Secondary survey (evaluation) of the adult trauma patient

INTRODUCTION — All trauma patients require a systematic evaluation to maximize outcomes. Once the initial evaluation (primary survey) and all necessary life- and limb-saving interventions are completed, a systematic evaluation of the patient, known as the secondary survey, is essential for ensuring that important injuries are not missed.

The initial management of adult trauma patients, including the primary survey, is reviewed separately (see "Initial management of trauma in adults"); performance of the secondary survey that follows is discussed here.

The initial evaluation and management of specific injuries and the management of pediatric trauma are reviewed in a wide range of UpToDate topics, including the following:

●Emergency trauma management (see "Emergency ultrasound in adults with abdominal and thoracic trauma" and "Initial management of moderate to severe hemorrhage in the adult trauma patient" and "Approach to shock in the adult trauma patient")

●Head, face, and neck trauma (see "Management of acute moderate and severe traumatic brain injury" and "Skull fractures in adults" and "Initial evaluation and management of facial trauma in adults" and "Penetrating neck injuries: Initial evaluation and management")

●Spine trauma (see "Acute traumatic spinal cord injury" and "Suspected cervical spine injury in adults: Choice of imaging" and "Cervical spinal column injuries in adults: Evaluation and initial management" and "Thoracic and lumbar spinal column injury in adults: Evaluation")

●Chest trauma (see "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of penetrating thoracic trauma in adults" and "Initial evaluation and management of chest wall trauma in adults" and "Initial evaluation and management of rib fractures" and "Initial evaluation and management of blunt cardiac injury")

●Abdominal and pelvic trauma (see "Blunt abdominal trauma in adults: Initial evaluation and management" and "Initial evaluation and management of abdominal stab wounds in adults" and "Abdominal gunshot wounds in adults: Initial evaluation and management" and "Pelvic trauma: Initial evaluation and management" and "Minor pelvic fractures (pelvic fragility fractures) in the older adult" and "Blunt genitourinary trauma: Initial evaluation and management" and "Penetrating trauma of the upper and lower genitourinary tract: Initial evaluation and management")

●Extremity trauma (see "Severe upper extremity injury in the adult patient" and "Severe lower extremity injury in the adult patient")

●Children, older adults, pregnancy, and other special populations (see "Trauma management: Approach to the unstable child" and "Trauma management: Overview of unique pediatric considerations" and "Geriatric trauma: Initial evaluation and management" and "Initial evaluation and management of major trauma in pregnancy")

SECONDARY EVALUATION AND MANAGEMENT

Key principles and commonly missed injuries — Definitive management of a hemodynamically unstable trauma patient must not be delayed to perform a more detailed secondary evaluation. Issues contributing to instability are addressed immediately in the primary survey. If patients continue to be unstable, they are taken directly to the operating room/angiography suite or transferred to a major trauma center. The primary survey and related management are discussed separately. (See "Initial management of trauma in adults", section on 'Primary evaluation and management'.)

A careful, head-to-toe secondary assessment (ie, secondary survey) is performed in all trauma patients determined to be stable upon completion of the primary survey. The secondary survey includes a detailed history, a thorough but efficient physical examination, and targeted diagnostic studies. It plays a crucial role in avoiding missed injuries. Clinically significant missed injuries occur in approximately 15 to 22 percent of patients with polytrauma [1].

