Examination secondary survey

Examination: secondary survey

A full secondary survey will be required. Particular attention must be paid to the head, neck and spine. Head Examination of the head should include inspection and palpa tion of the scalp for evidence of subgaleal haematoma and scalp lacerations, which may bleed profusely and potentially overlie fractures. Examine the face f or evidence of fractures, especially to the orbital rim, zygoma and maxilla. Clinical evidence of a skull base fracture may include Battle’s sign ( Figure 28.3 ) and ‘racoon’ or ‘panda’ eyes (bilateral periorbital bruising). Haemotympanum, or overt bleeding from the ear if the tympanic membrane has ruptured, and CSF rhinorrhoea or otorrhoea are also highly suggestive of a fracture of the base of the skull. A complete examination of the cranial nerves will reveal, for example, facial or vestibulocochlear nerve damage asso ciated with skull base fracture. Midbrain or brainstem dys function may produce gaze par esis (inability of the eye to look across beyond the midline), dysconjugate gaze (inability of the William Henry Battle , 1855–1936, surgeon, St Thomas’s Hospital, London, UK. conjunctiva and cornea of the eyes, and the retina using an ophthalmoscope, looking for hyphaema (blood in the anterior chamber of the eye), papilloedema or retinal detachment. Blood in the mouth may be due to tongue-biting at seizure. The GCS score and pupil status, assessed as part of the pri - mary survey , require re-evaluation at the secondary survey and regularly thereafter. Neck and spine Studies have demonstrated an incidence of cervical fracture of up to 10% in association with moderate and severe TBI. Cervical spine injury must be presumed in the context of head injury until actively excluded. In a high-energy mechanism such as a road tra ffi c accident or fall from a height, thoracic and lumbar spine injuries must also be excluded. Plain radio - graphs are of limited value in excluding significant cervical spine injury . Even CT imaging does not exclude the possibility - of significant ligamentous injury . Therefore, whenever feasible, these patients should be managed in a hard collar until the neck can be cleared clinically . A peripheral nerve examination with documentation of limb tone, power, reflexes and sensation needs to be performed early to identify spinal pathology . This is especially important in patients who may subsequently be intubated and ventilated when this assessment will no longer be possible. Obtunded patients should move all four limbs in response to an appropri - ate painful stimulus. The patient will need to be log-rolled to palpate for thoracic or lumbar deformity , and any cervical collar should be removed - at this stage to allow palpation of the cervical spine before it - is then replaced again. If there is associated spinal injury , a thoracic sensory level is much more easily established by sen - sory examination on the back. A per rectum examination is also performed at log-roll, assessing for anal tone, sensation in the awake patient and anal wink (sphincter seen to contract in response to a pinprick stimulus). Priapism is a strong predictor of sever e cord injury even in intubated patients. Summary box 28.5 Secondary survey /uni25CF /uni25CF /uni25CF

Figure 28.3 Battle’s sign. A skull base fracture may be associated with bruising over the mastoid process. Battle’s sign, periorbital bruising and blood in the ears/nose/ mouth may point to a base of skull fracture Cervical spine fractures are common and must be actively excluded Log-roll to check the whole spine for steps and tenderness and for a per rectum examination

Examination: secondary survey

A full secondary survey will be required. Particular attention must be paid to the head, neck and spine. Head Examination of the head should include inspection and palpa tion of the scalp for evidence of subgaleal haematoma and scalp lacerations, which may bleed profusely and potentially overlie fractures. Examine the face f or evidence of fractures, especially to the orbital rim, zygoma and maxilla. Clinical evidence of a skull base fracture may include Battle’s sign ( Figure 28.3 ) and ‘racoon’ or ‘panda’ eyes (bilateral periorbital bruising). Haemotympanum, or overt bleeding from the ear if the tympanic membrane has ruptured, and CSF rhinorrhoea or otorrhoea are also highly suggestive of a fracture of the base of the skull. A complete examination of the cranial nerves will reveal, for example, facial or vestibulocochlear nerve damage asso ciated with skull base fracture. Midbrain or brainstem dys function may produce gaze par esis (inability of the eye to look across beyond the midline), dysconjugate gaze (inability of the William Henry Battle , 1855–1936, surgeon, St Thomas’s Hospital, London, UK. conjunctiva and cornea of the eyes, and the retina using an ophthalmoscope, looking for hyphaema (blood in the anterior chamber of the eye), papilloedema or retinal detachment. Blood in the mouth may be due to tongue-biting at seizure. The GCS score and pupil status, assessed as part of the pri - mary survey , require re-evaluation at the secondary survey and regularly thereafter. Neck and spine Studies have demonstrated an incidence of cervical fracture of up to 10% in association with moderate and severe TBI. Cervical spine injury must be presumed in the context of head injury until actively excluded. In a high-energy mechanism such as a road tra ffi c accident or fall from a height, thoracic and lumbar spine injuries must also be excluded. Plain radio - graphs are of limited value in excluding significant cervical spine injury . Even CT imaging does not exclude the possibility - of significant ligamentous injury . Therefore, whenever feasible, these patients should be managed in a hard collar until the neck can be cleared clinically . A peripheral nerve examination with documentation of limb tone, power, reflexes and sensation needs to be performed early to identify spinal pathology . This is especially important in patients who may subsequently be intubated and ventilated when this assessment will no longer be possible. Obtunded patients should move all four limbs in response to an appropri - ate painful stimulus. The patient will need to be log-rolled to palpate for thoracic or lumbar deformity , and any cervical collar should be removed - at this stage to allow palpation of the cervical spine before it - is then replaced again. If there is associated spinal injury , a thoracic sensory level is much more easily established by sen - sory examination on the back. A per rectum examination is also performed at log-roll, assessing for anal tone, sensation in the awake patient and anal wink (sphincter seen to contract in response to a pinprick stimulus). Priapism is a strong predictor of sever e cord injury even in intubated patients. Summary box 28.5 Secondary survey /uni25CF /uni25CF /uni25CF

