Secondary Survey

What is a secondary survey?

Secondary Survey. The secondary survey is performed once the patient has been resuscitated and stabilised, in other words once the primary survey has been completed. It involves a more thorough head-to-toe examination, and the aim is to detect other significant but not immediately life-threatening injuries.

Why is a secondary survey important?

This process is especially important if the casualty is unconscious as after all they cannot tell you where it hurts or what has happened. 

They may have other injuries other than the one you can see and you need to identify and treat it as soon as possible. An untreated injury or condition could result in their condition worsening. 

Even if the casualty is conscious you would still need to complete the secondary survey as they may be unaware of any other injuries at that time. 

History, signs and symptoms

The process of a secondary survey starts with obtaining the history, signs and symptoms 

What happened before you arrived?

Every question asked is to ascertain the events leading up to your arrival, this helps you diagnose the casualty in order to administer the correct treatment.

 

Conscious casualty can be asked plenty of questions about what happened? 

An unconscious casualty cannot give you details but you can look for information from any bystanders.

Below are some examples of questions such as: 

What happened:

  • Description of what occurred

How did it happen?:

  • Did they fall?

  • Were they hit? By what?

  • Did they faint? 

Where did it happen?:

  • It may not of happened where you are now

Previous medical conditions:

  • Have they had this before?

  • How long ago?

  • How long did it last?

  • Are they on medication for it?

When did they last eat or drink?

  • Useful info for the ambulance

What​ time did it happen?

HISTORY

SIGNS

What you can hear, see or smell

These are the sensory signs that you are to look for when assessing your casualty such as:

Can you see:

  • any blood or vomit

  • Any disformaty in bone structure

  • Blue face or extremities

  • An item that could be the cause of the injury

  • Any medications on the person

  • Any clues on the person

Hear:

  • Agonal gasps

  • Crepitis - broken bones rubbing together

  • Wheezing breaths

Smell: 

  • Blood

  • Vomit

  • Urine

  • Poisons

  • Drugs

SYMPTOMS

What they can tell you about how they are feeling

This is what the casualty can tell you about how they are feeling however the art of questioning plays a part here. 

Avoid yes or no questions such as if I were to ask you "did you read this page today?" your answer would be "YES". 

Asked in a different way I would gain more information "What time did you read this page today?" your answer would what ever time you read it. 

This tells me you did read the page plus at what time you read it, giving me two answers instead of one.  

Try basing your questions by starting with the words:

  • Who

  • What

  • Why

  • Where

  • When

  • How

Practice this an you will gain more information quicker than using "did you...." or "have you...." style questions

The Secondary Survey Process

Remember this is a systematic process to ensure no part of the body is left unchecked and should not take any longer than a minute to conduct on the entire body. 

You start at the head and work your way down the body, now also remember your vital organs are contained within your head and torso (chest and abdomen area) so we must check these first. 

Secondary survey.png

TOP TIPS:    

The closer you are to bare skin the better

Check the entire body first before treating unless serious injury is evident

Do not move the casualty if you suspect a spinal injury

Keep monitoring their breathing throughout the whole process

Big coats for example will mean you may not be able to feel the injury.

Head injury
First Aid - secondary survey ey

STEP 1: HEAD AREA

Using the palms of your hands check around the head and neck area to look for any signs of bleeding.

 

Ears:

Check for signs of blood or clear liquid leaking from them, the clear liquid would be cerebrospinal fluid loss from inside the skull which could indicate a skull fracture. 

Nose:

Check for signs of blood or clear liquid leaking from the nostrils, the clear liquid would be cerebrospinal fluid loss from inside the skull which could indicate a skull fracture. Also is there any sign of a broken nose

Eyes:

Can they look at you, can they follow your finger, this means they are conscious and aware and can follow instructions.

 

Open the casualties eyes so you can check them, blood in the white of the eye can indicate head trauma. 

  • Dilated pupils could indicate head trauma or drug usage

  • Unequal pupil sizes could indicate cerebral compression or a stroke

Dilated_pupils.jpg
Unequal pupil sizes

Dilated pupils

(more black than colour)

Mouth: 

Look for anything that could block the airway, blood, vomit, foreign objects. If there is anything then turn them onto their side to try and remove or drain out, if you suspect spinal injury then log roll is to be used. 

