A secondary survey begins only after the primary survey is complete, abnormalities have been reassessed, resuscitation is underway, and the patient’s observations are improving. It involves a full head-to-toe assessment, including history, examination, and vital sign review.
At this stage, review the admission history and past medical history—especially prior falls, fracture risk, spinal conditions, and medications (notably antiplatelets or anticoagulants). Combine this with ward staff input and your initial assessment to consider possible causes of the fall.
i. History
- Was there direct impact onto the chest wall? Is the patient experiencing pain, shortness of breath, hypoxia?
ii. Examination
Observe for:
- increased work of breathing, expansion, asymmetrical or abnormal breathing
- contusions and haematomas
- distended neck veins (can be caused by tension pneumothorax or cardiac tamponade).
Feel for:
- crepitus (indicates subcutaneous emphysema due to pneumothorax), expansion, chest wall tenderness, tracheal deviation.
Percuss: is there hyper- or reduced resonance?
Auscultate: symmetrical air entry throughout? Added sounds? Heart sounds?
iii. Investigation
Consider a CT chest to diagnose rib fractures and lung contusions.
iv. Management
Rib fractures in the older patient should raise significant concern, as the incidence of pneumonia and mortality is significantly higher than in younger patients (17). Proactive pulmonary hygiene, e.g. chest physiotherapy within 24 hours (18), and analgesia are the mainstays of treatment to optimise ventilation and reduce complications. Access to regional or neuroaxial blocks is highly recommended, and therefore referral to pain/anaesthetic services to review the patient should be considered (19).
Use of risk scoring, such as the Battle score, can help identify those patients requiring a higher level of care and consideration of treatment escalation plan.
Follow local trauma network pathways for management of rib fractures to ensure access to appropriate specialist input.
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