11.4 Secondary Survey (FGHIJ) & AMPLE History Collection

11.4 Secondary Survey (FGHIJ) & AMPLE History Collection

Clinical Core: The Secondary Survey is a systematic, head-to-toe physical evaluation paired with a comprehensive medical history, conducted ONLY after the Primary Survey (ABCDE) is complete, life-threatening injuries are addressed, and resuscitation parameters are stabilized. The FGHIJ mnemonic structures this phase: Full set of vitals/Family presence, Give comfort measures, History/Head-to-toe evaluation, Inspect posterior surfaces, and Just keep re-evaluating. If at any point during the secondary survey the patient demonstrates physiological instability, the clinical team must IMMEDIATELY pause and revert to the Primary Survey (ABCDE).

The FGHIJ Framework Overview

F — Full set of vitals / Focused adjuncts / Family presence
G — Give comfort measures
H — History (AMPLE) & Head-to-toe physical examination
I — Inspect posterior surfaces (Log-roll protocol)
J — Just keep re-evaluating (Ongoing reassessment)

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F: Full Set of Vitals, Focused Adjuncts & Family Presence

• Full Set of Vital Signs: Re-assess baseline temperature, heart rate, blood pressure, respiratory rate, pulse oximetry, and continuous quantitative wave capnography. Establish dual-site blood pressure monitoring if vascular compromise is suspected.
• Focused Adjuncts:
  • ECG Monitoring: Continuous 12-lead ECG to detect cardiac contusion, dysrhythmias, or ischemic changes.
  • Urinary Catheterization: Place a Foley catheter to monitor hourly urine output (target 0.5 mL/kg/hr in adults, 1.0 mL/kg/hr in pediatrics). Contraindication: Suspected urethral disruption (manifested by blood at the urethral meatus, perineal ecchymosis, scrota/labial hematoma, or a high-riding prostate on rectal exam). If present, perform a retrograde urethrogram prior to catheter insertion.
  • Gastric Tube Insertion: Insert an Orogastric (OG) or Nasogastric (NG) tube to decompress the stomach and minimize aspiration risk. Contraindication: Suspected basilar skull fracture (facial fractures, Battle's sign, raccoon eyes, CSF rhinorrhea/otorrhea). Insert an Orogastric tube to avoid accidental intracranial placement of a nasogastric tube.
  • Diagnostic Imaging: Execute FAST exam (Focused Assessment with Sonography for Trauma), plain radiographs (Chest, Pelvis), and CT scans as clinically indicated.
• Family Presence: Facilitate family presence during trauma resuscitation. Assign a dedicated nurse or chaplain to support, inform, and guide family members through the resuscitation environment.

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G: Give Comfort Measures

Trauma produces severe physical pain and overwhelming psychological distress. Comfort measures must be integrated early once life-threats are controlled:

• Pharmacological Interventions: Titrated IV opioids (Fentanyl, Morphine) or non-opioid multimodal analgesics (IV Acetaminophen, Ketamine infusions). Regional nerve blocks (e.g., femoral nerve block for isolated femur fractures).
• Non-Pharmacological Interventions: Fracture splinting, realigning extremity deformities to relieve vascular traction, applying ice packs, repositioning, and providing calm, clear reassurance.

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H: History Collection (AMPLE Mnemonic)

Obtaining an accurate history provides essential context regarding injury mechanism, underlying baseline physiology, and risk factors for complications.

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H: Head-to-Toe Physical Examination

Systematic anatomical evaluation using inspection, auscultation, palpation, and percussion:

• Head & Scalp: Palpate scalp for lacerations, step-offs, and depressed skull fractures. Inspect eyes for pupil size/reactivity, extraocular movement, hyphema, and retrobulbar hematoma. Inspect ears and nose for blood or CSF leakage (Halo sign on filter paper). Inspect mouth for loose teeth, bone fragments, or malocclusion.
• Cervical Spine & Neck: Remove front of rigid collar while maintaining manual inline stabilization. Palpate posterior cervical spine for tenderness, deformity, or step-offs. Inspect neck for tracheal position, subcutaneous emphysema, JVD, and expanding hematomas. Re-secure collar.
• Chest: Re-evaluate respiratory excursion, inspect for abrasions, contusions, and flail segments. Palpate sternum, clavicles, and ribs for tenderness and crepitus. Auscultate heart and lung sounds.
• Abdomen & Pelvis: Inspect abdominal contour for distension, Grey Turner's sign (flank ecchymosis), or Cullen's sign (periumbilical ecchymosis indicating retroperitoneal or intraperitoneal hemorrhage). Auscultate bowel sounds. Palpate four quadrants for guarding, rigidity, and rebound tenderness.
  • Pelvic Assessment: Assess pelvic stability by applying gentle posterior and medial pressure over the anterior superior iliac spines ONCE ONLY. If movement or pain is elicited, stop immediately; do not repeat pelvic rocking, and apply a commercial pelvic binder to control bleeding.
• Extremities: Inspect all four limbs for deformities, swelling, and wounds. Palpate distal pulses (radial, dorsalis pedis, posterior tibial), capillary refill, temperature, motor function, and sensation. Monitor for Compartment Syndrome (the 6 Ps: Pain out of proportion to injury, Paresthesia, Pallor, Paralysis, Poikilothermia, Pulselessness).

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I: Inspect Posterior Surfaces (Log-Roll Protocol)

Failure to inspect the patient's posterior surface risks missing penetrating wounds, occult spinal deformities, or soft tissue injuries.

Log-Roll Protocol Execution

• Team Requirement: Minimum of 4 trained team members.
  • Leader (Position 1): Positioned at the patient's head; maintains manual inline stabilization of the C-spine and calls all movement commands.
  • Positions 2 & 3: Positioned at the side of the patient, controlling the chest, pelvis, and legs.
  • Position 4: Performs the physical inspection and rectal exam.
• Procedure: On the leader's count of three, the team rolls the patient as a single rigid unit toward the team members on the side.
• Inspection & Palpation: Inspect back, buttocks, perineum, and posterior legs for lacerations, ecchymosis, step-offs, and tenderness. Perform Digital Rectal Exam (DRE) if indicated to assess sphincter tone, mucosal integrity, and prostate position.
• Spine Board Removal: Remove the long spine board immediately after completing posterior inspection to prevent pressure injuries, tissue ischemia, and severe patient discomfort. Log-roll the patient back onto a firm trauma mattress while maintaining inline cervical stabilization.

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J: Just Keep Re-Evaluating

The Secondary Survey is an ongoing process. Continual re-evaluation is imperative because trauma is dynamic.

• Frequently re-assess vital signs, GCS, and pupillary response (every 5 minutes for unstable patients, every 15 minutes for stable patients).
• Re-assess response to fluids, blood products, and pain interventions.
• Track serial laboratory findings (arterial blood gases, lactate, base deficit, hemoglobin, coagulation profiles).
• If the patient exhibits unexplained hypotension, hypoxia, or neurological decline, ABORT the secondary survey and return immediately to the Primary Survey (ABCDE).