Trauma patients present a unique
challenge to the healthcare team as life-threatening injuries
must be rapidly identified and treated with consideration given
to clinical presentation, mechanism of injury, age, co-morbid
factors and pre-existing medical conditions (1). Often, these
patients are uncooperative or unresponsive and are unable to furnish
valuable event and medical history data. The American College
of Surgeons developed the Advanced Trauma Life Support (ATLS)
course to evaluate the trauma patient with a systematic approach
that utilizes primary and secondary surveys to ensure that all
injuries are identified. However, not all injuries are detected
by these two surveys. In fact, between 2 to 50% of combined life
threatening and non-life threatening injuries are missed (2).
Centers that examined the incidence of missed injuries concur
that patients who sustain blunt trauma have a higher rate of missed
injuries than those who sustain penetrating trauma (3). As a result,
a tertiary trauma survey (TTS) is increasingly being implemented
to avoid missed injuries.
“What” is the TTS?
The tertiary trauma survey is defined by the ACS as a patient
evaluation that identifies and catalogues all injuries after the
initial resuscitation and operative intervention (4). The timing
of this survey is institution specific, but typically occurs within
twenty four hours after admission and is repeated when the patient
is awake, responsive, and able to communicate any complaints. The
tertiary trauma survey is a comprehensive review of the medical
record with emphasis on the mechanism of injury and pertinent co-morbid
factors such as age. It includes the repetition of the primary and
secondary surveys, a review of all laboratory data, and a review
of radiographic studies with an attending radiologist (2). Any new
physical findings require further studies to rule out missed injuries.
“When” & “How”
should the TTS be performed?
Overall, the evidence suggests further longitudinal prospective
studies are needed to identify the appropriate timing of the tertiary
trauma survey. However, current practice is to perform the TTS within
24 hours of admission and also prior to discharge to reassess identified
injuries, to confirm suspected injuries, and to identify occult
injuries (4). After this complete review of the patient’s
medical record and when all injuries are identified a comprehensive
care plan is developed. At San Francisco General Hospital the standardized
TTS is performed by the Trauma Nurse Practitioners on Critical Care
admissions within 24 hours and repeated prior to discharge. For
patients admitted to the Ward, a TTS is performed prior to discharge.
The physical assessment is a complete “head to toe”
evaluation with a focus on mechanism of injury. All radiographic
imaging and laboratory value trends are then reviewed. If a new
injury is suspected then further studies are obtained. A standardized
worksheet that becomes part of the patient’s hospital record
is completed to catalogue all injuries.
Download the TTS form in Adobe
PDF or Microsoft Word
“Why” perform a Tertiary Survey?
Systematic re-evaluation of the multiply-injured trauma patient
with the tertiary trauma survey revealed missed injuries that had
the potential to be a clinically significant factor on patient morbidity
and mortality (4). Furthermore, these studies agreed that to understand
the etiology of missed injuries and to appreciate the significance
of early detection improved morbidity and mortality in this patient
population. The incidence of missed injuries ranged from 9% to 65%
of admitted blunt trauma patients in these studies (2,5). The most
frequently missed injuries in these studies were extremity and pelvic
fractures, spinal cord and head injuries, and abdominal and nerve
injuries, ranging from 28% to 85% of detected injuries.
Several factors have been identified as delaying the identification
of injuries during the initial evaluation in the emergency department.
These primary contributing factors included an altered level of
consciousness from a closed head injury, alcohol or drug intoxication,
use of sedation and paralytic agents for intubation, and hemodynamic
instability that required emergent operative evaluation (5). Neighboring
or “distracting” injuries and delayed transfer or presentation
to a trauma center have also been associated with delayed diagnoses
System factors also contribute to the missed injury rate - inadequate
clinical assessments and radiology errors being the most commonly
cited (6). Biffl, Harrington, & Cioffi (2003) furthered these
claims and demonstrated that clinically significant missed injuries
were detected within 24 hours of admission with Implementation of
standardized tertiary trauma surveys has been shown to significantly
reduced this delayed and missed injury rate (7).
“Who” should perform the Tertiary
Formal tertiary trauma surveys are performed by a myriad of providers
who have included bedside critical care nurses, nurse practitioners
and physicians. The literature recommends that a multiply-injured
patient be evaluated with serial examinations by a provider with
advanced skills. This approach provides care continuity and detects
subtle changes that may indicate missed injuries and their sequelae
Further investigation is needed to determine the most appropriate
person to perform this evaluation. A designated trauma team member
should have advanced assessment skills, provide consistent and frequent
evaluations of the multiply-injured patient and be able to review
laboratory findings and diagnostic studies with a radiologist (2).
This role is ideally suited for a trauma nurse practitioner (TNP).
