PATIENT ASSESSMENT

The patient assessment in first aid is divided into two parts:

a) Primary survey
b) Secondary survey
Difference between primary and secondary survey of patient assessment
Primary Survey Secondary Survey
First examination Second examination
Assesses and stabilities a person in life threatening Diagnoses and treats major injuries after
conditions stabilisation
Follows DRABC steps Follow AMPLE steps
Does not involves a head to toe examination Involves a head to toe examination
For responsive or unresponsive patients Typically for responsive patients
I. PRIMARY SURVEY
The primary survey should be conducted, when a person encounters someone who has been
injured or fallen seriously ill. An emergency medical situation may have an obvious cause, such
as a fall or other type of accident, or a person may collapse for no apparent reason because of an
underlying health issue, such as a heart condition.
Examples of when the primary survey should be used include, but are not limited to,
emergencies involving:
 Cardiac arrest
 Choking
 Anaphylaxis
 Stroke
 Serious blood loss
The steps used in primary survey are: The DRABC Steps

D – Danger

Before any action is taken, we must first look for danger. This means we must evaluate any risks
to yourself as well as anyone else in the immediate vicinity. This includes any potential
environmental hazards.

Examples of hazards to look for include:

 Live electrical currents

 Chemicals
 Broken glass
 Debris
  Unsafe structures
 Fire
 Smoke

If there is any danger identified, any such hazards they must be controlled before approaching a
casualty. For example, if there is a risk of electrocution, power should be cut at the source, or the
casualty must be moved away from the current without touching them directly. This can be done
by means of a non-conductive object made of plastic or wood. If such hazards cannot be
eliminated, then we must wait until emergency medical responders arrive.

R – Response

If it is safe to approach the casualty, their level of responsiveness must be evaluated. In simple
terms, these means speaking to them, introducting yourself and asking them what happened.

Another simple acronym exists for evaluating responsiveness, called AVPU. The letters of
AVPU stand for:

 Alert – Ascertain if the casualty is alert. Are they conscious? Are they moving or
talking? If not, go on to the next step.
 Voice – Ask the casualty if they are OK using a loud, commanding tone of voice. Try and
be in their line of sight while doing so. If you get no response, move on to the next stage.
 Place – Place your hand on the casualty’s collarbone, arm or shoulder and lightly shake
them. This must be done gently so as not to exacerbate any existing back or neck injuries.
If they still do not respond, move on to the last step.
 Unresponsive – At this stage, the casualty must be classified as unresponsive. If the
emergency services have not been alerted, then they must be called immediately. While
waiting for help to arrive, responders should move on to the next step in the primary
survey.

A – Airway

Step three of the primary survey is to check if the person’s airways are clear of any blockages. If
the casualty is responding, ask them to remove any blockages themselves if possible. If they
cannot remove the blockage themselves, then you should attempt to do so.
Fingers must not be placed into the casualty’s mouth. Blockages should be attempted to be
displaced by slapping the casualty on the back and performing abdominal thrusts.

B – Breathing

Once any choking hazard has been removed, the casualty’s breathing must be assessed. To
evaluate a person’s breathing, tilt their head back, then look for chest movements and listen for
sounds of breathing. Put your cheek or your fingers near their mouth or nose to see if you can
feel their breath. Ensure that you check the pace and rhythm of the breath for at least ten seconds.
If the casualty is not breathing normally and is unresponsive, emergency services must be
notified. If the responder has had appropriate CPR training, they can begin CPR with rescue
breaths. If not, then hands-only CPR must be used. If one is available, a defibrillator (AED) may
need to be used. The current guidance recommends caution when giving rescue breaths to avoid
transmission of Covid-19. If the casualty is unresponsive but breathing as normal, move them
into the recovery position (if it is safe) and wait for emergency services to arrive.