Commonly missed injuries include the following [2-4]:

●Blunt abdominal trauma

•Hollow viscus injury (see "Blunt abdominal trauma in adults: Initial evaluation and management" and "Traumatic gastrointestinal injury in the adult patient")

•Pancreatoduodenal injuries (see "Management of duodenal trauma in adults" and "Management of pancreatic trauma in adults")

•Diaphragmatic rupture (see "Recognition and management of diaphragmatic injury in adults")

●Penetrating abdominal-pelvic trauma

•Rectal injury (see "Traumatic gastrointestinal injury in the adult patient")

•Ureteral injury (see "Overview of traumatic and iatrogenic ureteral injury" and "Blunt genitourinary trauma: Initial evaluation and management" and "Penetrating trauma of the upper and lower genitourinary tract: Initial evaluation and management")

●Thoracic trauma

•Aortic injury (see "Clinical features and diagnosis of blunt thoracic aortic injury" and "Overview of blunt and penetrating thoracic vascular injury in adults")

•Pericardial tamponade (see "Cardiac tamponade")

•Esophageal perforation (see "Overview of esophageal injury due to blunt or penetrating trauma in adults")

●Extremity trauma

•Fractures (especially in distal extremities) (see "General principles of acute fracture management" and "General principles of fracture management: Early and late complications"); in addition, clinicians can refer to UpToDate topics discussing the management of specific upper and lower extremity fractures

•Vascular injury (see "Severe lower extremity injury in the adult patient" and "Severe upper extremity injury in the adult patient")

•Acute compartment syndrome (see "Acute compartment syndrome of the extremities")

Delayed re-evaluation of the trauma patient (ie, tertiary survey) is also useful for preventing missed injuries and for detecting injuries that present late [2,5]. It is most helpful if the patient is re-evaluated when fully alert. Any member of the trauma team with advanced assessment skills can perform the tertiary survey; however, it is best if the same clinician performs all serial examinations for a given patient in order to detect subtle changes.

History — The mechanism of injury increases suspicion for certain injuries. Prehospital personnel often know important information and should be queried regarding the mechanism and history of the injury. If this cannot be done immediately upon arrival because of the patient's status, ask the prehospital providers to remain in the emergency department until this can be accomplished. Often, the history is conveyed while medics and hospital clinicians transfer the patient, and important information may be forgotten or missed.

While listening to the history, keep in mind that the scenes of accidents can be chaotic, and not all information will be reliable. As an example, a patient described as "found down" may have been assaulted or struck by a car.

Mechanism-related information to be obtained from prehospital personnel includes [6]:

●Blunt trauma

•Seatbelt use

•Steering wheel deformation

•Airbag deployment

•Direction of impact

•Damage to the automobile (especially intrusion into the passenger compartment)

•Distance ejected from the vehicle

•Height of fall

•Body part landed upon

•Death at scene or in same vehicle

●Penetrating trauma

•Type of firearm

•Distance from firearm

•Number of gunshots heard

•Type of blade

•Length of blade

•Estimated amount of blood at the scene

Inquire also about the patient's medications, allergies, and medical and surgical history. If this information is unknown, it can be helpful to assign someone the task of contacting family members to obtain it. The use of anticoagulant and antiplatelet medications is steadily rising and increases the risk of internal bleeding in trauma patients; therefore, these agents should specifically be discussed [7-10]. (See "Management of bleeding in patients receiving direct oral anticoagulants" and "Reversal of anticoagulation in intracranial hemorrhage".)

As an example of the risks associated with anticoagulants, a retrospective study of 11,374 adult trauma patients reported that the use of antiplatelet drugs was associated with an increased risk of death (propensity adjusted outcome 9.4 versus 8 percent mortality) and major morbidity among the 1327 (11.7 percent) patients taking them at the time of their injury [7]. Patients taking multiple antiplatelet medications were at greater risk than those taking a single drug. Geriatric trauma patients taking anticoagulant medications are at increased risk for severe traumatic brain injury. (See "Geriatric trauma: Initial evaluation and management", section on 'Head injury'.)

Also important is evaluating for an underlying medical condition that may have caused the trauma, such as seizure, syncope, arrhythmia, or other conditions that may have altered the patient's level of consciousness. Obtaining specific information regarding symptoms prior to a trauma may elucidate medical conditions that require further evaluation. (See "Diagnosis of delirium and confusional states" and "Evaluation of abnormal behavior in the emergency department".)

