You are on page 1of 14

Primary Survey and Secondary Survey

Initial Assessment (Primary Survey)


Focused History and Physical Exam (Secondary Survey)

Initial Assessment (Primary Survey)

Initial Assessment
The initial assessment is designed to help the Emergency Medical Responder
detect all immediate threats to life.
Immediate life threats typically involve the patients ABCs, and each is
corrected as it is found.

The initial assessment has six components;

1. Form a general impression of the patient - The general impression


will help you decide the seriousness of the patient's condition based on
his level of distress and mental status

2. Assess the patient's mental status - Initially this may mean


determine if the patient is responsive or unresponsive. Classify the
patient by the AVPU scale
o A - Alert. The alert patient is will be awake, responsive,
oriented, and talking with you
o V - Verbal. This is a patient who appears to be unresponsive at
first, but will respond to a loud verbal stimulus from you - Note
that the term verbal does not mean that the patient is answering
your questions or initiating a conversation. The patient may
speak, grunt, groan, or simply look at you
o P - Painful. If the patient does not respond to verbal stimuli, he
may respond to painful stimuli such a sternal (breastbone) rub
or a gentle pinch to the shoulder
o U - Unresponsive. If the patient does not respond to either
painful or verbal stimuli

Geriatric focus - The presence of dementia in the elderly patient


can make it hard to accurately access the mental status. Utilize family
and caregivers to obtain baseline information.

3. Assess the patient's airway - Is the patient's airway open? If the


patient is unresponsive stabilize the head and neck and use the jaw-
thrust maneuver to ensure an open airway. If you do not suspect a
spine injury use the head tilt, chin lift maneuver.

4. Assess the patients breathing - Is the patient breathing


adequately? With the airway open, place your ear over the patient's
nose and mouth and watch for chest movement, note symmetry or
lack of symmetry in chest movement. Listen and feel for the presence
of exhaled air. Listen to the quality of the breath sounds. Sporadic
respirations are called agonal respirations and occur just prior to
death.

5. Assess the patient's circulation (pulse and bleeding) - Does the


patient have an adequate pulse. Is there serious bleeding. Did the
patient lose a large quantity of blood prior to your arrival?
o If the patient is not breathing check the pulse at the neck
(carotid).
o If the patient is breathing you can check the carotid or the pulse
at the wrist (radial)
o If you document the presence of a carotid pulse but the radial
pulse is absent this may represent a shock situation. A rapid or
weak pulse may also represent a shock situation.
o Although any uncontrolled bleeding may become life threatening,
you are only concerned with profuse bleeding during the initial
assessment
o Blood that is bright red and spurting may be coming from an
artery
o Flowing blood that is darker in color typically reflects a venous
origin
o Your concern is for the total amount of blood lost, not just how
fast or slow the bleeding is.
o Assessment of circulation also includes checking skin signs -
color, temperature, and moisture. Abnormal findings such as
pale cool , moist skin could be indicative of shock
Geriatric focus - The elderly often have an irregular pulse. This is
rarely life threatening. However the speed of the pulse, both too fast
and too slow can be life threatening. (See BLS)

6. Make a decision on the priority or urgency of the patient for


transport

Special consideration for infants and children


o Opening the airway of an infant involves moving the head into a
neutral position, not tilting it back as with an adult. Opening the
airway of a child requires only slight extension.
o Breathing and pulse rates are faster in infants and than in
adults. The pulse to check in an infant or a small child is the
brachial pulse
o An additional part of checking an infant's or child's circulation is
capillary refill. When the end of a child's fingernail is gently
pressed, it turns white secondary to blood flow restriction. When
the pressure is released, the nail turns pink again, usually in less
than two seconds. If it takes longer than two seconds for the nail
bed to become pink again or if it does not return to pink at all,
there may be a problem with circulation such as shock or
significant blood loss.

Usually when an adult goes into shock they typically worsen


gradually and the downward trend can be spotted in time to take
appropriate actions. However, an infant's or child's body can
compensate so well for a problem such as blood loss the he
(she) may appear stable for some time, and then suddenly
become much worse. Children can actually maintain their blood
pressure up to the time when almost half of their total blood
volume is loss. Therefore a normal blood pressure may not rule
out the presence of shock. A delayed capillary refill time may be
a more reliable indicator of circulatory compromise.

top of page
Focused History and Physical Exam (Secondary Survey)

A focused history and physical exam should be performed after the initial
assessment. It is assumed that the life-threatening problems have been
found and corrected. If you have a patient with a life-threatening problem
that requires intervention (i.e. CPR) you may not get to this component. The
main purpose of the focused history and physical is to discover and care for
a patient's specific injuries or medical problems.

