Tension pneumothorax may be manifested by contralateral tracheal shift, distended neck veins, and diminished breath sounds. However, a child's small chest size facilitates the contralateral lung's transmission of breath sounds that makes auscultation an insensitive marker for pneumothorax. Neck vein distention is difficult to appreciate and an insensitive marker when assessing for tension pneumothorax. Therefore, a hemodynamically unstable child should undergo immediate needle decompression thoracentesis if there is reason to suspect blunt or penetrating injury to the thorax. After thoracentesis, tube thoracostomy(ies) should be done. Impaled objects protruding from the chest should be left in place until the child undergoes surgery.
If the chest radiograph reveals a widened mediastinum or apical cap, or other signs suggesting aortic injury or there is a history of significant deceleration injury, CT angiography of the chest is indicated. Aortography may be needed in select circumstances. Although first or second rib fractures increase the likelihood of a vascular injury, their absence does not preclude an aortic injury.15
Air lucencies on chest radiography appearing to be of intestinal origin should be considered evidence of a diaphragmatic injury. Any penetrating injury to abdomen or lower chest carries a risk of diaphragmatic injury.
During the secondary survey, determining the exact etiology of an abdominal injury is secondary to determining whether or not an injury is present. Retroperitoneal injuries are difficult to identify, unless there is a high index of suspicion. Signs suggesting abdominal injury include abdominal wall contusion, distention, abdominal or shoulder pain, and signs of peritoneal irritation and shock. Penetrating wounds to the abdomen usually need immediate operative intervention.16,19
Controversies arise in diagnosing and managing blunt abdominal injuries. CT scan with IV contrast, and with or without oral contrast, may be the most sensitive and useful diagnostic modality (see Imaging section). Diagnostic peritoneal lavage (DPL) provides rapid, objective evaluation of possible intraperitoneal injury, especially involving the liver, spleen, and bowel. It can be considered more sensitive than a CT scan in diagnosing hollow viscous injuries, especially early in the evaluation of a child who is a victim of a deceleration injury while wearing a seatbelt (Fig. 22-3). It is much less sensitive than CT scan in diagnosing injuries to the pancreas, duodenum, genitourinary tract, aorta, vena cava, and diaphragm.
Children with bruises from seatbelts should be checked for deceleration injuries.
The role of the focused assessment sonography in trauma (FAST) in pediatric trauma is still equivocal. In children, FAST may identify intra-abdominal hemorrhage but this may not be adequate to dictate management. However, finding blood on a FAST examination in a patient who is hypotensive and is not responding adequately to crystalloid and packed red blood cell expansion would indicate a need for immediate laparotomy.20
DPL, although rarely performed in children, may have a role in the hypotensive, injured child because it is valuable in deciding whether or not a patient needs immediate laparotomy. Consider performing DPL in the patient requiring urgent anesthesia and nonabdominal surgery, such as evacuation of an epidural hematoma or treatment of a penetrating upper chest injury.
In children, after emptying the bladder with a Foley catheter, use a midline approach above or below the umbilicus. Instill 10 mL/kg of LR if the initial aspirate is not grossly bloody. An aspirate is considered positive if it has >100,000 red blood cells (RBCs)/μL, >500 white blood cells (WBCs)/μL, a spun effluent hematocrit >2%, bile, bacteria, or fecal material are found. False-positive tests most commonly occur in the face of a pelvic fracture. A positive DPL >100,000 RBCs may be due to a laceration of the liver or spleen but this would not be an indication for surgery, as many solid organ injuries are adequately treated nonoperatively (see Chapter 26).
Palpate the bony prominences of the pelvis for tenderness or instability. Examine the perineum for laceration, hematoma, or active bleeding, and examine the urethral meatus for blood. Blood loss from pelvic fractures can be critically significant and difficult to control, leading to fatal hemorrhage. If there is major pelvic disruption, stabilize the patient with IV fluids and blood products. In order to further reduce bleeding until definitive surgical care, bring the lower extremities together and apply an external pelvic sling made from a sheet to bind the pelvis or use the pneumatic antishock garment. Early use of angiography to embolize bleeding vessels may be lifesaving.
The perineum should be examined for contusions, hematomas, lacerations, and urethral bleeding. A routine rectal examination is not necessary in pediatric trauma patients, as it typically does not improve the identification of serious injury.21 However, it may be more useful as an adjunct to the examination in the patient if the patient has suspected abdominal, pelvic, or spinal cord injury. When performed, determine sphincter muscle tone, rectal integrity, prostatic position, presence of a pelvic fracture, and the presence of blood in the stool. For the female patient, a vaginal examination should also be considered in the secondary survey.
Examine all extremities looking for deformity, contusions, abrasions, intact sensation, penetrating injuries, pulses, and perfusion. The presence of a pulse does not exclude a proximal vascular injury or a compartment syndrome. Palpate long bones circumferentially assessing for tenderness, crepitation, or abnormal movement. Straighten severe angulations of the extremities if possible and apply splints and traction. Open fractures and wounds should be covered with sterile dressings. Inspect soft-tissue injuries for foreign bodies, irrigate to minimize contamination, and debride devitalized tissues. Remember to check for fractures involving the bones of the hands, wrists, and feet since they are commonly missed until the patient regains consciousness.
Examine the back, particularly in cases of penetrating trauma, looking for hematomas, exit or entry wounds, or spine tenderness. With the neck immobilized, log roll the patient for examination.
Examine for evidence of contusions, lacerations, burns, penetration sites, petechiae, and signs of abuse.
Obtain an additional GCS score and perform a more in-depth evaluation of motor, sensory, and cranial nerves. Presence of paresis or paralysis suggests a major neurologic injury. Conversely, lack of neurologic findings does not eliminate the possibility of a cervical cord injury, especially when the patient has a distracting injury and/or pain.
Any injured child is at risk for exposure to heat or cold. Because of their relatively larger body surface area, hypothermia can develop in the prehospital setting and/or in the ED. Hypothermia may impair circulatory dynamics and coagulation, worsen metabolic acidosis by increasing metabolic demand, and increase peripheral vascular resistance. The likelihood and risks of hypothermia can be minimized with the use of overhead warmers, warmed IV fluids, and warm blankets.