While such questions do not typically affect the immediate treatment of traumatic injuries, it is important to ask trauma patients about possible domestic violence. The prevalence of domestic violence continues to increase among both children and adults and can lead to a pattern of repeated injury [11]. (See "Intimate partner violence: Diagnosis and screening" and "Intimate partner violence: Childhood exposure" and "Elder abuse, self-neglect, and related phenomena" and "Peer violence and violence prevention".)

A history of mental illness, including thoughts or attempts at suicide, may be significant, particularly in the setting of single car accidents or falls from a height, which may be unrecognized suicide attempts. Knowledge of alcohol or drug abuse may help to detect or prevent withdrawal during hospital admission. (See "Suicidal ideation and behavior in adults" and "Alcohol withdrawal: Epidemiology, clinical manifestations, course, assessment, and diagnosis".)

Physical examination — The goal of the secondary survey is to identify injuries. This includes the performance of a thorough but efficient physical examination. Use standard precautions against blood- or fluid-borne infection.

Head and face — Inspect and palpate the entire bony structure of the head and face for tenderness, deformity (eg, step-off), and bleeding. Scalp lacerations are easily missed visually but often found by palpation. Be attentive for foreign bodies, such as glass in the scalp after a car accident. (See "Skull fractures in adults" and "Initial evaluation and management of facial trauma in adults".)

Note any signs suggesting basilar skull fracture (eg, hemotympanum (picture 1)). Retroauricular (Battle sign (picture 2)) and periorbital ecchymosis (raccoon eyes (picture 3)) are also indicative of basilar skull fracture but generally do not appear until at least 24 hours after an injury. Look for nasal septal hematoma (picture 4)or cerebrospinal fluid (CSF) leak, which may appear as rhinorrhea or otorrhea.

One bedside test used to evaluate for CSF leak is the "halo" or "ring" sign, which helps predict the presence of CSF in blood. The test consists of placing a drop of bloody fluid on a white bed sheet or filter paper. If CSF is present, the blood remains in the middle of the droplet while a clear halo will surround it. Specificity and sensitivity are not well studied, but the test is considered reasonable and practical, particularly given its simplicity. A positive result increases suspicion for basilar skull fracture [12]. (See "Cranial cerebrospinal fluid leaks", section on 'Assess for presence of CSF in patients with rhinorrhea or otorrhea'.)

Patients with mild traumatic brain injury may not have external signs of trauma. Validated decision tools, including the New Orleans Criteria [13] and the Canadian CT Head Rule [14], can be used to determine the need for neuroimaging [15] with computed tomography (CT). (See "Acute mild traumatic brain injury (concussion) in adults".)

Eyes — Perform an ocular examination including evaluation of pupillary size, shape, reactivity, and extraocular movement. (See "Approach to diagnosis and initial treatment of eye injuries in the emergency department", section on 'Physical examination' and "Overview of eye injuries in the emergency department".)

Look for signs of globe rupture and intraocular hemorrhage (picture 5 and picture 6 and picture 7 and picture 8). (See "Open globe injuries: Emergency evaluation and initial management" and "Traumatic hyphema: Clinical features and diagnosis".)

One under-recognized and potentially devastating injury that may occur with airbag deployment is ocular alkali burns. Check the eye pH in patients with ocular complaints in situations where alkali injury from airbags is a possibility.

Signs concerning for retrobulbar hematoma (picture 9) that can cause optic nerve compression include proptosis (figure 1 and picture 10), sluggish pupillary response, and an afferent pupillary defect (picture 11 and figure 2). Point-of-care ultrasound can be used to rule in retinal detachment (image 1 and image 2) and other traumatic ocular injuries but should not be used to rule out injuries in those patients in whom a high clinical suspicion of injury exists. These patients require emergency ophthalmologic consultation [16]. (See "Overview of eye injuries in the emergency department" and "Retinal detachment".)