As a member of the trauma team, they utilize their technical skills
and experience to provide consistent, competent, and comprehensive
care to the multiply-injured trauma patient. Since the TNP is an
integral part of the process, they are well-positioned to detect
subtle changes that may indicate an evolving injury. Moreover, consultations
and interventions may be expedited; resulting in a potential decreased
morbidity and mortality as well as hospital length of stay (4).
The importance of a singular, knowledgeable individual to coordinate
and to perform this role is likely to be a significant benefit to
the multiply-injured patient. The TNP can provide the expertise
and continuity of care required to perform advanced serial assessments
to avoid undiagnosed, potentially life-threatening injuries.
Food for Thought: Gaps in the Literature.
A comprehensive treatment plan be developed and implemented only
after the nature and severity of all injuries have been determined
(4). The tertiary survey allows the cataloging of all new injuries
and the re-evaluation of known injuries. Performing and documenting
the tertiary survey also promotes communication and interaction
between the surgical specialties, the critical care unit and the
radiology department. Deficits in collaboration and communication
between medical teams may hinder the timely identification and appropriate
treatment of injuries. As a result, patient outcomes may be compromised
(4). Similarly, a formal review of the diagnostic imaging studies
by an attending radiologist is necessary to achieve “loop
Very few of the studies mentioned identified the team member(s)
who performed the tertiary trauma surveys or non-standardized reassessments.
A designated team member to perform serial evaluations is ideal
to detect subtle changes that occur with an “evolving”
injury and to provide continuity prior to discharge to the ward
or to home from the hospital.
The completion of the TTS within twenty-four hours for severely
injured patients with ISS>15 is an arbitrary standard, yet most
studies accept this as appropriate. However, there is no data to
substantiate this time interval, or this injury severity, as the
foundation for the ideal trauma tertiary survey. This is an area
that warrants further investigation.
The standardized use of the primary and secondary trauma surveys
by pre-hospital, emergency departments, and trauma team members
is routine in many countries. However, the TTS has not been standardized
by organizations like the American College of Surgeons (ACS). They
recommend and support the re-evaluation of the multiply-injured
trauma patient, but fail to develop clear, standardized criteria.
As a result, internal validity challenges arise and make it difficult
to compare similar studies to determine the efficacy of the TTS
Potential contributing factors to missed injuries such as a high
volume and acutely ill patient admissions to the hospital, a decreased
number of surgical residents available and nurse staffing shortages
were not addressed in any of the studies. However, more clinically
significant missed injuries have been identified as occurring in
nighttime blunt trauma patients than during the daytime (2). This
observation may have been related to assessment errors by junior
The literature reviewed provided strong evidence that morbidity
and mortality may decrease with a re-evaluation of the multiply-injured
blunt trauma patient for re-evaluation of suspected injuries, and
identification of occult injuries by serial re-examinations and
review of (or additional) diagnostic studies. Completion of a formal
tertiary trauma survey (TTS) would strengthen the plan of care to
maximize the patient’s outcome. The communication chain can
be strengthened by using a standardized TTS assessment form to provide
clear and ongoing documentation of injury identification and diagnostic
results. As a result, the Trauma Nurse Practitioner would be instrumental
in ensuring a plan of care has been set with the trauma and consulting
teams to minimize the consequences of missed injuries.
1. Houshian, S., Larsen, M. S., & Holm, C. (2002). Missed
injuries in a level one trauma center. The Journal of Trauma, Injury,
Infection, and Critical Care 52(4), 715-719.
2. Janjua, K. J., Sugrue, M., & Deane, S. A. (1998). Prospective
evaluation of early missed injuries and the role of tertiary trauma
survey. The Journal of Trauma, Injury, Infection, and Critical Care,
3. Born, C. T., Ross, S. E., Iannacone, W. M., Schwab, C. W., &
Dong, W. G. (1989). The Journal of Trauma, 29(12),1643-1646.
4. Grossman, M. D., & Born, C. (2000). Tertiary survey of the
trauma patient in the intensive care unit. Surgical Clinics of North
America, 80(3), 805-824.
5. Enderson, B. L., Reath, D. B., Meadors, J., Dallas, W., DeBoo,
J. M., & Maull, K. I. (1990). The tertiary trauma survey: A
prospective study of missed injury. The Journal of Trauma, 30(6),
6. Buduhan, G., & McRitchie, D. I. (2000). Missed injuries
in patients with multiple trauma. The Journal of Trauma, Injury,
Infection, and Critical Care 49(4), 600-605.
7. Biffl, W. L., Harrington, D. T., & Cioffi, W. G. (2003).
Implementation of a tertiary trauma survey decreases missed injuries.
The Journal of Trauma, Injury, Infection, and Critical Care, 54(1),
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