DO A SECONDARY SURVEY OF THE VICTIM

EMERGENCY ACTION PRINCIPLES (BCLS)

DO A SECONDARY SURVEY OF THE VICTIM

A.    EMERGENCY ACTION PRINCIPLES; SECONDARY SURVEY OF VICTIM

The secondary survey (detailed or focused assessment) is a systematic head-to-toe examination of every part of the patient’s body, including assessing the vital signs and obtaining a patient history. The call for EMS assistance is often the patient's entry point into the medical care system. It is important that EMS personnel conduct a systematic secondary survey to ensure medical or traumatic conditions are identified and the patient’s baseline is established. This will permit identification of changes in the patient’s condition.

The secondary survey aims to detect and treat ‘everything else’. Therefore the secondary survey should not be started until the primary survey is complete, repeated, and the patient as stable as possible. There are three main elements to the secondary survey:

a)      Vital signs monitoring

b)      Top-to-toe survey

c)      Medical history (AMPLE)

1.         Assessment of Vital Signs

Initial set of vital signs should be taken on every patient. If it is not taken, a reason should be documented in the patient care report. Repeat at regular intervals (5-15 min.) or when there is a change in the patient’s status. If the patient’s condition is unstable more frequent assessments are required. Vital sign assessment must include:

a)      Respirations

·         present or absent

·         rate (document as breaths per minute)

·         rhythm

·         regular or irregular (note any patterns)

·         quality

·         evidence of dyspnea should be noted

·         shallow, labored, noisy (if possible, describe the sound)

·         evidence of accessory muscle use or diaphragmatic breathing

·         if EMS personnel are trained to perform chest auscultation this should be done in the primary survey and repeated in the secondary survey

·         bilateral, comparative auscultation of the lungs should be done anteriorly and posteriorly

·         note presence or absence of breath sounds

b)     Pulse

·      present or absent

·      rate (document as beats per minute)

·      rhythm

·      regular or irregular (note any patterns)

·      quality

·      strong, weak, absent

c)      Blood pressure

·      measure systolic and diastolic pressures, if possible

·      when assessing a BP

·      ensure the BP cuff size is correct

·      palpate a pulse distal to the BP cuff

·      rapidly inflate the BP cuff to approximately 30 mm Hg beyond the pressure at which the pulse initially disappears

·      place the stethoscope diaphragm over the site being utilized for assessment

·      deflate the BP cuff at a rate of approximately 2 mm Hg per second

·      note the systolic and diastolic pressures

·      fully deflate the BP cuff

·      document the pressures as systolic / diastolic in mm Hg

·      If the assessment was done by palpation, record the pressure as systolic/diastolic

·      document any difficulties in obtaining a blood pressure

·      patient’s position when measured

d)     Glasgow Coma Scale

·      score each component and record it on the patient care report

·      repeat the assessment at regular intervals (5-15 mins.) or when there is a change in the patient’s status

·      the “AVPU” scale can be used as an alternate method to assess level of consciousness during the primary survey, but a more formal assessment using the Glasgow Coma Scale is required for the Secondary Survey

2.      Head-To-Toe Survey

Detailed head-to-toe survey includes assessment of all parts of the body using observation, comparison for bilateral symmetry, inspection, auscultation (if within scope of practice), and palpation.

a)      Skin

·         check for evidence of cyanosis, diaphoresis, discoloration, or trauma

·         assess skin color, temperature and moisture

b)     Scalp and Skull

·         check for trauma or external bleeding

·         look for evidence of basilar skull fracture

·         inspect and gently palpate for depressions and impaled objects

·         assess for tenderness or pain

c)      Face

·         check for trauma or bleeding

·         check for cyanosis and diaphoresis

·         assess for tenderness or pain

·         assess for symmetry and facial droop

·         assess mouth for

·         foreign bodies

·         broken dentures and teeth

·         blood or vomitus

·         abnormal smells

·         impaled objects

·         assess lips for cyanosis or trauma

d)     Eyes

·         check for trauma or bleeding

·         look for glass eye or contact lenses

·         assess for tenderness or pain

e)      Pupils

·         check for abnormal shape(s)

·         look for cataracts or evidence of eye surgery

·         assess pupil size

·         note size in millimeters for each eye

·         assess the pupillary reaction to light

·         normal or slow

·         assess eye movement

f)       Ears and Nose

·         check for trauma or deformity

·         check for discharge or blood

·         assess for tenderness or pain

g)      Neck

·         check for trauma, jugular vein distension, or presence of a stoma

·         check for deformities of the bony spine or soft tissues

·         check for tracheal deviation

·         look for Medic-Alert identification

·         palpate for tenderness, swelling, or abnormalities

·         assess carotid pulse

h)     Chest

·         reassess the chest during the secondary survey

·         look for evidence of obvious trauma

·         examine for; signs of respiratory distress, use of accessory muscles, diaphragmatic breathing, paradoxical respirations, and penetrating injuries

·         palpate the chest for; symmetry on inspiration and expiration, tenderness and instability, subcutaneous emphysema