Focused History and Physical Exam


The focused history and physical exam includes a physical examination that
focuses on a specific injury or medical complaint, or it may be a rapid
examination of the entire body.
It also includes obtaining a patient history and vital signs.

Patient History - A patient history includes any information relating to the


current complaint or condition, as well as past medical problems that could
be related. Utilize bystanders/family... when needed

Acronym to obtain a patient's history

S - Signs/symptoms
A - Allergies
M - Medications
P - Pertinent past medical history
L - Last oral intake
E - Events leading to the illness or injury

Rapid assessment - this a quick, less detailed head - to toe assessment of


the most critical patients

Focused assessment - This is an exam conducted on stable patients. It


focuses on a specific injury or medical complaint.
Vital signs - This include pulse, respirations, skin signs, pupils and blood
pressure. This may include documenting the oxygen saturation level (this is
highly useful when dealing with chemical agent exposure).

Pulse - Assess for rate, rhythm, and strength

Respiration - Assess for rate, depth, sound, and ease of breathing

Skin signs - Assess for color, temperature, and moisture

Pupils - Check pupils for size, equality, and reaction to light. Constricted
pupils in a mass casualty event are highly suggestive of nerve
agent/organophosphate toxicity.

Age-associated Vital Signs

Age Blood pressure Pulse Respiratory rate


Term Newborn (3 kg)
Age 12 hours 50-70 / 25-45
Age 96 hours 60-90 / 20-60
74 +/- 22 mmHg 80-200 40-60
Age 7 days
(Systolic BP)
96 +/- 20 mmHg
Age 42 days
(Systolic BP)
Infant (6 months old) 87-105 / 53-66 80-180
Toddler (2 years old) 95-105/53-66 80-180 24
Schoolage (7 years old) 97-112/57-71 60-160
Adolescent (15 years old) 112-128/66-80 60-160 12

Head to Toe Examination of a Trauma Patient with Significant


MOI - The physical examination of the patient should take no more than
two to three minutes
Neck - Examine the patient for point tenderness or deformity of the cervical
spine. Any tenderness or deformity should be an indication of a possible
spine injury. If the patient's C-spine has not been immobilized immobilize
now prior to moving on with the rest of the exam. Check to see if the patient
is a neck breather, check for tracheal deviation

Head - Check the scalp for cuts, bruises, swellings, and other signs of
injury. Examine the skull for deformities, depressions, and other signs of
injury. Inspect the eyelids/eyes for impaled objects or other injury.
Determine pupil size, equality, and reactions to light. Note the color of the
inner of the inner surface of the eyelids. Look for blood, clear fluids, or
bloody fluids in the nose and ears. Examine the mouth for airway
obstructions, blood, and any odd odors.

Chest - Examine the chest for cuts, bruises, penetrations, and impaled
objects. Check for fractures. Note chest movements a look for equal
expansion.

Abdomen - Examine the abdomen for cuts bruises, penetrations, and


impaled objects. Feel the abdomen for tenderness. Gently press on the
abdomen with the palm side of the fingers, noting any areas that are rigid,
swollen, or painful. Note if the pain is in one spot or generalized. Check by
quadrants and document any problems in a specific quadrant.

Lower Back - Feel for point tenderness, deformity, and other signs of injury

Pelvis - Feel the pelvis for injuries and possible fractures. After checking the
lower back, slide your hands from the small of the back to the lateral wings
of the pelvis. Press in and down at the same time noting the presence of
pain and/ or deformity

Genital Region - Look for wetness caused by incontinence or bleeding or


impaled objects. In male patients check for priapism (persistent erection of
the penis). This is an important indication of spinal injury

Lower Extremities - Examine for deformities, swellings, bleedings,


discolorations, bone protrusions and obvious fractures. Check for a distal
pulse. The most useful is the posterior tibial pulse which is felt behind the
medial ankle. If a patient is wearing boots and has indications of a crush
injury do not remove them. Check the feet for motor function and sensation.

Upper Extremities - Examine for deformities, swellings, bleedings,


discolorations, bone protrusions and obvious fractures. Check for the radial
pulse (wrist). In children check for capillary refill. Check for motor function
and strength.

Rapid Physical Exam - Unresponsive Medical Patient

The rapid physical examination of the unresponsive medical patient is almost


the same as the rapid trauma assessment of a trauma patient with a
significant mechanism of injury. You will rapidly assess the patient's head,
neck, chest, abdomen, pelvis, extremities and exterior.

