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Clinical Practice Guidelines

Trauma: Tertiary Survey

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  • See also

    Trauma - primary survey
    Trauma - secondary survey

    Key Points

    1. The principal aim of a tertiary survey is to ensure all injuries are recognised, including those injuries not identified during primary and secondary survey
    2. Tertiary survey should be commenced within 24 hours of arrival
    3. The survey includes a thorough top-to-toe, front-to-back physical examination and review of all investigations
    4. Ensure documentation, appropriate management and referral to relevant specialty teams for all injuries
    5. Consider the possibility of child abuse or neglect for all children presenting with trauma

    Background

    • The performance of the tertiary survey reduces the risk of missed injuries in children with severe trauma
    • The timing of the tertiary survey should take place after the initial resuscitative and investigative phase. Typically, this will occur between 4-24 hours following the presentation
    • A delayed injury is a new injury identified at the tertiary survey 
    • A missed injury is any injury identified after the tertiary survey is complete, or after the child is discharged

    Assessment

    • Children presenting with severe trauma should have a tertiary survey commenced within 24 hours of arrival
    • Severe trauma is defined as having had:
      • a trauma team activation
      • an admission to PICU
      • delivery of definitive trauma management by two or more specialty teams
    • The tertiary survey is the responsibility of the admitting team, who may delegate the task to any clinician with the appropriate skills
    • If a child's critical condition prevents the tertiary survey being completed within 24 hours of arrival, this must be documented as ‘not performed’ or ‘incomplete’. This documentation should include the basis for being unable to complete the tertiary survey, as well as the plan to complete the tertiary survey

    Examination

    • Develop a rapport with the child, offer reassurance and explain what you are doing. Encourage the carer to comfort and distract the child
    • Keep the child warm. Remove clothing as required to complete a full examination and ensure the child is covered when the tertiary survey is complete
    • Assess vital signs and GCS. Children who are unable to communicate pain are at increased risk of missed injuries

    Head and face

    • Face, scalp and skull
      • Bleeding, lacerations, bruising, swelling, depressions/irregularities in the skull (to suggest skull fracture), bruising behind the ears (Battle’s sign: may indicate base of skull fracture), periorbital bruising (“Racoon eyes”: may indicate base of skull fracture)
    • Eyes
      • Palpate bony margins of orbit for fracture. Test eye movements, pupillary reflexes and vision. Inspect for penetrating injury (see Penetrating eye injury), irregular iris, foreign bodies, subconjunctival haemorrhage, hyphema
    • Ears
      • Bleeding, blood behind tympanic membrane (suggestive of base of skull fracture), tympanic membrane perforation (in blast injuries). Assess hearing
    • Nose
      • Bleeding, septal haematoma, CSF leak, palpate for bony crepitus or deformity
    • Mouth
      • Wounds to the lips, gums, tongue or palate
    • Teeth
    • Jaw
      • Identify pain, trismus or malocclusion and palpate for bony step

    Neck

    Inspect neck, whilst maintaining manual in-line stabilisation if C-spine has yet to be cleared. Open collar to do this
    Examine anterior neck for blunt or penetrating trauma by looking/feeling for the following (TWELVE-C):

    • Tracheal deviation
    • Wounds
    • Emphysema (subcutaneous)
    • Laryngeal tenderness/crepitus
    • Venous distension
    • OEsophageal injury (unlikely if child can swallow easily)
    • Carotid haematoma/bruits/swelling

    Assess C-spine if not completed in secondary survey. See C-spine assessment

    Chest

    • Observe work of breathing and effectiveness of breathing
    • Assess for any asymmetrical or paradoxical chest wall movement
    • Inspect for signs of injury such as bruising, seatbelt marks, wounds  
      • In cases of stabbing or other assault, look for ‘hidden’ wounds by checking areas such as axillae
      • Palpate for bony tenderness over ribs, crepitus (indicating subcutaneous emphysema)

    Abdomen

    • Inspect for bruising (eg from seatbelt or handlebar injury), abdominal distension
    • Palpate for signs of peritonism such as guarding or rigidity
    • Palpate for tenderness over the liver, spleen, kidneys and bladder

    Pelvis and perineum

    • Inspect for grazes over iliac crests, bruising, deformity
    • Feel for pain or crepitus on gentle palpation of bony prominences
    • Assess for pelvic instability by gentle compression of the iliac crests
      Tertiary Survey
    • Stressing/springing the pelvis is not recommended
    • Genital, if pelvic injury or high chance of injury needs external examination. Should include perineum

    Limbs

    Most common missed injuries, especially hands

    • Inspect for wounds, bruising, open fractures, burns, abrasions
    • Feel for soft tissue and bony tenderness or swelling, joint movement and stability
    • Examine pulses and perfusion
    • Examine sensory and motor function of any nerve roots or peripheral nerves that may have been injured
    • Assess gait if possible

    Back and spine

    • A log roll should be performed if spinal precautions required
    • Inspect entire length of back and buttocks
    • Palpate then percuss spine for tenderness
    • Palpate scapulae and sacroiliac joints for tenderness

    Management

    Investigations

    Imaging

    • Request imaging for any new injuries identified
    • Review images and reports of radiology already performed and review with radiology department if required

    Laboratory results

    • Review results of all blood tests and ensure abnormalities have been addressed

    Urinalysis/urine microscopy

    • Frank haematuria is highly suggestive of a urinary tract injury and should be further investigated
    • Isolated microscopic haematuria is not highly sensitive or specific for renal injury. Need for imaging should be guided by clinical suspicion, taking into consideration clinical signs and mechanism of injury

    Treatment

    • Document all injuries
    • Establish a plan for ongoing care of all injuries identified
    • Clearly articulate the findings to the admitting team and escalate where necessary
    • Further imaging should be considered if indicated

    Consider consultation with local paediatric team when

    • Child abuse or neglect is suspected
    • Child has complications or comorbidities that require paediatric medical care

    Consider consultation with local surgical team when

    • Child has injuries requiring surgical management, but not meeting threshold for transfer to trauma centre

    Consider transfer when

    • All children with major trauma should be transferred to a major trauma service for definitive management. This should be done in consultation with the local pre-hospital and inter-hospital transfer guidelines 
    • The child requires care beyond the comfort level of the hospital 

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Parent information sheets

    Fractures
    Hard collar
    Brain injury series

    Additional notes

    RCH Paediatric Trauma Manual
    RCH Paediatric Fracture Guidelines
    NSW Institute of Trauma and Injury Management

    Last updated November 2023

  • Reference List

    1. Avarello JT and Cantor RM. Pediatric major trauma: an approach to evaluation and management. Emergency Medicine Clinics of North America. 2007. 25(3):803-36.
    2. Casson C et al. Does microsopic haematuria after paediatric blunt trauma indicate clinically significant injury? Journal of Surgical Research. 2019. 241: 317-322.
    3. Choi PM et al. Missed Injuries and Unplanned Readmissions in Pediatric Trauma Patients. Journal Pediatric Surgery. 2017; 52(3): 382-385.
    4. Keijzers GB et al. The effect of tertiary surveys on missed injuries in trauma: a systematic review. Scandanavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20:77
    5. Kenefake ME et al. Nuances in Pediatric trauma. Emergency Medicine Clinics of North America. 2013. 31(3):627-52.
    6. Trauma Victoria, Major Trauma Guidelines and Education, https://trauma.reach.vic.gov.au/