Simple secondary survey study sheet
Note to on-line users not in my classes: this is a study sheet. It is not complete instruction in first aid. In a formal class you will learn steps for recognizing emergencies, how and when to call 911, protecting yourself, (including how to obtain consent and prevent disease transmission), how to prioritize care and much more. You would always deal with life-threatening situations before you start a simple secondary survey (also known as a secondary assessment).
Students in HLTH57E (CPR) should be familiar with the material down to the section on the names of arteries.
Students in HLTH57A (first aid) and lifeguard training or an enhanced staff first aid class should be familiar with everything.
Rule #1 Don’t make things worse
-don’t aggravate injuries-(don’t move anything you think
might be broken)
-don’t move victim (especially if you suspect a spinal injury) unless you absolutely must
increase danger to victim
-don’t expose others to risk and create more victims
-don’t force first aid on a conscious, sane, sober adult who doesn’t want it (get consent/explain what you are doing and keep getting consent/explaining as you go along)
Times to suspect a spinal injury: (and use a jaw thrust instead of a head tilt, chin lift).
involved in a motor vehicle, motorized cycle, or bicycle crash as an occupant or rider, (especially with significant intrusion into passenger’s space (side or even the roof).
a pedestrian hurt during the crash of a motor vehicle, motorized cycle, or bicycle
trauma that results in partial or complete paralysis, partial or complete loss of movement of any body part, numbness, tingling or loss of sensation
a fall on land from a height greater than the victim’s height (or some sources say: a fall of greater than ten feet onto head or legs, or injury as a result of a fall greater than standing height). BUT a fall from a lower height still can cause a spinal injury.
a seemingly minor injury might actually be a spinal injury if the victim: appears frail or is older than 65 years of age, is not fully alert, or appears to be intoxicated
a seemingly minor injury might also actually be a spinal injury if the victim is less than three years old
a person holding his or her neck and/or head and/or complaining of weakness, pain, tingling or burning sensation in the extremities
losing balance or stumbling as they try to walk/stand
skiing or sledding or riding a bike into into a fixed object (like a tree) or other sudden and violent deceleration
assault to head/neck with blunt object other than fist or feet
cracked or broken helmet (bicycle, motorcycle, football, surfer’s, ski, industrial hard hat)
or wasn’t wearing one when they should have been
excessive flexion, as in when the chin is forced to the chest
fall on buttocks that transfers force to spine
severe blunt force to head or trunk (hit by car)
injury that penetrates head or trunk (gunshot)
has a head or neck injury
stabbing or impalement near the spinal column
thrown from a motor vehicle or horse (as many as 75% of passenger vehicle occupants totally ejected in a crash die)
incident involving a lightning strike or near strike
injury by rockfall or avalanche
broken windshield or deformed steering wheel
not wearing a seatbelt
impact with other passengers not seatbelted
deployed airbag and no seatbelt
lap style seatbelt only
infant or child in in front passenger seat and deployed airbag
small driver and deployed airbag
infant or child found with shoulder seatbelt around neck
poorly adjusted or absent headrest in a rear-end collision
snowmobile or motorcycle under rope or wire
motorcycle accident with rider ejected or crushed between the bike and another vehicle
closed vehicle rollover
closed vehicle crash with death of another occupant
pedestrian hit by a vehicle who rolls onto the hood of the vehicle, and often hits the ground head first
hanging or attempted hanging
found under collapsed building material or heavy debris (after and earthquake or…)
tumbling downhill without skis releasing (excessive extension or rotation)
spear tackling in football (using the head)
while participating in any sport, sustained a blow to their head, collided with another player or the ground/equipment
unconscious in water 5 feet deep or less
any injury caused by an entry, especially head first dive, into shallow water
diving mishap or entering water from a height, involving a diving board, water slide, embankment, cliff or tower
diving onto an floating or submerged object/person/sandbar (at the water surface or underwater)
striking the water with a high impact (falling while water skiing or surfing, or impact with water on an imperfect dive from a great height)
