Secondary Survey

Once you have verified a casualty has the ability to breathe on their own, whether responsive or unresponsive, using the Danger Response Airway Breathing (DRAB) method (Primary Survey) described in my earlier article ‘Airway Management’, it is time to continue to the secondary survey. Thorough practice of the Primary Survey will satisfy first aiders’ that the casualty is not in immediate state of dying. The secondary survey is a further priority list; a systematically examination to discover any injuries a casualty may have, life-threatening or otherwise.

Following on from DRAB;

Circulation – once it has been confirmed that the casualty can breathe without assistance, a few seconds should be spent giving a full visual examination of the casualty, looking in particular for severe bleeds and severe burns. Anywhere that cannot be immediately seen, such as the natural hollows behind the knees and beneath the lower back, should be quickly examined; checking their gloves for fresh blood. Anywhere that may absorb or mask the blood such as hair and clothing should also be examined. Nevertheless, the examination should be brief with time only spent treating any discovered severe bleeding and burns.

Blood transports oxygen around the body and having wounds or injuries that produce heavy blood loss can quickly bring on ‘Hypovolemic Shock’ and death. Likewise, burns produce a natural defence mechanism in the form of blisters. Blisters are filled with plasma – the fluid constituent of blood – sizeable burns whether partial thickness or full thickness will produce large volumes of plasma and if this is lost through burst or leaking blisters, blood will lose its fluidity, its ability to transport oxygen and the likelihood of ‘Hypovolemic Shock’ increases.

Damage – This, head-to-toe-Survey is a further examination of your casualty to find anything you may have missed previously. It should be thorough but done in a firm and gentle way as not to move and exasperate any yet undiscovered injuries. You are now looking and feeling for any deformities, open wounds, tenderness to the casualty and swelling. Many discoveries may be beyond first aid care but the information gained and passed to the arriving definitive medical care can help and speed up the casualties on going treatment.

Head; your brain lives in a very tight box – the skull – and like any other muscle when injured, can swell. It literally has no room to swell into but can start appearing at the natural openings of the skull; eye sockets, ears, nasal and mouth. Your brain is also bathed in straw coloured cerebral fluid and if the skull is fractured this fluid may also leak into these areas.

Start by gently cupping your hands around the back of the casualty’s skull and then running your fingers down the back of the neck. The skull should feel like your own skull and the neck like your own neck – simplified; like a stack of polo’s with jelly tots between them. The nape of your neck is where the spine starts its journey down your back; protected within it runs your internet super highway – the spinal cord. If you suspect anything is not quite right, make a note and start treating your casualty as if the ‘C’ spine is injured; in other words immobilise by holding the head still and do not move them unless they stop breathing and are in need of CPR – which will take precedence over a neck injury.  

Now look at the face noting the colour and temperature. Run your fingers along the forehead, down the bridge of the nose, then along the cheek bones pausing to open and look in the eyes. The pupils should react to light normally – the more light there is the smaller the pupils react – making a note any abnormalities. While looking in the eyes also look for the straw coloured fluid and look to see if the capillaries in the bottom of the eye area are a nice healthy bright pink, hinting at good oxygenated circulated blood arriving where it should. Continue your facial examination by feeling the jaw bone.

Neck and throat; any damage to this bodily area can cause severe breathing problems; look at the front of the neck for any ‘tracheotomy’. Also look to see if the casualty is wearing a ‘Medic-alert’ necklace. Medic alert is a charity based organisation that has access to the medical records of patients who have opted to have them made available to emergency services in need of medical emergency. The necklace has the symbol of first aid on one side – a cross with a snake wrapped around it – and on the other it will have a unique patient number to access a data file and a brief description of any medical problems. If one is discovered, never remove it but make a note of it and make its presence known to the emergency services. Some younger patients may wear them around the wrist or around the ankles.

Chest; you can imagine under the human chest it is rather busy. Several vital organs are within the torso and it is to here we now divert our attention. Damage to these organs can quickly become life-threatening and it is for this reason it is known as ‘the kill zone’

We do not possess x-ray eyes and cannot see inside the chest so visually and physically we need to examine it. Start by feeling the rib cage; we all have one and it should feel like our own.

Tip: Broken ribs can be extremely painful so on conscious casualties, if you suspect broken ribs ask the casualty first; be patient led.

Press on the four quadrants of the ‘six-pack’ (tummy). Even the best athletes of this world, with abs to die for (Jessica Ennis), should have a soft springy tummy when pressed. If any of the four areas feel rigid it could be the sign of an internal bleed. Muscle is naturally soft and spongy and will soak blood up readily; once blood soaks into the muscle it will change its texture and will become noticeable rigid when touched.

Tip: When touching a casualty during an examination, especially of the opposite sex; if you use your thumbs during the examination it can be misconstrued as a grope. Using the palm of your hand or just the outstretched fingers of your hand on the casualty will gain the results you are searching for and give the correct impression to the patient.

Hips; fractured hips can very quickly become life-threatening, especially if it has become complicated with an internal bleed. Fatal blood loss in excess of 40% can occur before noticeable swelling can be seen. It is because of this dangerous consequence only a visual examination of the hips should be made by the first aider. Slight movement during a physical examination could accelerate blood loss so it is extremely important to only visually examine the casualty for hip/pelvic injuries. Nevertheless, there can be visual clues to pelvic fractures; the casualty will want to sit on the uninjured side, while the leg on the injured side can look shortened and slightly rotated. If the casualty is conscious encourage them to sit still.

Legs; the Femur is the largest bone in the body and once again can warrant enough blood loss if blood vessels are damaged to be fatal. So before moving onto the arms check the legs for deformities, open wounds, tenderness and swelling; not forgetting to look for ‘medic-alerts’ around the ankles.

Arms; the final examination of the secondary survey should be the arms. Visual and physical examination should be completed. Competent pulse checkers may also take a pulse at this point but it isn’t necessary for the lay first aider. Unless you take regular pulses this exercise can be quite difficult and daunting; a pulse can be difficult to find. A person breathing and with good colour will have a pulse. A good test to see if the casualty has circulation problems in their arms is the ‘cuticle refill test’. Pressing the bed of the thumb nails – or just beneath if they are wearing nail polish – for five seconds, this pushes blood out and makes the nail pale in colour. When you release the nail a person with good perfusion will see it regain its natural pink colour and should refill within two seconds.

Tip: If you do take a pulse the paramedic not only likes to know the pace of the heart beat but likes to know what it felt like. If you take your own pulse now you will know how a regular pulse feels and can use the phrase ‘regular pulse’ to describe a normal pulse. Other description are ‘fast and weak’ or ‘Slow and bounding’

Once the arms have been checked you have completed the ‘Secondary Survey’ and should be in a position to tell the emergency services the complete state of your casualty and injuries they may have. If help is at hand you can send them to the telephone to call for medical help but if there is no one you may have to do this yourself. Most people these days carry a mobile phone and will be able to make this call from the side of the patient but, in the worst case scenario and you don’t have one you will have leave your patient to make the call. If this situation arises and the casualty is unresponsive but breathing you will have to place them in the recovery position. Attending a first aid course will teach how to do this.

Tony Clough