The purpose of a secondary assessment (composed of a head-to-toe, history and vitals) is to continually monitor the victim’s condition and find any non-life-threatening conditions requiring treatment. A secondary assessment should be done for any victim requiring ambulance intervention, or if there is a concern that the victim’s condition may deteriorate. In some cases, you may want to do a shortened secondary survey - use your best judgment.
Who is this for?
The Head-to-toe assessment is a technique used by lay rescuers, first responders, and ambulance personnel to identify an injury or illness or determine the extent of an injury or illness.
It is used on victims who meet the following criteria:
- Victim of trauma injuries (except minor injuries affecting peripheral areas, such as a skinned knee or paper cut)
- Unconscious victims
- Victims with very reduced level of consciousness
If a victim is found unconscious, and no history is available, you should initially assume that the unconsciousness is caused by trauma, and where possible immobilize the spine, until you can establish an alternative cause.
The secondary assessment should be performed on all the victims meeting the criteria (especially trauma) regardless of gender of rescuer or victim. However, you should be sensitive to gender issues here (as with all aspects of first aid), and if performing a full body check on a member of the opposite sex, it is advisable to ensure there is an observer present, for your own protection. In an emergency however, victim care always takes priority.
Priority of ABCs
The head-to-toe should be completed after the primary survey, so you are already confident in the victim having a patent airway, and satisfactory breathing and circulation.
You should always make ABCs a priority when dealing with victims who are appropriate for a secondary survey. In the case of trauma victims, where the victim is conscious and able to talk, keep talking to them throughout. This not only acts to reassure them and inform them what you're doing, but will assure you that they have a patent airway and are breathing.
For unconscious victims, if you are on your own, check the ABCs between checking every body area, or if you are with another competent person, make sure they check ABCs continuously whilst you perform the survey.
Remember that if the person is unconscious and if you know or suspect it to be a trauma injury (evidence of blood, fall etc.) than you MUST treat it as a potential spinal injury in the first instance. This is because in trauma, any blow to the head sufficient to cause unconsciousness is also sufficient to cause spinal injury. In this case immobilization of the head, neck and spine takes priority over the secondary survey. If you have a second rescuer or bystander, then have them immobilize while you perform the head-to-toe.
What is being looked for?
The head-to-toe is a detailed examination where you should look for abnormality. This can take the form of asymmetry; deformity; bruising; point tenderness (wincing or guarding - don't necessarily expect them to tell you); minor bleeding; and medic alert bracelets, anklets, or necklaces.
It is important to remember that some people naturally have unusual body conformation, so be sensitive about this, but don't be afraid to ask the conscious victim or relatives if this is normal for them. It is always worth looking for symmetry - if it is the same both sides, the chances are, it's normal.
The six areas
Divide the body into 6 areas; after you examine each area, you reassess ABCs.
- Head and neck - The head and neck are important areas to assess, and you should take time and care to look for any potential problems.
- Head - Using both hands (with gloves on), gently run your hands across the skull, pressing in gently but firmly, starting at the forehead and working around to the back of the head. Feel for indentations, look for blood or fluid and watch the victim for signs of discomfort. If it is a trauma injury, check both ears and nose for signs of blood or CSF (cerebral spinal fluid).
- Neck - The neck is an important area. Start at the sides of the neck and gently press in. Watch carefully for signs of pain. Move around until you reach the spine, moving as far down the neck as possible without moving them, if they are on their back. If there is pain, tenderness or deformity here, then you should stop the survey and immediately immobilize the neck, placing one hand on each side of the head, with the thumb around the ear. This is most comfortable done from 'above' with the victim lying supine on their back, although you should support the victim in the position you find them. If there is room, you can also lie on your front, with your elbows on the floor to support the head. If there are two people, one should immobilize the head, whilst the other continues the survey. If there is only one person, immobilize the head and wait for help.
- Shoulders, chest and back - This area of the body contains many of the vital organs, such as the heart and lungs, so it is important to look for damage which could indicate internal injury.
- Shoulders - You should try and expose the shoulders if possible, looking for obvious deformity, especially around the collar bones. You can try pressing along the line of the collar bone, watching for deformity or pain. You should then place a hand on each shoulder, and gently push down, looking to ensure that one side does not move more than the other.
- Chest - The chest is ideally done exposed, although you should be aware of the sensitivity of females to this, and if you are able to keep breasts covered, it is advisable to do so. You should be looking for sections of the chest which are out of line with the rest of it, or which are moving differently to the rest of the chest whilst breathing. You should also look for obvious wounds. You can then gently press on the chest. The best way to do this is to imagine the chest divided in to four quarters running neck to stomach. You should place one hand (balled as a fist works well here, to avoid concerns over excess touching) and press down one on the left and one on the right in each quarter (avoiding breasts if applicable). You are watching for one side moving differently to the other, or for pain being caused.
- Back - If the victim is lying on their side, or front, you can also feel down their spine. If they are lying on their back, then skip this part of the check, and leave it for the ambulance crew.
- Arms and hands - Run both your hands down one arm at a time, looking for deformity or pain.
- Abdomen - The abdomen contains the remainder of the body's critical organs, such as the intestines, so it should be checked for potential damage. The abdomen is mostly done by gentle pushing, using the flat of your hands. Again, use symmetry, and push both sides simultaneously. Check if the abdomen feels hard (called 'boarded') or for pain caused by the palpation.
- Pelvis - The pelvis (hips) is a large bone, with potential for a fair amount of damage. The main diagnostic test to place a hand on each hip and first gently compress the hips together with both hands (there should be very little movement, and little to no pain). If the patient has moderate to severe pain when the hips are compressed, or the hips move when compressed, do not rock the hips from side to side. If there is no pain or movement, gently push down on the hips in a "rocking" motion to see if there is any movement.
- Legs and feet - As with arms, use both hands at the same time, running them down the inside and outside of each leg simultaneously (avoiding the groin area on the inside). You should also look for any shortening or rotation of one leg compared to the other. Finally, you take each foot, check that it has normal motility (can be moved normally) and has no obvious injuries.