hit by a boat, personal watercraft, skier, surfer, ski, or surfboard
receiving a blow to the head, including colliding with another swimmer or when plunging head-first into a breaking wave or shallow water
jumped on by someone entering the pool at the side who did not see the person swimming underwater along the side
any trauma situation where the victim stays unconscious, is not fully alert or you have any doubt
USLA, lifeguards at beaches/open water, remind us:
“Signs of a spinal injury can include things other than paralysis, but they require immediate attention. They include:
Bruises, scrapes or cuts to the head or face
Pain or tenderness in the neck or back
Partial or complete paralysis, difficulty breathing
Weakness in the arms and/or legs
Numbness and tingling in the arms and legs”
Reasons why a person might become unconscious or semi-conscious
Alcohol or other substance abuse or misuse
Insulin (diabetes, high or low blood sugar)
Trauma, especially head injury
Altered mental status (and possibly a confused or combative state) can be caused by:
any of AEIOUTIPS above
electrolyte imbalance (hyponatremia)
shock and/or any condition that results in less blood flow (and therefor less oxygen) to the brain
conditions resulting from mental, emotional or behavioral disorders
severe drug withdrawal – (Delirium tremens or other) is sometimes mistaken for an acute psychiatric problem
Mental status is also known as Level of Consciousness (LOC).
SUDDEN Altered mental status, (and possibly a confused or combative state) AKA delirium, which can indicate a life-threatening condition,
can be caused by the above. Note that this can be relatively common in elderly people and might seem like dementia, but is not.
infections including urinary tract infections, a wound, pneumonia
cancer spreading to the brain and causing hallucinations
head injury with intracranial bleeding
use of or withdrawal from alcohol/drugs
poisoning from lead, mercury, carbon monoxide, pesticides
chronic lung disease
Note that heatstroke or diabetes can seem like a acutely intoxicated person.
causes of fainting
fright, stress or excitement
tight clothing at neck
carbon monoxide poisoning
dehydration, especially severe dehydration brought on by diarrhea, vomiting or sweating, especially if the victim has not been drinking enough fluids
slow gastrointestinal bleeding with or without pain
blood volume changes (stood up too fast after prolonged sitting or lying down (more likely for pregnant, elderly), after a large meal (especially with alcohol))
inflammation of inner or middle ear
panic disorders and hyperventilation
dysrhythmia causing a fast heartbeat
a very slow heart rate
standing too long, especially in the heat
benign hyperventilation: an anxious person (fear of heights, animals, etc.) hyperventilates (breathes rapidly and deeply) which causes dizziness, a sensation of choking, tingling in hands & feet, chest pain &/or tightness, blurred vision and more. These symptoms being close to those of a heart attack or other serious problem can cause more concern and more hyperventilation sometimes leading to fainting. (No, do not have them breathe into a paper bag.)
some medications for high blood pressure or heart disease
recent arrival at high altitude
Arm = brachial
Neck = carotid
Groin = femoral
Wrist = radial
Students in HLTH57E (CPR) should be familiar with everything above this part.
Students in HLTH57A (first aid) and lifeguard training or an enhanced staff first aid class should be familiar with everything.
causes of seizures
most common is epilepsy, especially if medicine is not taken in proper dosage and on time
lack of oxygen
brain tumor / concussion / increasing intracranial pressure from swelling or internal bleeding in the brain
diabetic emergency / low blood sugar
failure to use prescribed anti-seizure medications (often the biggest cause of seizures)
drug or alcohol use or withdrawl
measles, mumps and other childhood diseases
eclampsia (pregnancy complication)
child with a high fever
child with aspirin poisoning
hit by lightning
high altitude can cause brain swelling
continuing stress from bereavement, divorce, abuse, money/family worries, critical incident stress
Signs and symptoms of a concussion:
(Symptoms of a concussion may be delayed. They can take several hours or even days to present themselves.)
(Many teams require that an athlete with concussion symptoms be evaluated by a medical staff member with experience in the evaluation of concussions and prohibits them from returning to play on the day of the activity. Mild symptoms can resolve themselves in less than two days, but the victim still needs to seen by a doctor.)
