Trauma Secondary Survey – Paediatric Patients

The secondary survey is a head-to-toe, systematic assessment performed after the primary survey and initial resuscitation (ABCDE) are complete and life threats are being managed. In children, it should be done gently, with parental involvement where possible, and repeated as the child’s condition evolves.

General Assessment & Head-to-Toe Examination

Observe the child from the end of the bed first, then proceed methodically. Look, listen, and feel.

• General appearance & level of consciousness: Note distress, agitation, lethargy, abnormal behaviour, or reduced interaction. Children may show age-specific signs (clingy, inconsolable, unusually quiet).
• Skin examination: Inspect for bruises, abrasions, lacerations, contusions, burns and pattern injuries. Consider that bruising may be harder to see in darker skin tones – use good lighting and a systematic approach.
• Head & neck: Look for scalp lacerations, boggy swellings (possible underlying skull fracture), facial trauma, periorbital bruising, CSF leak from nose/ears. Palpate scalp and facial bones gently. Maintain cervical spine precautions where indicated.
• Chest: Inspect for bruising, abrasions, seatbelt marks, asymmetry, paradoxical movement (flail segment). Palpate for tenderness or crepitus. Auscultate for equal air entry and added sounds – think pneumothorax, haemothorax or pulmonary contusion.
• Abdomen: Look for distension, bruising (e.g. seatbelt sign), abrasions. Palpate gently for tenderness, guarding, or rigidity. High suspicion is needed for intra-abdominal injury, especially after high-energy mechanisms.
• Pelvis: Assess carefully for tenderness or instability; avoid repeated springing of the pelvis. Suspect pelvic fracture with pain on movement, haemodynamic instability, or high-risk mechanism.
• Extremities: Inspect and palpate each limb for deformity, swelling, tenderness, and wounds. Check joint range of motion and distal neurovascular status (pulses, capillary refill, sensation, movement). Be alert for injuries not matching the history (possible non-accidental injury).
• Back & spine: Logroll the child (with spinal precautions if indicated) to inspect the back for bruising, wounds, deformity, or step-offs along the spine.

Neurological Assessment

The neurological portion of the secondary survey expands on the “D” in the primary survey and should be repeated frequently.

• Level of consciousness & orientation: Use AVPU (Alert, responds to Voice, responds to Pain, Unresponsive) and a paediatric Glasgow Coma Scale (pGCS) where possible. Look for confusion, agitation, lethargy, or unresponsiveness.
• Pupils: Check size, symmetry, and reaction to light. Anisocoria or sluggish/absent reaction can be a sign of raised ICP or focal brain injury.
• Motor & sensory function: Assess spontaneous movement of all limbs, tone, and power (as age-appropriate). Look for asymmetry, weakness, or abnormal posturing. Check sensation to light touch where the child can cooperate.

Paediatric GCS – general guide:

Use your local paediatric GCS chart for exact age-specific descriptors and scoring. A total GCS ≤ 8 is generally considered severe and requires urgent senior input and airway consideration.

Apgar Scoring for Newborns

The Apgar score is a quick assessment performed at 1 and 5 minutes after birth (and sometimes later) to give a snapshot of a newborn’s condition and guide immediate interventions. It is not a long-term prognostic tool.

APGAR Components

Each component is scored 0, 1, or 2; the total score ranges from 0–10.

• A – Appearance (colour): blue/pale; body pink–extremities blue; completely pink.
• P – Pulse (heart rate): absent; < 100 bpm; ≥ 100 bpm.
• G – Grimace (reflex irritability): no response; grimace; active response (cry, cough, sneeze).
• A – Activity (muscle tone): limp; some flexion; active movement.
• R – Respiration: absent; slow/irregular; strong cry/regular breathing.

Interpretation

• 7–10: Generally reassuring.
• 4–6: May need some resuscitative support and closer observation.
• 0–3: Indicates significant compromise; requires immediate resuscitation.

Additional Assessments and Tests

Investigations are guided by mechanism, clinical findings and local trauma protocols. Common options include:

• Imaging: X-rays, ultrasound (e.g. FAST), CT scans where indicated to detect fractures and internal injuries.
• Laboratory tests: FBC, U&E, liver function, coagulation studies, blood type and cross-match, arterial/venous blood gas.
• Cardiac monitoring: ECG and continuous monitoring in moderate–severe trauma and suspected cardiac involvement.
• Urinalysis: Screening for haematuria or infection; may suggest urinary tract or renal injury.
• Serial observations: Frequent vital signs and pain scores to detect trends or subtle deterioration.

Documentation and Ongoing Monitoring

Accurate documentation is critical in paediatric trauma for both clinical care and medico-legal reasons. Record:

• Mechanism of injury, pre-hospital care, and timeline of events.
• Primary and secondary survey findings, including neurological status and pain scores.
• All interventions, medications, fluids, and the child’s response.
• Discussions with caregivers and other team members.

Continue to reassess ABCDE and pain. Any changes in the child’s status must be promptly communicated to the team, and the management plan adapted.

ATLS Manual

For more detailed trauma guidance, see: View ATLS Manual (PDF)