C – Circulation

This step should only be completed if the casualty is breathing on their own accord. If they are
breathing independently, a responder should check them for any signs of bleeding. If there is a
wound that is bleeding severely, direct pressure to the wound must be applied using a sterile
dressing or a clean cloth.
If there is no bleeding and the person is responsive, stay with them and reassure them until help
arrives. If they are unresponsive, and it can be done safely, move them into the recovery position
and wait with them until emergency services arrive. After find out patient is responsive we
moved on to next step.
 II. SE
C
O
ND
AR
Y

SURVEY
Rendering care to a trauma patient can be a challenging endeavor due to the potential for numerous
injuries. This part of evaluation should not be performed until the primary survey is completed. However,
in patients with multi-system trauma, evaluation and management can often occur simultaneously.
Therefore, secondary survey occurs both in series and in parallel with the primary survey. This evaluation
ensures that all potentially life-threatening conditions have been identified and satisfactorily addressed.
Not all injuries are immediately apparent in trauma patients. Occult injuries may be missed and delayed
diagnosis can contribute to morbidity and mortality. The secondary survey is a rapid but thorough head-
to-toe examination assessment to identify all potentially significant injuries. It is helpful to set the
priorities for continued evaluation and management. It should be performed after the primary survey, and
initial stabilization is complete. The purpose of the secondary survey is to obtain pertinent historical data
about the patient and his or her injury, as well as to evaluate and treat all significant injuries not found
during the primary survey by performing a systematic, complete examination. Since trauma is a dynamic
process, frequent reassessment is required in patients with trauma. If deterioration of clinical status is
noted, primary survey should be repeated and evaluation of ABCs should be started. This will identify
conditions that require immediate intervention.
Indications
The secondary survey is indicated in all trauma patients who have had their primary surveys completed.
The purpose of the secondary survey is to obtain a detailed history, perform a head-to-toe physical exam,
reassess all vital signs, and obtain pertinent lab and imaging studies to identify injuries and metabolic
abnormalities.
Contraindications
In certain patients who are too unstable to move on from their primary survey and are unable to be
resuscitated and stabilized, a secondary survey should not be performed. The only contraindication to the
secondary survey would be if the patient succumbs to their injuries. Otherwise, the secondary survey must
be completed on all trauma patients. If the patient is severely injured, they might not be capable of
providing a history. In these situations, the history can be obtained from EMS and family members or
even bystanders.
Personnel
Personnel would include members of the trauma team as well as ancillary support staff.
Preparation
Observe standard precautions for blood or fluid-borne infection.
Technique or Treatment
A secondary survey should not be performed until:
 The primary survey has been completed
 Resuscitation has been initiated
 All life-threatening conditions have been identified and addressed
 Normalization of vital signs has started
Patients who are hemodynamically unstable should be stabilized first before they are transferred to a
trauma center.
An attempt should be made to obtain the patient's history regarding the mechanism of injury, since certain
mechanisms can raise the suspicion for certain injuries such as the following:
 Blunt trauma (seat belt use, airbag deployment, extent of damage to the automobile, ejection, and
distance ejected)
 Penetrating trauma (which firearm and how many gunshots).
AMPLE History
This mnemonic device can be used for obtaining a quick, focused history:
 S stands for Symptoms: What the person feels, like pain or weakness.
 A stands for Allergy: Do they have any allergies? These could be to nuts or medicines like
penicillin or aspirin.
 M is for Medication: Are they taking any medicines?
 P is for previous medical history: Do they have any ongoing health conditions like diabetes or
epilepsy? Have they had any surgeries or injuries before?
 L is for Last Meal: When did they last eat or drink?
 E is for Event history: What happened (example mechanisms such as blunt, penetrating, burns
or any hazardous environment, such as exposure to chemicals, toxins or radiation. These
considerations are important for the following reasons due to exposure to chemical agents can
cause pulmonary, cardiac and other internal organ dysfunction, or hazardous environment can
pose a threat to the health.
Check the Level of Consciousness
Checking someone’s level of consciousness (LOC) helps us understand how aware they are. We often use
the letters AVPU to do this:
 A for Alert: If someone is alert, they’re fully awake and can answer questions. They know who
they are, where they are, and what time it is.
 V for Verbal: If they respond only when spoken to but aren’t fully alert, they’re in the verbal
stage. They might seem confused and not know where they are or what’s happening.
 P for Pain: If they only react when you give them a little pain, like pinching them, they’re in the
pain stage. They might move or make noises, but they cannot communicate appropriately.
 U for Unresponsive: If they’re not reacting, even to pain, they’re unresponsive. This is serious,
and we need to act quickly to help them.
Physical Examination
The purpose of the secondary survey is to identify significant injuries. This involves a complete head-to-
toe examination; examine all areas including front, back, sides, under and over. This examination
involves a second review of the airway and lung examination. Throughout the evaluation, standard
precautions for blood or fluid-borne infections should be observed.
Vital Signs
Assess vital signs; A narrow pulse pressure and tachycardia indicate hypovolemic shock in a trauma
setting until proven otherwise. Vital signs should be closely monitored and response to interventions
should be assessed. In elderly population, normal vital signs should not be reassuring as hemodynamic
changes such as tachycardia or hypotension may be delayed.
Head and Face Examination