Appears dazed or stunned
Answers questions slowly
Loses consciousness (even briefly)
Shows behavior or personality changes / mood changes like feeling sad, anxious or listless or becoming easily irritated or angry for little or no reason. Might resist treatment.
Mental status deteriorates – sometimes moving from disoriented, to irritable, to combative to a coma.
another source says: feeling sluggish, feeling unusually irritable
goes in and out of responsiveness
Can’t recall events prior to hit or fall and/or after hit or fall
Headache or ‘pressure’ in head
Nausea or vomiting
Balance problems or dizziness
(Often brief) double or blurry/fuzzy vision
Sensitivity to light and/or noise
Hearing problems, ringing in ears
Feeling dinged or dazed, sluggish, hazy, foggy, or groggy
Concentration or memory problems
Does not ‘feel right’
In later stages pupils may become unequal
Athlete who is confused about assignment or position, forgets sports plays, is unsure of game, score, or opponent
An elderly person can have a concussion from a seemingly minor fall. Sometimes their symptoms are mistaken for a stroke. You might not witness the fall of an elderly person, for example, but after the fact would notice some of the symptoms above and/or:
low-grade headache that won’t go away
having more trouble than usual remembering things, paying attention or concentrating, organizing daily tasks or making decisions or solving problems
slowness in speaking, acting, thinking or reading
getting lost or easily confused
changes in sleep patterns, inability to wake up from sleep
sensitive to light or noise
doesn’t recognize people or places
seizures (arms and legs jerk uncontrollably)
weak arms or legs, unsteady on feet
Note that confusion in an elderly person that comes on suddenly could be caused by a head injury OR by a medication / improperly taking a medication, OR by pneumonia/infection (sometimes without a fever or coughing).
An infant can’t answer questions or tell you they have symptoms, but you might notice they cry persistently and it is difficult to console them, are not interested in toys they usual are fond of (or might not even reach for a toy offered them), have changes in eating/drinking/nursing.
They might not interact normally with a parent/sibling, give eye contact.
They might not pay their usual attention the their surroundings. Their eyes might not follow a person/object near them, or they could even have a blank or trance-like stare.
NOLS Wilderness Medicine says “evacuation is recommended for any patient who has become unresponsive, even for a minute or two, or who exhibits vision or balance disturbances, irritability, lethargy, or nausea and vomiting after a blow to the head regardless of whether they were knocked out. A patient who exhibits loss of responsiveness but who awakens without any other symptoms may be walked out of the wilderness with a support party capable of quickly evacuating the patient if his or her condition worsens.” This could also apply after an earthquake.
Treatment for closed soft tissue injuries
Rest to allow clots to form. Do not move or straighten the area
Cold: apply plastic bag of ice (with a thin barrier between the ice and skin) 20 minutes on, 20 minutes off
Elevate above heart level unless it causes more pain
Signs of wound infection
(Older adults are at higher risk for wound infection.)
pain does not get better a few days after the injury
increasing pain, swelling or tenderness
small pimple over the wound
swelling beyond what might be considered normal for that wound
pus (with or without odor) coming from the wound (varies from white to pink or light green)
redness spreading from around the edges of the wound, progressing to red streaks extending from the wound up a limb
advanced: chills and fever, swollen glands in the groin, armpit or neck
(Especially watch punctures for early signs of infection.)
To care for a victim of stroke, think FAST.
Face – weakness on one side of the face
Arm – weakness or numbness in one arm
Speech – slurred speech or trouble speaking
Time – Time to summon EMS personnel (call 911) if any of the above are seen and note the time the signs and symptoms began
Normal respiration for an adult is 12 to 20 breaths per minute, children ranges with age, from pre-teens at 12 or 15 to 20 to newborns to about six weeks at 30 to 50
Adult 60 to 100
Child 80 to 150
newborn to about six weeks, 100-160
infant 80 to 120 to possibly 150
an athlete may have a pulse of 50 beats per minute or lower
Normal capillary refill is 2 seconds (not effective on very cold fingers)
normal body temperature taken at the mouth is 98.6°F (within a range of 97°F to 99°F )
normal rectal temperature is 99.6°F
normal armpit (axillary) temp is 97.6°F
Levels of consciousness
Person, place, time, event
(their name is the last thing of these they’ll remember).
