Tertiary survey and missed injury prevention

A tertiary survey is a planned reassessment after the primary and secondary surveys, initial imaging and urgent treatment. Its purpose is to discover injury that was obscured or not yet apparent and to reconcile the entire clinical record. It is not simply a repeated form. Timing follows local trauma policy, often within twenty-four hours, with another examination after extubation, sobriety or adequate analgesia if the first tertiary assessment remains unreliable.

Begin with what has changed. Review pre-hospital mechanism and physiology, interventions, operations, transfusion, imaging, laboratory trends and new symptoms. Repeat ABCDE before detailed examination. A new oxygen requirement, falling haemoglobin, abdominal distension, reduced consciousness or limb neurovascular change triggers urgent problem-specific care. The tertiary survey must not normalise deterioration by labelling it expected after trauma or surgery.

Reconstruct history using AMPLE and collateral information. Confirm allergies, medicines—especially anticoagulants, insulin, steroids and antiepileptics—past disease, pregnancy possibility, last intake and exact events. Establish baseline cognition, mobility, neurological deficit and dominant hand. Ask about pain in areas not previously discussed, visual or dental symptoms, hearing change, numbness, weakness and inability to load a limb. Review safeguarding and self-harm concerns where mechanism or context suggests them.

The examination is systematic and comparative. Inspect and palpate scalp, face, mouth, neck, chest, abdomen, pelvis, perineum when indicated, spine and every limb. Map all wounds and bruises. Move joints only when safe, assess tendon function and named peripheral nerves, and document pulses, capillary refill and temperature. Check posterior surfaces with movement tailored to pelvic, spinal and haemodynamic risk. A painful immobilised joint still needs a plan for later examination.

Imaging reconciliation is central. Review scout, reconstructions and all imaged regions with the report, checking that clinical areas were covered and that a binder, splint or positioning did not conceal abnormality. Confirm that every preliminary interpretation has a final authorised report and every addendum reached the treating team. If focal signs conflict with imaging, discuss senior re-review, additional views, CT, MRI or ultrasound according to the suspected tissue rather than accepting a generic negative result.

Devices and treatments can create or conceal injury. Check tracheal tube and drain positions, line sites, splint pressure, binder duration, tourniquet time, catheter indication and skin beneath equipment. Reassess distal neurovascular findings after reductions and operations. Reconcile antibiotics, tetanus, thromboprophylaxis and home medicines. Ensure restrictions on weight bearing, spinal movement, feeding and therapy reflect the latest definitive diagnosis, not an obsolete provisional plan.

Close the loop through one current problem list. Classify each item as confirmed, excluded, still possible, incidental or treatment-related; assign a named specialty, action and deadline. Explain newly discovered injury and altered plans to the patient and family. At transfer, send images and final reports, not merely a summary. At discharge, provide red flags and appointments. Record delayed diagnoses transparently and review them through trauma governance to correct recurrent handover, imaging or examination failures.