Secondary Assessment

3 components, order varies by patient type

The secondary assessment has 3 components: the history, the physical exam, and baseline vital signs. It follows the scene size-up and the primary assessment. For a medical patient the history carries most of the weight; for a trauma patient the physical exam does. With a critical patient the secondary assessment is often done en route, while with a stable patient it is fine to do it on scene. Patients are approached as one of 3 types: medical, trauma, or unknown nature.

The assessment gathers signs and symptoms, and the distinction between them matters. A sign is something you can observe, such as a deformity or edema. A symptom is something the patient reports, such as pain or shortness of breath (SOB).

Medical patient — responsive vs. unresponsive

The order of the secondary assessment for a medical patient depends on whether the patient is responsive, as the table below shows.

Table 15.1Medical patient — responsive vs. unresponsive

In the unresponsive patient, always check the pupils, which are the finding most often forgotten when the eyes are closed, and look for medical identification (ID) jewelry or a medical tattoo. Ask bystanders for the patient's name, what happened, any prior complaints, known illnesses, and medications; say "medications," not "drugs."

Trauma patient — minor vs. serious injury

For a trauma patient with a minor injury who is a low priority, take the history, perform a focused physical exam, obtain vital signs, and then gather the past medical history (PMH). The findings you look for in the exam are summarized by the mnemonic DCAP-BTLS: Deformities, Contusions, Abrasions, Punctures or penetrations, Burns, Tenderness, Lacerations, and Swelling.

For a patient with serious or multisystem trauma who is a high priority, continue manual stabilization of the spine, consider calling for advanced life support (ALS), perform a rapid trauma assessment covering the whole body from head to toe, obtain vital signs, and, if the patient is unresponsive, take a brief history from bystanders.

A significant mechanism of injury (MOI) puts a patient in the serious category. A significant fall is more than 10 feet (3 m) at any age under the 2021 national field triage guideline — it was taught as 20 feet for years. In a child aged 5 or under or an adult aged 65 or over, a low-level fall with a significant head strike is a risk factor to weigh (yellow, EMS judgment), and so is anticoagulant use. A high-risk crash is one with intrusion of more than 12 inches at the occupant's site or more than 18 inches at any site, ejection, a death in the same passenger compartment, a pedestrian or cyclist thrown, run over, or struck with significant impact, or a rider separated from a motorcycle or similar vehicle with significant impact.

Rapid trauma assessment (head-to-toe)

The rapid trauma assessment moves from head to toe. At each area you look and feel for wounds, tenderness, and deformities (WTD), plus the specific findings for that area listed in the table below.

Table 15.2Rapid trauma assessment (head-to-toe)

Detailed physical exam & cervical collars

The full-body secondary exam (older texts call it the detailed physical exam) is done after the critical interventions and the rapid trauma assessment. It is the lowest priority of the assessment steps and is usually performed en route. It is most appropriate for the unresponsive trauma patient, the patient with a significant injury, or the patient with an unknown MOI.

A cervical collar must be rigid and correctly sized; soft collars have no role in prehospital care. The size is determined by the length of the neck, not its width. A collar of the wrong size can obstruct the airway, and you must never compromise the airway for the sake of a collar. Assess the neck before you apply the collar, because once it is on you can no longer inspect or palpate the back of the neck.

Pediatric exam notes

A child's anatomy changes what the examination shows. Never press on the fontanelles. A fontanelle that bulges while the infant is crying is normal, but one that bulges when the infant is not crying suggests meningitis or increased intracranial pressure (ICP), and a sunken fontanelle suggests dehydration. Blood or clear fluid from the nose or ears should make you suspect a skull fracture. Because children are nose-breathers, an obstruction of the nose is more dangerous for them than for an adult.

The child's head is proportionally heavier and the neck supports it less well, so the cervical spine is highly vulnerable to injury, and because the bones are incompletely calcified there may be no visible fracture even when the spinal cord has been injured. The ribs are soft and may not fracture despite significant injury inside the chest. The abdominal organs are proportionally larger and less protected, and children 8 years old and younger are abdominal breathers.

In the extremities, capillary refill is checked by squeezing rather than by pressing the nail bed. The bones are pliable and will bend, buckle, or splinter before they fracture.