Neck — Assume initially that all patients with blunt trauma have sustained an injury to the cervical spine. This assumption may be obviated by appropriate application of clinical decision rules, such as NEXUS or the Canadian C-Spine Rule, or by radiologic evaluation using plain radiographs or CT (algorithm 1). Assessment of the cervical spine following trauma is discussed separately. (See "Cervical spinal column injuries in adults: Evaluation and initial management" and "Suspected cervical spine injury in adults: Choice of imaging".)

Inspect and palpate the entire neck for signs of injury. Injuries to the neck can be missed if the area under the cervical collar is not examined. In-line stabilization is maintained while the collar is removed temporarily for examination of the neck, or for tracheal intubation. The management of penetrating neck trauma is discussed separately. (See "Penetrating neck injuries: Initial evaluation and management".)

Chest — Inspect and palpate the entire chest wall. Pay particular attention to the sternum and clavicles. Injuries at these sites are often missed, and fractures of these bones suggest the presence of further injury, including of intrathoracic structures [17]. Careful auscultation can detect a previously missed small hemothorax, pneumothorax, or pericardial effusion not yet causing tamponade. The NEXUS-Chest criteria may be used to determine whether chest imaging is necessary in an adult following blunt trauma (algorithm 2) [18]. (See "Initial evaluation and management of blunt thoracic trauma in adults".)

Abdomen — Inspect the abdomen and flanks for lacerations, contusions (eg, seatbelt sign (picture 12 and picture 13)), and ecchymosis; palpate for tenderness and rigidity. The presence of a seatbelt sign, rebound tenderness, abdominal distension, or guarding all suggest possible intra-abdominal injury. Note that the absence of abdominal tenderness does not rule out such injury. (See "Blunt abdominal trauma in adults: Initial evaluation and management" and "Initial evaluation and management of abdominal stab wounds in adults" and "Abdominal gunshot wounds in adults: Initial evaluation and management".)

Keep in mind that the abdominal examination is often unreliable (particularly in older adults, patients with distracting injuries or altered mental status, and patients late in pregnancy) and can change dramatically over time. (See "Geriatric trauma: Initial evaluation and management" and "Initial evaluation and management of major trauma in pregnancy".)

Rectum and genitourinary — Inspect the perineum of all patients for signs of injury. Should signs of injury be detected, further evaluation for genitourinary and gastrointestinal injury is needed. (See "Blunt genitourinary trauma: Initial evaluation and management" and "Penetrating trauma of the upper and lower genitourinary tract: Initial evaluation and management" and "Blunt abdominal trauma in adults: Initial evaluation and management".)

Traditionally, the digital rectal examination was considered an essential part of the physical examination for all trauma patients. However, the sensitivity of the digital rectal examination for injuries of the spinal cord, pelvis, and bowel is poor; and false-positive and false-negative results are common [19]. Thus, while routine performance is unnecessary and generally unhelpful, the rectal examination is warranted in cases where urethral injury or penetrating rectal injury is suspected.

If the examination is performed, check for the presence of gross blood (sign of bowel injury), a high-riding prostate (sign of urethral injury), abnormal sphincter tone (sign of spinal cord injury), and bone fragments (sign of pelvic fracture).

Asking patients who are alert to contract their gluteal muscles is not a suitable substitute for the digital rectal examination. It does not test the same nerves as a digital rectal examination, and there is no evidence that the ability or inability to contract these muscles rules out or in, respectively, the presence of bowel, urethral, or spinal cord injury.

Perform a vaginal examination on all patients at risk for vaginal injury (eg, those with lower abdominal pain, pelvic fracture, or perineal laceration) [20]. Clinicians should take care to avoid sustaining an injury from bone fragments if a pelvic fracture is known or suspected.

Musculoskeletal system — Inspect and palpate the pelvis. Ecchymosis over the pelvis or tenderness along the pelvic ring warrants diagnostic imaging. Examination findings (eg, instability) or imaging studies consistent with pelvic ring disruption indicate the need for pelvic immobilization and immediate orthopedic evaluation. Repeat examinations to assess pelvic stability are unnecessary and likely to exacerbate bleeding. (See "Pelvic trauma: Initial evaluation and management".)

