Primary Survey and Secondary Survey
Initial Assessment (Primary Survey)
The initial assessment has six components;
- 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
- 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
- A - Alert. The alert patient is will be awake, responsive, oriented, and talking with you
- 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
- 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
- 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.
- 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.
- 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.
- 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?
- If the patient is not breathing check the pulse at the neck (carotid).
- If the patient is breathing you can check the carotid or the pulse at the wrist (radial)
- 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.
- Although any uncontrolled bleeding may become life threatening, you are only concerned with profuse bleeding during the initial assessment
- Blood that is bright red and spurting may be coming from an artery
- Flowing blood that is darker in color typically reflects a venous origin
- Your concern is for the total amount of blood lost, not just how fast or slow the bleeding is.
- 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)
- Make a decision on the priority or urgency of the patient for transport
Special consideration for infants and children
- 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.
- 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
- 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.
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
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
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||80-200||40-60|
|Age 96 hours||60-90 / 20-60|
|Age 7 days||74 +/- 22 mmHg (Systolic BP)|
|Age 42 days||96 +/- 20 mmHg (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;
- 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
- Is stridor present
- Are the muscles in the neck "pulling"
- 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
- 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
- Is the abdomen painful, tense, distended or rigid?
- Does the patient have cramping, vomiting or diarrhea
- Check for incontinence of urine or feces
- 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?
- Is the skin painful, burning numb or tingly
- Is the skin erythematous
- Are there vesicles, bullae
- Is there necrosis