Focused Physical Exam - Responsive Medical Patient

The focused physical exam of the responsive medical patient is usually brief.
The most important information is obtained through the patient history and
the taking of vital signs. Focus the exam on the body part that the patient
has the complaint about.

In a mass casualty situation pay particular attention to


following signs and symptoms;

Head
Is headache present
Are the pupils are the pinpoint, dilated, asymmetrical in size
Are the conjunctiva injected, draining,
Does the patient complain of eye pain, photophobia or blurring of
vision
Is salivation, drooling, and/or rhinorrhea present
Is nasal flaring present
Note skin color - i.e. is the patient cyanotic
Note the smell of the patients breath
Is the patients throat sore, red

Neck

Is stridor present
Are the muscles in the neck "pulling"

Chest/Lungs

Note the presence of increased work of breathing i.e. retractions,


increased rate
Note the presence of stridor
Note the presence of wheezing, rhonchi, rales, decreased breath
sounds
Note the presence of central cyanosis
Does the patient complain of burning in the chest or chest pain

Heart/Circulation

Note the presence of irregular, fast or slow heart rhythms


Note the presence of diminished or absent peripheral pulse
Note the presence of prolonged capillary refill in children
Note the color and temperature of the distal extremities

Abdomen

Is the abdomen painful, tense, distended or rigid?


Does the patient have cramping, vomiting or diarrhea

Pelvis

Check for incontinence of urine or feces

Neurological
What is the patient's mental status? Is he (she) seizing?
Is the patient dizzy?
Did syncope occur?
Was there sudden collapse
Does he (she) have muscle twitching?

Skin

Is the skin painful, burning numb or tingly


Is the skin erythematous
Are there vesicles, bullae
Is there necrosis

The Primary Survey


The Primary Survey is a quick way for you to find out if someone
has any injuries or conditions which are life-threatening. If you
follow each step methodically, you can identify each life-
threatening condition and deal with it in order of priority.
Use the letters DR. ABC to remember the
steps: Danger, Response, Airway, Breathing and Circulation.
Youll need to go through the Primary Survey every time you help someone, and
make sure you dont get distracted by anything else. Only move onto
the Secondary Survey, if youve already done the Primary Survey and succeeded
in dealing with any life-threatening conditions.

Watch our video - Primary survey


Danger:
If someone needs help, before you go up to them check is it safe?
No: If you can see or hear any danger nearby, for you or them, like broken
glass or oncoming traffic, then make the situation safe before you get any closer
Yes: If you cant see or hear any danger then it is safe to go up to them.

Response:
Do they respond when you ask them: Are you alright? or if you say: Open your
eyes!
No: If they dont respond, pinch their ear lobe or gently shake their shoulders,
or with a child - tap their shoulder, and with a baby - tap their foot. If they still
dont respond, then you can presume theyre unresponsive and move on to the
next stage Airway. Someone whos unresponsive should always take priority
so you should treat them first and as quickly as possible.
Yes: If they respond by making eye contact with you or some gesture then you
know that theyre responsive and you can move on to the next stage Airway.

Airway:
Is their airway open and clear?
No:
o Responsive: If theyre responsive, treat them for conditions that may be
blocking their airway, such as choking. Only move on to the next stage
Breathing once their airway is open and clear.
o Unresponsive: If theyre unresponsive, tilt their head and lift their chin to
open their airway. Only move on to the next stage Breathing once their
airway is open and clear.
Yes: If their airway is open and clear, move on to the next stage Breathing.

Breathing:
Are they breathing normally? You need to look, listen and feel to check theyre
breathing.
No:
o Responsive: If theyre conscious, treat them for whatever is stopping them
breathing, for example, an obstructed airway. Then go to the next stage
Circulation
o Unresponsive: If theyre unresponsive and not breathing, call 999/112 for
an ambulance, or get someone else to call if possible, and start giving chest
compressions and rescue breaths CPR cardiopulmonary resuscitation. If
this happens you probably wont move on to the next stage as the casualty
needs resuscitation.
Yes: If they are breathing normally, move on to the next stage circulation.
Circulation:
Are there any signs of severe bleeding?
Yes: If theyre bleeding severely, control the bleeding with your gloved fingers,
dressing or clothing, call 999/112 for an ambulance and treat them to reduce the
risk of them going into shock.
No: If they arent bleeding, and youre sure you have dealt with any life-
threatening conditions, then you can move on to the Secondary Survey, to check
for any other injuries or illnesses.