Inspect and palpate the entire length of all four extremities looking for areas of tenderness, deformity, or decreased range of motion. This is particularly important in patients with an altered level of consciousness who may not be able to verbalize where they are having pain. Look and palpate closely for possible foot injuries, as missed fractures and ligamentous injuries of the foot are easily overlooked in patients with multiple other injuries or who are otherwise unable to ambulate [21]. Assess and document the neurovascular status of each upper extremity (figure 3 and figure 4 and figure 5 and figure 6) and lower extremity (figure 7 and figure 8). Manipulate all joints thought to be uninjured both passively and actively to verify their integrity; immobilize and obtain radiographs of any area with a suspected fracture.

Note all penetrating wounds, especially those overlying suspected fractures, suggesting an open injury. The treatment of open fractures includes irrigation and debridement, application of a clean dressing, and prophylactic antibiotics. Preliminary low-pressure wound irrigation can be performed in the trauma bay, but definitive irrigation and debridement is performed in the operating room. (See "Osteomyelitis associated with open fractures in adults".)

Post-traumatic compartment syndrome is an important source of patient morbidity. Increasing pain, tense compartments, and pain with passive stretching of the muscles contained within the compartment should prompt immediate measurement of intracompartmental pressures, ideally performed by the consulting orthopedic surgeon determining the need for fasciotomy when this is possible. (See "Acute compartment syndrome of the extremities".)

Neurologic system — The trauma patient's neurologic status can change dramatically over time (eg, from the effects of an expanding subdural hematoma). Serial examinations should be performed and carefully documented.

Hypoxia can exacerbate traumatic brain injury, and rapid airway management may be required in critically ill trauma patients to prevent this [22]. During the primary survey or whenever emergency intubation may be necessary, a brief, focused neurologic examination should be performed before neuromuscular blockade. This examination should include assessment of the pupils and general sensorimotor function of the extremities, and calculation of the Glasgow Coma Scale (GCS) score (table 1). Such assessment provides a baseline for subsequent neurologic evaluation.

During the secondary survey, repeat the pupillary examination and assessments of the GCS score (table 1) and lateralizing signs, and perform a detailed assessment of the sensorimotor function of the extremities [23]. (See "The detailed neurologic examination in adults".)

Skin — Examination of the skin may reveal lacerations, abrasions, ecchymosis, hematoma, or seromas. Look closely at areas where lesions may be missed, such as the scalp, axillary folds, perineum, and, particularly in obese patients, abdominal folds. Do not neglect examination of the back, gluteal fold, and posterior scalp. Penetrating wounds may be present anywhere. The management of skin wounds is discussed separately. (See "Basic principles of wound management".)

Appropriate tetanus prophylaxis should be given as appropriate to patients with breaks in their skin (table 2). (See "Infectious complications of puncture wounds", section on 'Tetanus immunization'.)

Additional imaging

Plain radiographs — Plain radiographs are used during the secondary survey primarily to evaluate the spine, pelvis, and extremities for fractures, dislocations, and foreign bodies. Clinicians can refer to any of a wide range of UpToDate topics discussing specific injuries of the spine, pelvis, and extremities.

Bedside ultrasound — The extended focused assessment with sonography for trauma (eFAST) is used primarily as an adjunct to the primary survey in the unstable trauma patient. The eFAST examination provides critical information during the assessment of complex trauma patients, helps to determine next steps for hypotensive patients, and decreases delays to needed surgical intervention. Performance of eFAST and its role in the primary survey are reviewed in detail separately. (See "Initial management of trauma in adults", section on 'Ultrasound (FAST exam)' and "Emergency ultrasound in adults with abdominal and thoracic trauma".)

