A 32-year-old male is brought to the trauma bay following a motor vehicle collision. During the secondary survey, all of the following investigations are routinely performed EXCEPT:

Explanation

## Secondary Survey: Investigations and Imaging ### The Secondary Survey Framework The secondary survey is a **systematic head-to-toe examination** performed after the primary survey is complete and life threats have been addressed. It includes focused history, physical examination, and **selective imaging** based on mechanism of injury and clinical suspicion. **Key Point:** NOT all trauma patients require CT imaging of all body regions. Imaging is **risk-stratified and mechanism-based**, not routine for every patient. ### Appropriate Secondary Survey Investigations | Investigation | Indication | Timing | |---|---|---| | **FAST exam** | Suspected intra-abdominal or pericardial bleeding | Performed at bedside during primary/secondary survey | | **Pelvic X-ray** | Hemodynamic instability, abdominal trauma, pelvic pain | Part of trauma imaging protocol | | **Selective CT imaging** | Based on mechanism, clinical findings, and injury pattern | Only if clinically indicated | | **Urinalysis** | Suspected rhabdomyolysis, crush injury, or myoglobinuria | Routine in crush injuries, prolonged entrapment | | **Serum creatinine** | Baseline renal function, assess for AKI | Routine labs | ### Why Routine CT of All Body Regions is WRONG **High-Yield:** ATLS and modern trauma protocols emphasize **selective imaging** based on: 1. **Mechanism of injury** — high-energy vs. low-energy trauma 2. **Clinical findings** — tenderness, distension, neurological signs 3. **Hemodynamic stability** — unstable patients may not tolerate CT 4. **Radiation exposure** — unnecessary imaging increases cancer risk **Mnemonic for Trauma Imaging Triage — FAST-FIRST:** - **F**AST (bedside ultrasound) — immediate, no transport - **A**irway/Breathing/Circulation stabilized first - **S**elective imaging based on mechanism - **T**ransport to CT only if stable - **F**ocused exams guide which regions to image - **I**nstability → FAST, pelvic X-ray, portable chest X-ray - **R**outine head/C-spine/chest/abdomen/pelvis CT only if indicated - **S**table patient with high-energy mechanism → consider full-body CT - **T**ransfer to definitive care with appropriate imaging ### Clinical Scenarios for Imaging ```mermaid flowchart TD A[Trauma patient]:::outcome --> B{Hemodynamically stable?}:::decision B -->|No| C[FAST exam + portable X-rays]:::action B -->|Yes| D{High-energy mechanism?}:::decision D -->|Yes| E[Consider whole-body CT]:::action D -->|No| F[Selective imaging based on exam]:::action C --> G{Positive FAST or X-ray?}:::decision G -->|Yes| H[Proceed to OR or ICU]:::action G -->|No| I[Reassess clinically]:::action ``` **Clinical Pearl:** A stable patient with a low-energy mechanism (e.g., fall from standing height, minor motor vehicle collision at low speed) may not require CT imaging at all — clinical examination and serial reassessment are often sufficient.