A person who is oriented to their surroundings and situation should be able to tell you their name, where they are, what time it is (not to the exact hour but at least if it is morning or evening, what month and year it is) and what happened to them.
Alert: able to respond appropriately to questions (including person, place, time and event)
Verbal: Responds appropriately to
verbal stimuli when you speak or shout
Painful: Only responds to painful stimuli, such as a pinch
Unresponsive: Does not respond; no gag or cough reflex
a response could include grimacing, rolling away from your voice, moaning
Your palm (or another source says palm and fingers) is approximately 1% of your body surface, use this to estimate extent of burns
Sierra Club wilderness first aid “rule of fours” you can live 4 minutes without oxygen, 4 hours without shelter, 4 days without water, 4 weeks without food (but that may be the limit of any reasonable expectation of survival)
–see pages 24-28 in American Red Cross First Aid/CPR/AED participant’s manual OR 216 (skill sheet on page 239) in Lifeguarding–
Simple secondary survey , (also known as a secondary assessment) used after the initial assessment after you have ruled out or taken care of any life-threatening conditions. You might or might not have already called 911.
(Remember, don’t have them move any body part you suspect is injured and if you suspect a spinal injury you would be manually protecting the spine/neck from movement and would not want them to tilt their head yes or no in the process of answering questions. You could tell them to not move, and not nod their head yes. Instead of asking “do you have any pain,” you could say “tell me about your pain.”)
Note that elderly victims might not have their hearing aids in, or might not have hearing aids that they need.
If you did not do so already, introduce yourself, ask permission to give care, get victim’s name. (At any point while you are taking this brief history or during the head-to-toe exam, if you find something that requires emergency medical personnel, stop the survey to call 911 immediately, then continue the survey.)
Interview victim (write notes, including negative answers) and give the information to EMS personnel when they arrive.
use SAMPLE as an easy way to remember the questions
Signs and symptoms
What happened to you?
(You might also note if they are anxious or indifferent.)
Do you feel pain anywhere?
Do you feel any numbness, tingling or loss of sensation? (If yes, where?)
Are you experiencing any lightheadedness, nausea?
(If they felt dizzy, was it a spinning feeling, or just lightheaded and did they lose balance?)
Sometimes ask for details about pain:
Onset (What were you doing when it started hurting? Resting or active? What made it start hurting? Was it severe at first or did it get this bad over time?)
Provokes (What makes it worse/better? Does it only happen after you eat? Does it only hurt when you breathe deeply?)
Quality Ask them to describe the pain. (Don’t use a leading question such as, is your pain a burning pain? Answers could include sharp pain, stabbing, cramping, aching, burning, dull.)
Radiates / or another source says Region/Radiates Referred (Does it start in one place, and move to another? What makes it move? (spleen injury pain can be felt in the left shoulder, heart attack chest pain can radiate to the neck and jaw, kidney stones are associated with severe back/flank pain radiating to the groin, gallbladder pain can be felt in the right shoulder blade, a slowly bleeding abdominal aneurysm can cause abdominal pain radiating to the back)
Severity (Where is the pain on a scale of one (least) to ten (most))
Time (When did it start hurting? How frequently does it occur? How long does it last? Does it come and go? Get better or worse? ) (Intermittent, hard to locate pain is common with problems of the abdomen.)
(If the onset and time categories seem to be redundant, think of the onset as WHY and the time as WHEN.)
Do you have any allergies, (including food, plants/pollen, insects and medications)? What type of reactions have you experienced when you were exposed? Any recent exposure? Tightness in their throat?
Medications / Medical Conditions
Do you have any medical conditions or are you taking any medications? If so, what conditions do you have or what medications are you taking? Have you taken any in the past 12 hours?
(including prescription, over-the-counter, herbal)?
