Secondary Survey of Resuscitation
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As the severity patients condition on presentation increases, so does the relative importance of the physical examination. Thus, both primary and secondary surveys in resuscitation are primarily directed at physical findings. There is a significant
| Pulse oximetry |
Pulse oximetry is considered "a fifth vital sign". It is tremendously
helpful when it can be recorded accurately; however, in severe
shock states diminished pulses and cool extremities may make it
impossible to obtain. Pulse oximetry probes can be placed on
the earlobes as well as the extremities. Falsely reassuring
readings may occur with abnormal hemoglobins, such as with
CO toxicity or methemoglobinemia. |
| Neurological status |
 Neurological status Mental status has also been referred to as a vital sign. A progressive alteration in mental status has a broad differential diagnosis,
but within the context of an individual resuscitation its significance is often clear. In shock states, it may represent worsening
cerebral perfusion or hypoxia and the need for more aggressive
resuscitative efforts. In patients with intracranial pathology, it may
represent brain herniation and the need for lowering intracranial
pressure, especially when combined with localizing signs. When
toxic, metabolic and endocrinologic derangements are present,
worsening electrolyte abnormalities or hypoglycemia may be
present and a multitude of interventions, ranging from simple
dextrose administration to hemodialysis may be necessary. |
| Pain scales |
Signs of pain, both verbal and non-verbal, should not be ignored.
These may indicate the need to search for an occult injury such
as a fracture or penetrating trauma that may change the direction
of the resuscitation. Pain can also be used as a guide to the
success of resuscitation, as is the case when chest pain and
dyspnea resolve with adequate treatment of myocardial ischemia
or pulmonary edema. |
Continuous cardiac
monitor |
Continuous telemetry is essential in any resuscitation to monitor
for life-threatening dysrhythmias and responses to treatment. |
| Electrocardiography |
|
| 12-lead EKG |
The 12-lead EKG is enormously helpful in resuscitation. It has
utility in both cardiac and non-cardiac emergencies. EKG
findings may be either the cause or result of the underlying
condition requiring resuscitation. Attention is directed at signs of
myocardial infarction and ischemia, electrolyte derangements
and clues to other life threatening pathologies such as decreased
voltage in cardiac tamponade or signs of acute right-sided heart
strain in pulmonary embolus. Certain drug toxicities have
characteristic EKG findings as well. |
| Additional EKG leads |
Right-sided precordial leads (RV3 and RV4) may be critical in
identifying the cause of cardiogenic shock as right ventricular
MI. Posterior leads (V8 and V9) may unmask the presence of
posterior MI. |
| Bedside laboratory tests |
|
| Blood glucose |
Critically low blood glucose results from many different life-
threatening processes and must be addressed immediately. The
finding of high blood glucose is similarly important and may
help tailor early resuscitative efforts. Blood glucose should be
measured in all patients with altered mental status and, when
abnormal, frequent rechecks are indicated. |
Hemoglobin or
hematocrit |
Both of these tests express hemoglobin concentration and, assuch, can appear misleadingly high in acute hemorrhage before volume resuscitation has occurred. These tests are subject to error, and repeat and serial values should be obtained when they are utilized to guide resuscitation. |
| Pregnancy test |
A positive serum or urine pregnancy test may lead to a diagnosis of the underlying pathology in a critically ill female. In addition, this finding may affect decisions made during resuscitation with
respect to monitoring, emergent procedures, the selection of medications and imaging studies and disposition. |
Blood type and
crossmatch |
This is an essential test that must be performed to facilitatetreatment with blood and blood products in a multitude of resuscitations, both traumatic and non-traumatic. The infusion of
fresh frozen plasma and platelets also requires crossmatching. |
| Bedisde electrolytes |
The availability of blood electrolyte analysis at the bedside is
increasing and very helpful. Knowledge of the electrolytes in the
first few minutes may enable critical interventions to be started
early. In some cases, such therapies should be started even