While eFAST is included in multiple trauma management algorithms, there is little evidence available to determine the appropriate use or utility of repeat ultrasound examinations for patients that remain hemodynamically stable and without change in their physical examination during the secondary survey or thereafter. Ultrasound examination may be a reasonable first step for hemodynamically stable adult trauma patients being observed in the hospital who develop new or worsening complaints (eg, shortness of breath, abdominal pain). As an example, in a single-center study, sensitivity for intra-abdominal injury was increased from 31 to 72 percent with serial ultrasound examinations performed within 24 hours of presentation [24]. However, ultrasound cannot be considered a definitive study in such circumstances.

eFAST demonstrates high specificity for several important injuries, including pneumothorax and pericardial tamponade. When evaluating for pneumothorax, the sensitivity of eFAST is superior to the supine plain chest radiograph frequently obtained during the initial trauma evaluation [25]. Ultrasound can be useful when screening for other injuries. In a review of studies assessing the use of ultrasound for identifying rib fractures, 12 of 13 studies found ultrasound to be more sensitive than plain radiograph [26]. For sternal fractures, the sensitivity and specificity of ultrasound approaches 100 percent [27,28]. However, a normal eFAST examination in a hemodynamically stable patient does not obviate the need for further imaging if intra-abdominal or intra-thoracic injury is a concern.

Computed tomography, including total-body CT — Multidetector computed tomography (MDCT) has become the modality of choice for imaging trauma patients because of its speed and accuracy. However, most studies of comprehensive whole-body CT scanning ("pan scan") for all patients with significant trauma are methodologically limited and have reached contradictory conclusions [29-34]. Pending further research, we do not advocate comprehensive CT scanning in patients without significant alterations in mental status or suggestive, high-energy mechanisms, and we believe imaging studies should be performed selectively based upon clinical assessment and the mechanism of injury.

Evidence from large observational studies suggests that high-energy mechanisms of injury warrant whole-body CT [35]. Such mechanisms include:

●Motor vehicle collision >60 mph (>100 km/hour)

●Motor bike accident >30 mph (>50 km/hour)

●Falls from heights greater than standing

●Prolonged extrication time (>30 minutes)

●Any penetrating thoracic or abdominal trauma

These mechanisms can be associated with injuries not apparent on physical examination, such as blunt aortic injury. Additional studies support the use of whole-body CT in other uncommon clinical scenarios, such as mass casualty incidents and explosions [36,37].

While whole-body CT scanning may improve outcomes for these high-risk trauma scenarios, we believe it should not be used indiscriminately given the short-term risk of contrast-related renal injury and the long-term risk of radiation-induced cancer, as well as the substantial costs and resource utilization [38]. (See "Contrast-associated and contrast-induced acute kidney injury: Clinical features, diagnosis, and management" and "Radiation-related risks of imaging".)

In an international, multicenter trial, adult trauma patients with evidence of severe injury were randomly assigned to either whole-body CT (n = 541) or selective CT imaging (n = 542) [39]. In-hospital mortality did not differ between groups (whole-body CT 86 [16 percent] versus selective CT 85 [16 percent]), nor did it differ significantly among patients with polytrauma or brain injury.

Some authors advocate whole-body CT for severely injured patients with alterations in mental status. In a retrospective database analysis of 5208 patients in Japan with scores on the GCS ranging from 3 to 12, decreased mortality was noted in patients who received whole-body CT scans [40]. Although further study of the outcomes and cost effectiveness of whole-body CT is needed, the approach may be beneficial in such patients, in whom examination findings are often limited or unclear.