Figure 28.3 Battle’s sign. A skull base fracture may be associated with bruising over the mastoid process. Battle’s sign, periorbital bruising and blood in the ears/nose/ mouth may point to a base of skull fracture Cervical spine fractures are common and must be actively excluded Log-roll to check the whole spine for steps and tenderness and for a per rectum examination

Examination: secondary survey

A full secondary survey will be required. Particular attention must be paid to the head, neck and spine. Head Examination of the head should include inspection and palpa tion of the scalp for evidence of subgaleal haematoma and scalp lacerations, which may bleed profusely and potentially overlie fractures. Examine the face f or evidence of fractures, especially to the orbital rim, zygoma and maxilla. Clinical evidence of a skull base fracture may include Battle’s sign ( Figure 28.3 ) and ‘racoon’ or ‘panda’ eyes (bilateral periorbital bruising). Haemotympanum, or overt bleeding from the ear if the tympanic membrane has ruptured, and CSF rhinorrhoea or otorrhoea are also highly suggestive of a fracture of the base of the skull. A complete examination of the cranial nerves will reveal, for example, facial or vestibulocochlear nerve damage asso ciated with skull base fracture. Midbrain or brainstem dys function may produce gaze par esis (inability of the eye to look across beyond the midline), dysconjugate gaze (inability of the William Henry Battle , 1855–1936, surgeon, St Thomas’s Hospital, London, UK. conjunctiva and cornea of the eyes, and the retina using an ophthalmoscope, looking for hyphaema (blood in the anterior chamber of the eye), papilloedema or retinal detachment. Blood in the mouth may be due to tongue-biting at seizure. The GCS score and pupil status, assessed as part of the pri - mary survey , require re-evaluation at the secondary survey and regularly thereafter. Neck and spine Studies have demonstrated an incidence of cervical fracture of up to 10% in association with moderate and severe TBI. Cervical spine injury must be presumed in the context of head injury until actively excluded. In a high-energy mechanism such as a road tra ffi c accident or fall from a height, thoracic and lumbar spine injuries must also be excluded. Plain radio - graphs are of limited value in excluding significant cervical spine injury . Even CT imaging does not exclude the possibility - of significant ligamentous injury . Therefore, whenever feasible, these patients should be managed in a hard collar until the neck can be cleared clinically . A peripheral nerve examination with documentation of limb tone, power, reflexes and sensation needs to be performed early to identify spinal pathology . This is especially important in patients who may subsequently be intubated and ventilated when this assessment will no longer be possible. Obtunded patients should move all four limbs in response to an appropri - ate painful stimulus. The patient will need to be log-rolled to palpate for thoracic or lumbar deformity , and any cervical collar should be removed - at this stage to allow palpation of the cervical spine before it - is then replaced again. If there is associated spinal injury , a thoracic sensory level is much more easily established by sen - sory examination on the back. A per rectum examination is also performed at log-roll, assessing for anal tone, sensation in the awake patient and anal wink (sphincter seen to contract in response to a pinprick stimulus). Priapism is a strong predictor of sever e cord injury even in intubated patients. Summary box 28.5 Secondary survey /uni25CF /uni25CF /uni25CF

Figure 28.3 Battle’s sign. A skull base fracture may be associated with bruising over the mastoid process. Battle’s sign, periorbital bruising and blood in the ears/nose/ mouth may point to a base of skull fracture Cervical spine fractures are common and must be actively excluded Log-roll to check the whole spine for steps and tenderness and for a per rectum examination