Examine the head for scalp hematoma, skull depression, or laceration. The scalp should be
palpated, since scalp lacerations or bony step-offs may be identified only by careful palpation.
Palpate the entire facial bony margins including orbit, the maxilla, the nose and jaw.
A nasogastric (NG) tube should not be inserted if there is facial trauma or evidence of basilar
skull fracture. Also, ears should be evaluated for hemotympanum (the presence of blood in the
middle ear cavity) or retro-auricular ecchymosis (Battle's sign)- bruising behind the ears that can
be a sign of a basilar skull fracture, a fracture at the base of the skull. . The presence of blood or
clear drainage from the ear canal indicates basilar skull fracture with cerebrospinal fluid (CSF)
leak. Beware that facial fractures may be subtle. Examine the nose for septal hematoma.
The pupillary size and response, as well as eye movements should be assessed. The ocular
examination should also include ocular mobility/entrapment, or periorbital ecchymosis (Raccoon
eyes)- bruising and discoloration around the eyes, often associated with head trauma, particularly
basal skull fractures, but can also be a sign of other conditions. .
Neck Examination
The neck should be carefully inspected and palpated while it is carefully immobilized. Inadequate
immobilization increases morbidity. Beware that injuries under the hard collar may not be readily
apparent. Assume an injury to cervical spine with blunt trauma until proven otherwise. C-spine can be
cleared either clinically by applying decision rules, or by obtaining imaging studies, such as plain
radiographs or a CT scan. Also evaluate whether there is a neck swelling or pulsatile neck mass.
Examination of the Chest