·         assess shape and symmetry

·         assess chest as far to the posterior as possible

·         auscultate for equality of breath sounds through bilateral comparison (if within scope of practice)

·         note any changes from assessments in the primary survey

·         treat for any flail segments, penetrating injuries, or impaled objects

i)        Abdomen

·         expose the abdomen

·         inspect the abdomen prior to a physical assessment for

·         obvious trauma, impaled objects, or evisceration

·         distension

·         use of accessory muscles during respirations and for diaphragmatic breathing

·         palpate the abdomen

·         assess each quadrant, by palpating gently using a flat hand and fingers

·         assess for evidence of peritoneal irritation

·         pain, guarding, or rigidity

j)       Pelvis

·         check for obvious trauma, impaled objects, or pain

·         check for symmetry or deformity

·         note pain or crepitus when the pelvis and symphysis pubis are palpated

·         assess for priapism and incontinence of urine or feces

·         check for evidence of hemorrhage

k)     Extremities

·         expose the extremities

·         check for obvious trauma, impaled objects, or hemorrhage

·         check for symmetry or deformity

·         check for pain or crepitus

·         check for color, warmth, circulation and movement in each extremity

·         pay particular attention to the hands and feet

·         check for paralysis, or changes or loss of sensation

·         look for any shortening or rotation

·         look for any joint injury

·         assess hand and foot strength

·         compare bilaterally

·         assess for edema

·         assess for pulses and adequacy of sensation and movement distal to any injury

·         look for the presence of Medic-Alert identification

l)        Back

·         if not contraindicated, the patient should be carefully log rolled to assess the back

·         cervical spine control should be maintained during assessment of the back

·         if appropriate, a back board (or equivalent device) should be positioned so that when the patient is log

·         rolled back it is directly onto the back board

·         check for obvious trauma or hemorrhage

·         check for localized pain or deformity of the spine

·         check for generalized pain and crepitus

·         check for movement and sensation distal to any suspected spinal injury

·         look for penetrating injuries or impaled objects

·         palpate for subcutaneous emphysema

3.      Medical History

A detailed history of a medical complaint is beyond the scope of this session and handout. However, for most casualties it’s worth asking the following questions and certainly for anyone likely to go to A&E:

·         Allergies (especially to any medication)

·         Medication (over the counter, prescribed, ‘recreational’)

·         Past Medical History (health problems, previous surgery)

·         Last food and drink

·         Events leading up to the situation (“How have you been recently?”)

Much of this will not affect the first aid management, but can have a huge impact on later care. Remember that seriously ill and injured people can fall unconscious, and so others may not have chance to ask these questions.    

B.     PRACTISE SESSION: SECONDARY SURVEY OF THE VICTIM

1.      Interview casualty

Ask:

·         His or her name.

·         What happened (mechanism of injury).

·         If he or she feels pain anywhere.

·         AMPLE (allergies, medications, past medical history, last meal, events preceding).

·         About pain-PQRST (provokes, quality, region/radiates, severity, time).

2.      Check vital signs

Level of consciousness

Note whether…

·         Person is alert (A).

·         Responds to verbal stimuli (V).

·         Responds to painful stimuli (P).

·         Is unconscious (U).

3.      Pulse

·         Locate pulse site.

·         Determine pulse rate.

Note…

·         Pulse rate.

·         If pulse is regular or irregular.

·         If pulse is hard to find.

4.      Breathing

Determine breathing rate.

·         Note breathing rate or whether the person is

·         Gasping for air.

·         Making unusual noises as he or she breathes.

·         Breathing excessively fast or slow.

·         Experiencing pain when breathing.

5.      Skin characteristics

·         Feel person's forehead with back of your hand.

·         Look at person's face and lips.

Note if skin is

·         Cold or hot.

·         Unusually wet or dry.

·         Pale, bluish, or flushed.

·         Check capillary refill.

·         Blood pressure  (Note: Blood pressure skill sheets follow.)

6.      Do head-to-toe examination

·         Look carefully for bleeding, cuts, bruises, and obvious deformities.

·         Ask if person has pain or discomfort.

·         Note any abnormalities.         

□ Check head

    Feel the skull for blood, lumps, or depressions.

    Look for fluid or blood in the ears, nose, or mouth.

    See if pupils respond to light.

    Note any changes in level of consciousness.

□ Check neck

    Feel sides and back of the neck.

    Feel shoulders and collarbone.

    Ask person to shrug shoulders.

□ Check chest

    Feel ribs and sternum.

    Ask person to take deep breath and blow air out.

□ Check abdomen

    Apply slight pressure to each side of abdomen, high and low.

□ Check hips/pelvis

    Push down and in on both sides of hips with your hands.

□ Check legs

    Feel both sides of each leg and foot, one at a time.

    Ask person to try to; Move toes, foot, ankle; Bend leg.

□ Check back

    Gently reach under person and feel the back.

□ Check arms

    Feel both sides of each arm and hand, one at a time.

    Ask person to try to move fingers, hands, and arms.