The secondary assessment of a responsive medical patient is performed in what order?

 The secondary survey is performed once the patient has been resuscitated and stabilised. It involves a more thorough head-to-toe examination, and the aim is to detect other significant but not immediately life-threatening injuries. If during the examination any deterioration is detected, go back and reassess the primary survey.Taking an adequate history from the patient, bystanders or emergency personnel of the events surrounding the injury can assist with understanding the extent of the injury and any possible other injuries. 
Use the AMPLE acronym to assist with gathering pertinent information:

Allergies
Medication
Past medical history including tetanus status
Last meal
Events leading to injury12

During this examination, any injuries detected should be accurately documented and any required treatment should occur, such as covering wounds, managing non-life-threatening bleeding and splinting of fractures.Inspect the face and scalp. Look for any lacerations or bruising, including mastoid or periorbital bruising which may be indicative of a base of skull fracture. Gently palpate for any depressions or irregularities in the skull.Look in the eyes for any foreign body, subconjunctival haemorrhage, hyphaema, irregular iris, penetrating injury or contact lenses.

Assess the ears for any signs of cerebrospinal fluid leak, bleeding or blood behind the tympanic membrane.

Check the nose for any deformities, bleeding, nasal septal haematoma or cerebrospinal fluid leak.Look in the mouth for any lacerations to the gums, lips, tongue or palate. Note any swelling which may indicate inhalation injury. Inspect the teeth, noting if any are loose, fractured or missing.Test eye movements, pupillary reflexes, vision and hearing.Palpate the bony margins of the orbit, maxilla, nose and jaw.

Inspect the jaw for any pain or trismus.

Neck

A plain lateral neck x-ray may be indicated when assessing a poly-trauma patient but if normal does not clear the C spine. This is particularly relevant in the intubated patient.To examine the neck the cervical collar should be opened and the head supported with manual in-line stabilisation throughout the exam. Three staff members are normally required to conduct a neck examination safely.Gently palpate the cervical vertebrae. Note any cervical spine pain, tenderness or deformity.Check the soft tissues for bruising, pain and tenderness.

Note the following:

• Trachea (midline or deviated): The trachea may deviate away from the side of a tension pneumothorax
• Wounds: blunt or penetrating injuries, size and depth.
• Subcutaneous emphysema: The presence indicates an airway disruption such as a laryngeal fracture or pneumothorax.
• Larynx: Laryngeal tenderness or crepitus; this may indicate an underlying laryngeal fracture.  Caution: firm palpation may disrupt a fractured larynx leading to total airway obstruction.
• Veins. : Look for distension – neck vein distension may be seen in tension pneumothorax or pericardial tamponade (a late and peri-arrest sign).
• Oesophagus:  To assess the oesophagus, ask the patient to swallow. An oesophageal injury may be suspected if the patient has pain or difficulty swallowing.

Re-apply the cervical collar carefully after examining the neck.  The cervical spine will generally be cleared after transfer to a major trauma service and specialist assessment.

Chest

The chest should be palpated for rib tenderness and subcutaneous emphysema. The entire thorax must be palpated including the supraclavicular fossae, right and left ribs and both axillae. A hand can be slid posteriorly along a supine patient to check for occult blood loss; however, a formal examination of the back of the chest occurs when the patient is log rolled.Auscultate the lung fields; note any percussion abnormality, lack of breath sounds, wheezing or crepitations.

Check the heart sounds: apex beat and presence and quality of heart sounds.

Abdomen

Inspect the abdomen. Palpate for areas of tenderness especially over the liver, spleen, kidneys and bladder. Look for any bruising, lacerations or penetrating injuries. Document seat belt marks.
Check the pelvis. Perform a pelvic x-ray if there is any suspicion of injury. Gently palpate for any tenderness. Do not spring the pelvis. Any additional manipulation may exacerbate haemorrhage.13 Apply a binder if a pelvic fracture is suspected even if low clinical suspicion.Auscultate bowel sounds.

Inspect the perineum and external genitalia for bruising or haemorrhage

Limbs

Inspect all the limbs and joints, palpate for bony and soft-tissue tenderness and check joint movements, stability and muscular power. Note any bruising, lacerations, muscle, nerve or tendon damage. Look for any deformities, penetrating injuries or open fractures.Examine sensory and motor function of any nerve roots or peripheral nerves that may have been injured.

Assess distal colour, warmth, movement, sensation and capillary refill.

Back

Log roll the patient. Try to do this once. It can be achieved at the time of patient transfer when you have the most personnel to do it safely. Maintain in-line stabilisation throughout. Inspect the entire length of the back noting any deformity, bruising and lacerations.Palpate the spine for any tenderness or steps between the vertebrae. Include a cervical examination at this stage.A digital rectal examination should be performed only if a spinal injury suspected.

Note any loss of tone or sensation.

Buttocks and perineum

Look for any soft-tissue injury such as bruising or lacerations.

Genitalia

Inspect for soft-tissue injuries such as bruising, lacerations or burns. Note any priapism that may indicate a spinal injury. 