Palpate the entire chest wall for crepitus (subcutaneous emphysema)- crackling, or crunching
sound or sensation felt or heard when moving a joint and tenderness. The area over the sternum
and clavicles require special attention as fractures involving these bones may suggest significant
force and need for further evaluation of other intrathoracic injuries. Assess any respiratory effort
and work of breathing. Evaluate whether breath sounds are symmetrical and heart sounds are
normal and not muffled. Inspect whether there is any bruising related to a seatbelt.
Examination of the Abdomen
The abdomen should be examined for distension, bowel sounds, bruising, skin marks or tenderness. The
presence of these findings requires further evaluation. Also, the presence of a seatbelt sign or other marks
to the abdomen should prompt further evaluation. It is important to keep in mind that the absence of
abdominal tenderness does not eliminate the possibility of abdominal injury. In addition, an initial
abdominal examination may not be reliable particularly in the following cases:
 Elderly population
 Presence of distracting injuries
 Altered mental state
 Pregnant patient, especially late pregnancy
 Examination of the rectum and the genitalia.
The perineum should be inspected for any evidence of injury. Historically, a digital rectal examination
has been included. However, its necessity as been questioned. A digital rectal examination should be
performed when there is a suspicion of urethral injury or penetrating rectal injury.
Look for the following:
 Gross blood in the rectal vault, which may indicate bowel injury
 Displaced or high-riding prostate, which may suggest urethral injury
 Abnormal sphincter tone and sensation, which may be due to a spinal cord injury.
If blood is present at the meatus, urethral injury should be suspected. In this situation , retrograde
urethrography should be performed before a Foley catheter is inserted.
Consider vaginal injury in patients with lower abdominal pain, pelvic fracture or perineal laceration. In
such situations, a vaginal examination should be performed.
A focused abdominal sonography examination for trauma (FAST) is a part of the secondary survey.
In pregnant patients, a complete obstetric examination should be performed in secondary survey. This
includes measurement of fundal height and auscultation of fetal heart tones. Assess for uterine tone and
whether contractions and tenderness are present.
Examination of the Extremities
The extremities should be assessed for fractures by carefully palpating each extremity over its entire
length for tenderness and decreased the range of motion. Assess the integrity of uninjured joints by both
active and passive movements. Injured joints should also be immobilized, and radiographs should be
obtained if necessary.
The neurovascular status of each extremity should be assessed and documented. Check pulses, the
capillary refill time and evaluate each compartment. The presence of significant pain, tense
compartments, or pain with passive movement may indicate a development of compartment syndrome.
Pelvic Examination
The pubis and anterior iliac spines should be evaluated for any signs of pelvic instability. The presence of
ecchymosis over the iliac wings, pubis, labia, or scrotum and tenderness along the pelvic ring also,
requires diagnostic evaluation.
Neurologic Examination
In this evaluation, the sensory and motor functions should be assessed, and the Glasgow Coma Scale
score should be repeated. This is important, since a patient's condition may change rapidly over time. The
neurological assessment should also include an examination of the pupils, including pupillary response to
light.
Skin Examination
In this, visualize all possible areas of skin. This includes the locations of lacerations, abrasions,
ecchymosis, hematoma, marks or bruises. Pay attention to the hidden areas:
 Scalp
 Axillary abdominal and gluteal folds
 Perineum
 Back should be evaluated by log-rolling the patient, and the spine should be palpated for step-offs
or focal tenderness.
When secondary survey is completed, one should be able to
 Obtain relevant diagnostic tests
 Request necessary consultations
 Make decision regarding the level of care needed; initiate transfer to a trauma center, if required
resources are not available
During the secondary survey, following considerations should be included
 Complete systematic physical examination including a neurologic exam
 Update tetanus status
 Vital signs monitoring
 Urine output assessment
  Special diagnostic tests
Special Considerations
 All dressings should be removed and injuries should be thoroughly evaluated
 The cervical collar should be removed while another team member maintains in-line
immobilization ant the neck should be evaluated for injuries and then the cervical collar is
reapplied in standard fashion.
 All clothing should be removed from all patients to completely perform an evaluation.
Environmental concerns and modesty should be maintained at all times by covering the patient
with warmed blankets as able.
 Certain injuries may not be evident during the secondary survey unless specifically considered
and evaluated. For example, injuries to the esophagus, diaphragm, and small bowel may remain
unrecognized, even with good examination.
 A tertiary survey is helpful to identify injuries not recognized during the secondary survey. This
should be performed in patients with multisystem trauma within the first 24 hours.
Complications
The risk of missed injuries. This risk may be higher for the following injuries:
 Abdominal Trauma; hollow viscus injury and retroperitoneal injuries may be missed
 Blunt Trauma: Bowel injury, pancreatic and duodenal injuries, diaphragmatic rupture
 Penetrating Trauma: Rectal injuries
 Thoracic Trauma: Aortic injuries, pericardial tamponade, esophageal perforation
 Extremity Trauma: distal extremity fractures, compartment syndrome
 Blood loss in the pelvis may be under-estimated