Skin Colour: 

Is their skin colour normal?

  • Pale blue/grey and cold and clammy to the touch as this could indicate a range of serious issues such as lack of oxygen

  • Red hot flushed face could mean fever or heat stroke

STEP 2: NECK AREA

Look for anything that might be tightening around the throat and potentially blocking the air way, remove it. Neck ties for example loosen them off.

BE CAREFUL not to injure the neck or touch it in the event of a suspected spinal injury.

Look for medical alert necklaces as these can contain vital information if they are suffering from a previous medical condition, remember though if on a medallion it may have swung down to behind the neck if they are facing upwards. 

You are feeling for any kind of blood loss, lumps, bumps or deformities around the neck.

First Aid - secondary survey
Sternal fracture.jpg

STEP 3: SHOULDERS AND CHEST

Is there chest raising and falling equally on both sides?

 

Using the flat of your hands feel underneath the shoulders as much you can without moving them, pull your hands out and examine them for any signs of blood. Feel all over the shoulder area looking for signs of lumps, bumps, swelling, deformities and blood loss. 

Using the flat of your hands feel around the chest area and sternum and as far underneath as you can without moving the casualty. Pay attention to the rib area as you may feel a slight dip in the ribs if they have fractured ribs for example.

Again keep looking for lumps, bumps, swelling, deformities and blood loss and keep note of any difficulties or pain when breathing.

First Aid - secondary survey
First Aid - Capillary finger refill test

STEP 4: ARMS

Do they have any unusual feelings or loss of movement in their arms or hands? Tingling or pin and needles for example could indicate a spinal issue.

 

Using the flat of your hands feel all around the arms looking for lumps, bumps, swelling, deformities and blood loss.

Do not slide your hands down the arms, if the have a open fracture (bones has come through the skin) you may run the risk of cutting yourself. 

Once at the hand perform a capillary refill test by pinching the index finger nail for 5 seconds, you will see it turn white as this cuts off the blood circulation to the finger tip, when you release you will see it return to normal colour quite quickly, this is the blood returning to the finger nail, this means there is good blood flow. If it remains white or is slow refilling then this could mean there is poor blood circulation. 

STEP 5: ABDOMEN / HIPS /PELVIS AREA

Using the flat of your hands push firmly down across the abdomen area again looking for signs of lumps, bumps, stiffness and soreness. 

Do they cry out in pain when touched or show signs of discomfort?

Check the pelvis and hips for any signs of a fracture, are there any signs of incontinence this could mean a spinal or bladder injury.  

STEP 6: LEGS / FEET AREA

Leg sizes all vary so you must ensure you get around the whole leg to ensure you check them properly, like with the arms do not simply run down the legs in case there is a risk of an open fracture. 

Use the flat of your hands to check each part of the leg looking for swelling, deformities, blood loss. Is the casualty displaying signs of discomfort around a certain area? 

Ask them (if conscious):

  1. to raise one leg then the other

  2. to bend the knees one at a time 

  3. to move their ankles one at a time

STEP 7: RECOVERY POSITION

If you are complete satisfied there is no risk of spinal injury then you are to place the casualty into the recovery position. See our Recovery Position section here

STEP 8: BACK OF CASUALTY

Once the casualty is in the recovery position this now gives you the opportunity to check the rear of the casualty. 

Again using the palm of your hands start from the back of the head and check each part all the way down to the feet. 

STEP 9: MONITOR THE CASUALTY

Once the secondary survey has been completed then you are to monitor the casualties condition and look for signs of improvement or their condition worsening.

 

Breathing:

Monitor the number one priority of "breathing", constantly check to ensure the breathing is normal. 

Skin colour: 

Is their skin colour normal, red, blueish? 

Heart rate:

Check their heart rate to ensure it is within normal BPM (beats per minute) see our heart rate section here.

Conscious level:

Keep talking to them to ensure they remain coherent and are able to respond normally to questions