Don’t ask if they are taking any drugs, as they may misunderstand and think you are accusing them of illegal activities. But if that might be the reason they are having problems, you certainly need to find out.
Diabetic? Heart problems? (may get you a better answer than asking about ‘Cardiac history’?)
Epilepsy? Asthma? Pregnant? Check for medic alert tag.
Example: if they are taking Viagra, giving them nitroglycerin could have serious side effects. Some antibiotics may decrease the effectiveness of hormonal birth control such as the pill.
Pertinent past medical history
Have you experienced any recent falls, accidents or blows to the head? Have you ever been in any medical, surgical or trauma incidents? (If you didn’t get the answer to this in the medical conditions questions): Are you under a doctor’s care for anything?
If appropriate: Have you experienced anything like this before?
(history of high blood pressure? recent surgery/illness? (complications?) Dehydrated? Didn’t eat
any breakfast? Lack of sleep? Substance abuse? Previous injury to same site? Same type of pain previously – was there a diagnosis? Same location of pain previously – is the pain the same this time?)
Last oral intake
(also referred to as Last food or drink)
When did you last eat or drink anything? What did you last eat or drink? You could also ask the amount. This includes solids, liquids and medications. (Don’t ask the victim “when was your last oral intake?”).
Perhaps ask if oral intake over the past few days has been normal for them. Perhaps ask if urination and defecation have been normal. Changes in diet that might have caused that stomach upset.
Perhaps notice if they smell of alcohol.
Events leading to the incident
What were you doing before the accident happened? What were you doing when the incident occurred? Why do you think this happened? (As in, why do you think you just fainted?)
Finally, you could ask: Is there anything else I should know?
Write down all the answers.
Then do a head to toe exam, starting by telling the victim what you are going to do. Keep explaining as you go along.
Head to toe exam
(in a simple secondary survey you hardly touch the victim, they do the moving around, but only if you do not suspect a spinal injury)
Visually inspect the body, including the scalp, face, ears, eyes, nose and mouth for cuts, bumps bruises and depressions.
(DOTS: Deformity, Open injuries, Tenderness, Swelling)
(DCAP BLTS deformities, contusions, abrasions, penetrations (another source says punctures/penetrations),
burns, lacerations, tenderness, swelling)
Look at face and lips (unusually wet or dry, pale, bluish, jaundice (yellow skin combined with yellow whites of the eyes = liver problems) flushed, ashen; note abnormalities).
Check eyes (pupils – big, tiny, uneven size, both react the same to light?) ears, nose,
ask them to open mouth; look for fluid or blood (don’t try to control fluid coming from ears)
A significant percentage of people normally have pupils of slightly different size, but both should react to light the same way if, for example, you shine a flashlight in their eyes.
Determine skin appearance and temperature. Feel person’s forehead with back of your hand to determine if it is cold or hot.
Write down all observations, including anything that does not look right.
Don’t do the following if you suspect a spinal injury or move any body part you suspect was injured.
– Ask person to move head from side-to-side if there is no discomfort and if an injury to the neck is not suspected.
Note pain, discomfort or inability to move the neck.
– Ask person to shrug shoulders.
– Ask person to take a deep breath and blow out air.
Listen for changes in breathing and ask victim if he or she is experiencing pain during or right after breathing.
Breathing (gasping, unusual noises, fast or slow, labored, noisy, gurgling, shallow or deep, pain
when breathing, dry or productive cough, difficulty swallowing, difficulty speaking in full sentences/using phrases or partial sentences)
Stridor = high pitched noise when breathing in; wheezing = high pitched noises when breathing out.
If coughing, increased frequency and severity? If sputum, increased production and/or changes in character?
If nasal discharge, what color? (Clear, yellow, green, reddish, brownish?)
Ask if any pain in abdomen (which quadrant?)
(If they are vomiting, describe what is vomited, if diarrhea, describe the consistency.)
– Ask person to move hands, fingers, bend arm. Compare grip strength.
– Ask person to move feet, ankles, bend leg. Check one limb at a time.