The priorities for further investigation and treatment may now be considered and a plan for definitive care established.

By Marven Ewen, MD, Medical Director

The purpose of the Primary Assessment (aka Primary Survey or Initial Assessment) is to determine the nature of the primary complaint and rule out, prioritize, and treat any immediate life-threatening airway, breathing and circulation problems. The purpose of the Secondary Assessment is to fill in gaps in your understanding of the patient’s condition that did not become apparent in the Primary Assessment. There may be associated conditions that are present that the patient has not volunteered to tell you in the Primary Assessment because the patient didn’t think it was significant or related.

My approach to the Secondary Assessment is to simply collect information about the patient in a head-to-toe direction. You will examine and inquire at each level, thereby combining a review of systems and physical exam at the same time. Having a systematic approach that you do the same way with every patient will make you more efficient and accurate.

Here is the Secondary Assessment step-by-step with the physical exam and review of systems for each area in both video format as well as the written steps below the video. This is a basic screening history and exam that can be done very rapidly. It is not meant to be comprehensive for each system. When a complaint pertains to a particular system you would do more on that particular system than what I list here. I have included in brackets the relevant systems you are examining in each area.

Head (Neuro, integumentary, GI, Respiratory) Exam:

- Orientation questions
- Facial symmetry (both sides of the face moving symmetrically)
- Speech (clear or slurred).

SKIN: Color/temp/condition - flushed vs pale, dry vs diaphoretic, rashes.

NOSE: Just note bleeding or drainage.

EYES: Color of sclera (yellow=Jaundice), pupil size (do they look abnormally small or large? Are they symmetrical?), and light reactivity (look for symmetry of extraocular movement of the eyes also while you are evaluating the patient). Just be observant.

MOUTH: Have patient say ‘ah’ and shine your pen light to see color and level of hydration of mucus membranes, size of tongue and symmetrical movement of tongue and throat, state of their teeth.

Head (Neuro, GI, Respiratory) History: Do you have a headache or dizziness? Have you had any changes in your vision recently? Do you have any pain or swelling in your mouth or throat?

Neck (Integument, Vascular, Endocrine) Exam: Inspect for rashes, swelling, asymmetry.

Neck (MSK, GI) History: Do you have pain in your neck or problems swallowing?

Chest (Respiratory) Exam: Auscultate chest, back first then front, working from your left to right; note also any tenderness when you place your stethoscope. Always compare air entry side to side.

Chest (Respiratory) History: Does it hurt to take a breath? Are you short of breath? Do you have a cough?

Heart (Cardiovascular) Exam: Auscultate heart (if you did the chest exam in the order I recommended, you would find your stethoscope near the heart after finishing listening to the lungs).

Heart (Cardiovascular) History: Do you have chest pain or funny beating of the heart?

Abdomen (GI, GU) Exam: Inspect for obvious asymmetry or masses (does the patient’s abdomen look pregnant? Or distended?); lightly palpate the abdomen once in all 4 quadrants (is it soft and non-tender?).

Abdomen (GI) History: Do you have any abdominal pain? Have you had any constipation or diarrhea? Have you had any black stools or blood in your stools?

Pelvic (GU) Exam: You don’t need to examine the genital area unless there is an injury to the area or a pregnant female feels the urge to push - your abdominal exam would have alerted you to possible pelvic pathology when you palpated the lower abdominal quadrants

Pelvic (GU) History: Have you had any pain or difficulty with urination?

Upper Extremities (Integument, Cardiovascular, Neuro, MSK) Exam: Inspect skin for rashes, check both radial pulses at the same time to be efficient, and ensure pulses are not only present, but equal, side to side. While you are doing this ask the patient if he can feel you doing this. Then ask the patient to raise his hands a few inches and open and close his hands. Note any weakness, tremor or complaints of pain.

Upper Extremities (MSK, Neuro, Integumentary) History: Do you have any pain, swelling or weakness of your arms or hands? Are you itchy?

Lower Extremities (Integumentary, Cardiovascular, MSK, Neuro) Exam: Inspect ankles for rashes or swelling (edema). Check both posterior tibial pulses at the same time to be efficient and ensure pulses are not only present, but equal, side to side. (Note that palpation of posterior tibial pulses can be difficult. Don’t waste too much time on this if you can’t find them. If you really need to know if the patient has pulses down there, you could ask the patient to remove their shoes and check for the Dorsalis Pedis pulses. However, be aware that around 15% of the population do not have palpable Dorsalis Pedis pulses.) As you do this ask the patient if he can feel it and if he is tender. Then gently squeeze both calf muscles for tenderness. Ask the patient to wiggle his feet.

Lower Extremities (MSK, Cardiovascular) History: Do you have any pain or swelling in your legs or feet?

This seems like a lot to do, but in fact it takes longer to read it than actually do it. You should be able to do a secondary assessment in 1-2 minutes. The key is to practice doing it the same way every time so it becomes automatic. Also practice verbalizing what you are doing so your NREMT examiner knows what you are observing.