While CT may be useful in the evaluation of patients with blunt trauma [41], it has limited utility for evaluating the trajectory and effects of low-velocity penetrating injury (eg, stab wounds) because of the lack of tissue disruption and gas dispersion (seen with high-velocity injuries) [42] and because injuries to luminal structures are often difficult to detect [43]. Diagnostic laparoscopy may be useful in patients with penetrating injury and signs of peritoneal penetration despite negative CT imaging. Although it is improving, the accuracy of CT for detecting diaphragm injuries is also limited, and depending on the nature of the patient's injuries, additional diagnostic studies may be needed. The use of CT for specific injuries is discussed in detail separately, including topics devoted to particular injuries. (See "Initial evaluation and management of abdominal stab wounds in adults" and "Abdominal gunshot wounds in adults: Initial evaluation and management" and "Pelvic trauma: Initial evaluation and management" and "Recognition and management of diaphragmatic injury in adults".)

Most patients should be hemodynamically stable before CT imaging is performed, and resuscitation should be sufficient to minimize the risk of decompensation while the patient is in the CT scanner. If the patient is unstable, CT imaging is usually deferred. (See "Initial management of trauma in adults", section on 'Emergency computed tomography (CT)'.)

Analgesia and sedation — Injured patients are frequently in significant pain. Do not neglect to provide them with appropriate analgesia if needed and be sure to address acute pain before administering sedation that may mask pain. Analgesia for critically ill patients is reviewed in detail separately; concerns directly pertinent to early pain management in adult trauma are discussed briefly here. (See "Pain control in the critically ill adult patient" and "Approach to the management of acute pain in adults".)

Historically, the most common approach to pain management in trauma patients has been intravenous (IV) opioids. Short-acting medications, such as fentanyl, are generally preferred to avoid adverse hemodynamic effects. Multimodal analgesia is becoming more common to reduce the need for opioids. Such agents include ketamine, ketorolac, and acetaminophen. The results of a few randomized trials suggest that inhaled methoxyflurane provides effective analgesia for trauma patients, but it may not be available in many emergency departments [44,45].

The use of local and regional anesthesia allows for a more immediate and targeted approach to pain control. Single-injection nerve blocks such as femoral nerve block or fascia iliaca compartment blocks for femur and hip fractures, supraclavicular and interscalene blocks for upper extremity fractures and dislocations, and intercostal or plane blocks (serratus anterior and erector spinae) for rib fractures or chest tube placement are a few important examples. These nerve blocks provide high-quality analgesia that is site-specific and avoids systemic side effects. The American College of Surgeons includes regional anesthesia for pain control in its Best Practice Guidelines for Acute Pain Management in Trauma Patients [46]. Nerve blocks are discussed in detail separately. (See "Overview of peripheral nerve blocks" and "Lower extremity nerve blocks: Techniques" and "Upper extremity nerve blocks: Techniques" and "Thoracic nerve block techniques" and "Abdominal nerve block techniques".)

Sedation may be needed for the agitated or injured trauma patient either to facilitate the workup for life-threatening injuries or for patient and staff safety. Altered mental status may be due to intoxication, head injury, shock, or metabolic encephalopathy (table 3 and table 4 and table 5). Sedation in the non-intubated trauma patient must be approached cautiously, particularly before imaging is completed and life-threatening injuries are identified. Short-acting agents, such as midazolam, ketamine, droperidol, or dexmedetomidine, may be used to address agitation. These issues are discussed separately.

Victims of crime — Clinical evaluation and treatment of injuries are the foremost responsibilities of the clinician caring for a trauma patient. When possible, caretakers should consider and act on the need to preserve potential evidence if the trauma may be connected to a crime. As examples, placing removed clothing into paper bags, avoiding cutting through holes in clothing created by penetrating injuries, and careful documentation of injuries may all be significant. (See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department" and "Intimate partner violence: Intervention and patient management".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General issues of trauma management in adults".)

SUMMARY AND RECOMMENDATIONS

●Key principles – Definitive management of a hemodynamically unstable trauma patient must not be delayed to perform a detailed secondary evaluation. (See "Initial management of trauma in adults".)

