Synopsis
Use repeated structured assessment, definitive report reconciliation and closed-loop handover to detect injuries obscured by resuscitation, altered consciousness, distracting pain or transfers.
- Schedule a documented tertiary survey after initial resuscitation and imaging, commonly within 24 hours, and repeat when the patient is awake, sober or able to cooperate.
- Start with interval events and another CABCDE review; any deterioration takes priority over completing the checklist and triggers immediate treatment.
- Rebuild the mechanism and AMPLE history from patient, witnesses, ambulance and records, including anticoagulants, baseline function, pregnancy and pre-existing deficits.
- Perform a complete head-to-toe examination with every limb exposed, wounds mapped and joint, tendon, nerve and distal perfusion findings compared with prior documentation.
- Review all images, not only reports; reconcile preliminary and final interpretations, adequacy of coverage and clinical-radiological discordance with a senior radiologist.
- Check tubes, lines, drains, splints, binder and pressure areas, and confirm that every device still has an indication, position check and removal plan.
- Maintain a single problem list containing confirmed injuries, unresolved possibilities, incidental findings, pending tests and the named team responsible for each action.
- At transfer and discharge, communicate final diagnoses, restrictions, warning signs and follow-up directly; audit delayed diagnoses to improve systems rather than conceal them.
Key red flags
New hypoxia, shock, falling GCS, focal deficit, escalating pain or loss of distal perfusion after admission represents active deterioration, not a routine tertiary-survey finding.
Persistent focal tenderness, swelling, inability to bear weight or unexplained anaemia despite negative initial imaging requires re-examination and senior radiology or specialty review.
An outstanding preliminary report, unreviewed transferred image, undocumented wound or uncertain ownership of an incidental finding is a system-level missed-injury risk requiring closure.
Investigation priorities
Identify incomplete assessments, pending results and discrepancies across transitions.
Management branches
Initial resuscitation and urgent treatment are complete enough for systematic reassessment.
- Schedule the survey within the trauma pathway and identify which regions or history remain unreliable because of sedation, pain, intoxication or urgent intervention.
- Collect ambulance, emergency, operative and transfer records, preliminary and final imaging reports, laboratory trends and current device lists before bedside review.
- Ask the patient and collateral sources for interval symptoms, baseline function and a reconstructed AMPLE history.
- If the patient cannot cooperate, document limitations and set a specific trigger and owner for repeat examination after waking or stabilisation.