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OSCE
-Buster: Secondary Survey Basics & Protocol
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01.14.05 (3 years ago)
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secondary survey entails a head to toe examination of the injured patient, provided the primary survey has been done, all life threatening injuries have been identified and dealt with, and the patient is stable from the point of view of his airway, breathing, circulation, the adjuncts to the primary survey have been done, and history obtained.
Introduce yourself to the patient if he is awake (i.e if an actor is present) and state the purpose of your visit.
Tell the examiner that you would wear gloves and apron and make sure that the patient is stable from Airway ,Breathing and circulation point of view.
Head and Maxillofacial
Look for skull fractures, scalp lacerations, nasal fractures.
Inspect and palpate entire head and face
Evaluate pupils- dilated, reaction to light, equal
Assess eyes for hemorrhage, visual acuity
Inspect ears and nose for CSF and blood. Remember battle sign, raccoon eys.
Inspect mouth for evidence of bleeding soft tissue, lacerations, loose teeth.
Look for maxillofacial injuries, fractures of the mandible, check if the tongue is falling backwards and obstructing the airway.
Cervical spine and Neck
Make sure the C-spine is still protected. Either by collar or in-line manual immobilisation by a trained assistant.
Check for neck injuries, Look for bruises engorged veins lacerations tracheal deviation, hematoma.
Feel the posterior aspect for spinal tenderness, or any obvious step deformity. If there is a cervical collar say to the examiner that you will ask some one to maintain inline stabilization of the neck before you remove the collar to palpate the c-spine). To do this you will need an assistant as this needs 2 people.
Chest
Inspect for chest wall movements any bruises on the chest wall, paradoxical breathing (should really have been picked up in primary survey).
In case of penetrating injuries, look for any wound of entry and wound of exit.
Feel for subcutaneous emphysema, tenderness, symmetry of expansion.
Percuss for resonance, dullness of hemothorax,
Auscultate lungs and listen to heart sounds, symmetry of air entry, adventitious sounds.
Abdomen
Inspect for bruises, distension, penetrating injury wounds,
Palpate for tenderness, guarding, rigidity
Deep palapation for liver and speen
Percuss for fluid
Auscultate for bowel sounds, check which quadrants.
Pelvis.
This may be asked in the PLAB
test.
Ckeck pelvic stability. Do the compression test only once. With your hands on either ASIS and iliac crest, compress the pelvis only once. If there is an unstable pelvic ring injury, you will feel movement in real life. Also external rotation of leg may be a clue.
Perineum/Rectum/Vagina
Bruising of external genitalia
Urethral bleeding, scrotal hematoma. Blood at the urethral meatus should make you suspect urethral injury.
Mention to the examiner that you would want to do a digital rectal examination for high riding prostate, rectal injury, and anal sphincter tone in case of spinal cord injury.
Musculo skeletal – both upper and lower limbs
Check from shoulder to hand, and hip to toes.
Inspect for bruises, deformities, abnormal joint posture, colour of limb, spontaneous finger movements.
Move at the joints, and look for any pain. See if pain is localised.
Check neurovascular status as best as you can. Look for capillary refill. Feel the peripheral pulses. Check the compartments.
Neurological examination
(In a five minute station you may not have time to do this – tell the examiner you would normally do it)
Assess GCS
This may be a separate station. Practice doing the Glasgow coma scale.
Motor and sensory function in both upper and lower limbs.
Anal sphincter function at the end- say you want to do a P/R examination as mentioned above.
Log Rolling
In the end say that you would normally examine the back by log rolling to one side with the help of a few people.
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