After initial evaluation (primary survey) and all necessary life- and limb-saving interventions are complete, a systematic evaluation of the patient (secondary survey) is essential for ensuring that important injuries are not missed. The secondary survey includes a detailed history, a thorough but efficient physical examination, and targeted diagnostic studies. (See 'Key principles and commonly missed injuries' above.)

●Commonly missed injuries – Injuries that are often missed in adult trauma patients include the following:

•Blunt abdominal trauma:

-Hollow viscus injury (see "Blunt abdominal trauma in adults: Initial evaluation and management")

-Pancreatoduodenal injuries (see "Management of duodenal trauma in adults" and "Management of pancreatic trauma in adults")

-Diaphragmatic rupture (see "Recognition and management of diaphragmatic injury in adults")

•Penetrating abdominal-pelvic trauma:

-Rectal injury (see "Traumatic gastrointestinal injury in the adult patient")

-Ureteral injury (see "Overview of traumatic and iatrogenic ureteral injury" and "Blunt genitourinary trauma: Initial evaluation and management" and "Penetrating trauma of the upper and lower genitourinary tract: Initial evaluation and management")

•Thoracic trauma:

-Aortic injury (see "Clinical features and diagnosis of blunt thoracic aortic injury" and "Overview of blunt and penetrating thoracic vascular injury in adults")

-Pericardial tamponade (see "Cardiac tamponade")

-Esophageal perforation (see "Overview of esophageal injury due to blunt or penetrating trauma in adults")

•Extremity trauma:

-Fractures (especially in distal extremities) (see "General principles of acute fracture management").  

-Vascular injury (see "Severe lower extremity injury in the adult patient" and "Severe upper extremity injury in the adult patient")

-Acute compartment syndrome (see "Acute compartment syndrome of the extremities")

●History – Prehospital personnel often know important information and should be queried regarding mechanism and history. Often, the history is conveyed while medics and hospital clinicians transfer the patient, and important information may be forgotten or missed. Scenes of accidents can be chaotic, and not all information will be reliable. Potentially important information from the history may include (see 'History' above):

•Mechanism of blunt trauma (eg, seatbelt use, airbag deployment, damage to vehicle, death at scene, height of fall)

•Mechanism of penetrating trauma (eg, length of blade, type of firearm, estimated blood at scene)

•Patient information, including medications (eg, anticoagulants, antiplatelets), allergies, past medical and surgery history (including illness that may have contributed to trauma, such as seizure, arrhythmia, diabetes, or depression)

●Physical examination – Clinicians should perform a thorough but efficient head-to-toe physical examination while using standard precautions against blood- or fluid-borne infection. Important aspects of the examination of each body part are described in the text. (See 'Physical examination' above.)

●Diagnostic imaging – Plain radiographs are used primarily to evaluate the spine, pelvis, and extremities for fractures, dislocations, and foreign bodies. Bedside ultrasound examination may be a reasonable first step for hemodynamically stable patients who develop new or worsening complaints (eg, shortness of breath, abdominal pain) but cannot be considered a definitive study in such circumstances. (See 'Additional imaging' above.)

If significant internal injury is a concern, computed tomography (CT) is the imaging modality of choice in most cases because of its speed and accuracy. We do not advocate comprehensive, whole-body CT scanning (ie, pan scan) in patients without significant alterations in mental status or suggestive, high-energy mechanisms.

●Analgesia and sedation – Appropriate analgesia is essential for injured patients. Options include short-acting opioids (eg, fentanyl) possibly combined with other medications (ie, multimodal analgesia) such as ketamine, ketorolac, and acetaminophen. (See "Pain control in the critically ill adult patient" and "Approach to the management of acute pain in adults".)

Local and regional anesthesia, including single-injection nerve blocks, allow for a more immediate and targeted approach to pain control. (See "Overview of peripheral nerve blocks" and "Lower extremity nerve blocks: Techniques" and "Upper extremity nerve blocks: Techniques" and "Thoracic nerve block techniques" and "Abdominal nerve block techniques".)