before electrolytes are available (e.g., giving emergent treatment
for hyperkalemia in the presence of a typical EKG and history) |
| Arterial blood gases |
Although an assessment for hypoxia and hypercarbia should be
made clinically, arterial blood gases have a special role when
pulse oximetry is not possible or unreliable, to assess for certain
toxins such as carbon monoxide and methemoglobin, and to
assist with mechanical ventilation management. The pH and
base excess values obtained from blood gases (including venous
gases) may also be used as an adjunct to gauge the severity of
shock states and response to resuscitative efforts. |
Pooled venous
oxygen levels |
Requires the placement of central venous line with a specialprobe. May be used to gauge the severity and response to resuscitation. |
| Other bedside assays |
Although there are many potential pitfalls in their application
and interpretation, bedside assays may be extremely helpful. In
some cases, elevated cardiac markers may confirm suspicion of
an MI. A variety of toxicological tests are now available, and, in
the appropriate circumstances, bedside screening assays for
various bioterrorism agents. |
| Diagnostic imaging |
|
| Chest film |
An early portable chest X-ray is of paramount importance. It
may, by itself, identify the type of shock state present (e.g., the
finding of cardiomegaly and pulmonary edema in cardiogenic
shock, tension pneumothorax in obstructive shock, hemothorax
or pleural effusion in hypovolemic shock). It may also be helpful
in pulmonary embolism�less for the presence of rare signs such
as Hampton�s Hump and Westermark�s sign than for the absence
of significant findings pointing to alternative diagnoses such as
pulmonary edema and pneumonia. A widened or abnormal
mediastinum may represent aortic rupture or dissection. |
| Cervical spine films |
The presence of cervical spine trauma may help explain the
findings of shock, neurological deficits and ventilatory failure. |
| Pelvis |
This is an important film that may identify a source of hemorrhage and occult trauma. |
| Lateral soft tissue neck |
This film may identify mechanical airway obstruction, a source
of septic shock or foreign bodies. |
| Abdominal films |
Although rarely helpful in resuscitation, a single abdominal film may show a pattern of calcification of the aorta in the case of a ruptured aortic aneurysm and the presence of radiopaque toxic
ingestions such as iron, phenothiazines and enteric release
tablets. |
| Ultrasonography |
Bedside ultrasound is ideal for use in resuscitation because of its
availability, repeatability and speed.
Bedside echocardiography can be used to reveal the presence of
various shock states by identifying cardiac tamponade, global
hypokinesis or right ventricular outflow obstruction. In the future,
it may be utilized by emergency physicians to evaluate valvular
lesions and dyskinesis. It can also assist with the distinction
between pulseless electrical activity and cardiac standstill
(electromechanical dissociation). This may help to determine
when resuscitation efforts should be terminated.
Abdominal ultrasound may quickly identify free-fluid (most
importantly, hemorrhage) in the peritoneal cavity. Hemothorax,
as well as pleural effusions, may also be identified during the
focused assessment with sonography for trauma (FAST)
examination.
The aorta may be quickly imaged to assess for abdominal aortic
aneurysm.
Pelvic ultrasonography in the female patient with intraperitoneal
hemorrhage may further delineate the source of shock. The
absence of an intrauterine gestation in a pregnant female may
represent ectopic pregnancy, whereas its presence may indicate
a bleeding cyst, heterotopic ectopic pregnancy or occult trauma.
Ultrasonography also has a role in assisting with emergency
procedures, such as line placement and pericardiocentesis. |
| Cranial CT |
Of all CT studies, cranial CT, because of its speed and lack of need for contrast, may be performed even in the unstable patient. It may identify the need for emergent surgical decompression, measures to lower intracranial pressure or the search for other causes of altered mental status, all which may change the course of a resuscitation. |
overlap in the examination during the primary and secondary surveys, but the secondary survey tends to reveal those features which would be missed unless specifically looked for. In the context of an individual resuscitation, some of these findings may be very important or even critical.
