Secondary Survey: Head-to-Toe Assessment and Vital Signs

Secondary Survey: Head-to-Toe Assessment and Vital Signs

The secondary survey is a systematic, head-to-toe physical examination performed after the primary survey and any immediately life-threatening conditions have been addressed. Its purpose is to find injuries or signs of illness that were not obvious during the initial assessment. In the field, you must complete this survey efficiently and accurately — missing a finding can delay definitive care or lead to patient harm.

When to Perform the Secondary Survey

Begin the secondary survey only after the primary survey is complete and the patient is stable enough to allow it. For a trauma patient who is unstable, prioritize rapid transport and defer detailed assessment to en route. For responsive medical patients, a focused history and physical exam may replace or precede portions of the head-to-toe survey. Always reassess the primary survey if the patient's condition changes.

The DCAP-BTLS Framework for Trauma

For each body region in a trauma patient, use the mnemonic DCAP-BTLS to guide your hands and eyes:

• D — Deformities
• C — Contusions
• A — Abrasions
• P — Punctures or penetrations
• B — Burns
• T — Tenderness
• L — Lacerations
• S — Swelling

For medical patients, shift your focus to organ-specific findings: breath sounds, bowel sounds, pedal edema, skin color, and so on.

Head and Face

Begin at the head. Inspect and palpate the scalp for deformities or bleeding. Examine the face: look for asymmetry, periorbital bruising (raccoon eyes), and Battle's sign (bruising behind the ear) — both suggest basilar skull fracture. Check the nose and ears for fluid, which may indicate cerebrospinal fluid leakage. Assess the mouth for airway obstructions, dental trauma, or unusual odors.

Pupils: Using a penlight, assess each pupil individually. Note size, equality, and reactivity to light. Unequal pupils (anisocoria in a trauma patient) may indicate increasing intracranial pressure and is a critical finding. Normal pupils are equal, round, and reactive to light (PERRL).

Neck

Inspect and palpate the anterior and posterior neck. Feel for tracheal deviation — the trachea should be midline. Deviation suggests tension pneumothorax or massive hemothorax on the opposite side. Check for jugular vein distension (JVD), subcutaneous emphysema, and point tenderness along the cervical spine. Maintain spinal motion restriction when indicated by mechanism or symptoms.

Chest

Expose the chest fully. Look for paradoxical movement, open wounds, and unequal rise. Auscultate bilateral breath sounds in at least four fields. Absent or diminished sounds on one side suggest pneumothorax, hemothorax, or main-stem intubation. Percuss if training and protocols allow. Palpate the ribs, sternum, and clavicles for crepitus or tenderness.

Abdomen and Pelvis

Palpate all four quadrants of the abdomen for rigidity, guarding, distension, and tenderness. Rigidity suggests peritoneal irritation. Gently compress the pelvis medially and downward once — if unstable or painful, do not repeat; an unstable pelvis indicates possible major hemorrhage. Inspect the perineum for bleeding or injury if mechanism warrants.

Extremities

Assess all four extremities for DCAP-BTLS. Check distal neurovascular status: pulses, motor function, and sensation (PMS) distal to any injury. Absent distal pulse after a fracture or dislocation is a limb-threatening emergency. Note any deformity, angulation, or crepitus.

Posterior Body

Log-roll the patient with spinal precautions maintained. Inspect and palpate the back, flanks, and buttocks for wounds, deformities, or tenderness. Flank ecchymosis (Grey Turner's sign) may indicate retroperitoneal bleeding.

Baseline Vital Signs

Obtain a full set of baseline vitals at the scene whenever possible:

• Blood pressure (BP): Measure by auscultation as the standard. Palpation gives only a systolic estimate and is used when auscultation is not possible (e.g., a noisy environment).
• Pulse: Rate, rhythm, and quality (strong/weak/bounding/thready).
• Respirations: Rate and effort (labored, shallow, normal depth).
• SpO2: Pulse oximetry; interpret in context — low perfusion states and carbon monoxide poisoning can give misleading readings.
• Capnography (EtCO2): Waveform capnography reflects ventilation and perfusion; a normal waveform with a normal value provides reassurance about airway and circulation.
• Skin signs: Color, temperature, and moisture. Pale, cool, diaphoretic skin suggests shock.

Document every vital sign with the time obtained. Trend over multiple sets is more informative than a single reading.

Documentation: The PCR

The Patient Care Report (PCR) is a legal and medical document. Record all findings in objective, anatomical terms. Note both normal findings ("breath sounds clear and equal bilaterally") and abnormal findings. Incomplete documentation implies an incomplete assessment. Complete your PCR while information is fresh — ideally before transferring care.

Safety Reminders

• Maintain spinal motion restriction throughout the secondary survey when mechanism or symptoms indicate spinal injury risk.
• Reassess the primary survey any time you find a serious secondary survey finding.
• Standard precautions (gloves at minimum) must be worn during all physical assessments.
• Never skip the primary survey to begin the secondary survey faster — the primary survey finds life threats first.
• Communicate abnormal findings to the receiving facility early so they can prepare.