The Secondary Survey


Only move onto the Secondary Survey if youve already done the Primary
Survey and succeeded in dealing with any life-threatening conditions.
Then you can start questioning the casualty about whats happened and carefully
check someone for any other injuries or illnesses. If you can, jot down everything
you find out and give all this information to the emergency services or whoever
takes responsibility for the child, like a parent.
You need to find out:
History: Question them about what happened leading up to them injuring
themselves or feeling unwell? Ask those around them too and write everything
down if they can.
Symptoms: What symptoms do they tell you they have?
Signs: Check them over from head to toe. What signs do you find on their
body?

History
Event history
Ask them to describe exactly what happened leading up to them feeling unwell or
injuring themselves.
You can ask other people near the scene too and also look for clues. For
example, if theyve had a car accident the impact on the car will help you work
out what type of injury they could have.

Medical history
Then, ask them to tell you their medical history. Use the word AMPLE to
remember all the things you need to ask them:
Allergy do they have any allergies?
Medication are they taking any regular or prescribed medication?
Previous medical history did they already have any conditions?
Last meal when did they last eat something?
Event history what happened?

Symptoms
Ask them to give you as much detail as possible about how they feel. Listen
carefully to what they say and make notes, if possible.
Here are they key questions to ask them:
Can they feel any pain?
Can they describe the pain, e.g. is it constant or irregular, sharp or dull?
What makes the pain better or worse?
When did the pain start?

Signs
Check the casualty over from head to toe, using all your senses look, listen,
feel and smell.
You may have to loosen, open, cut away or remove clothing. Ask their
permission to do this and make sure youre sensitive and discreet.
Make a note of any minor injuries as you go. Only return to these when you have
finished checking the whole body, to make sure you dont miss any more serious
injuries.

Head to toe examination


Breathing and pulse: How fast and strong is their breathing and pulse?
Bleeding: Check the body from head-to-toe for any bleeding.
Head and neck: Is there any bleeding, swelling, sensitivity or a dent in the bone,
which could mean a fracture?
Ear: Do they respond when you talk to them? Is there any blood or clear fluid
coming from either ear? If so, this could mean a serious head injury.
Eyes: Are they open? What size are their pupils (the black bit)? If theyre
different sizes this could mean a head injury.
Nose: Is there any blood or clear fluid coming from the nostrils? This could mean
a serious head injury.
Mouth: Check their mouth for anything which could block their airway. Look for
mouth injuries or burns in their mouth and anything unusual in the line of their
teeth.
Skin: Note the colour and temperature of their skin. Pale, cold, clammy skin
suggests shock. A flushed, hot face suggests fever or heatstroke. A blue tinge
suggests lack of oxygen from an obstructed airway, poor circulation, or asthma.
Neck: Loosen any clothing around their neck to look for signs like a medical
warning medallion or a hole in their windpipe. Run your fingers down their spine
without moving it to check for any swelling, sensitivity or deformity.
Chest: Check if the chest rises easily and evenly on each side as they breathe.
Feel the ribcage to check for any deformity or sensitivity. Note if breathing is
difficult for them or painful in any way.
Collar bone, arms and fingers: Feel all the way along the collar bones to the
fingers for any swelling, sensitivity or deformity. Check they can move their
elbows, wrists and fingers.
Arms and fingers: Check they dont have any unusual feeling in their arms or
fingers. If their fingertips are pale or greyish-blue this could suggest their blood
isnt circulating properly. Also look for any needle marks on the forearms, which
suggest drug use. See if they have a medical warning bracelet.
Spine: If theyve lost any movement or sensation in their legs or arms. Dont
move them to check their spine as they may have a spinal injury. Otherwise,
gently put your hand under their back and check for any swelling or soreness
Abdomen: Gently feel their abdomen to check for any signs of internal bleeding,
like stiffness or soreness, on each side.
Hips and pelvis: Feel both hips and the pelvis for signs of a fracture. Check their
clothing for any signs of incontinence, which may suggest a spinal injury or
bladder injury, or bleeding from body openings, which may suggest a pelvic
fracture.
Legs: Check the legs for any bleeding, swelling, deformity or soreness. Ask them
to raise one leg and then the other, and to move their ankles and knees.
Toes: Check their movement and feeling in their toes. Compare both feet and
note the colour of the skin: greyish-blue skin could suggest a problem with their
circulation or an injury due to cold, like hypothermia.

You might also like