How to Give a Complete First Aid Secondary Survey
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Learn how to give a complete first aid secondary survey.
This post includes how to take and record a patients SAMPLE history and vital signs. It also goes through how to give a full body physical exam and the use of SOAP notes to record your findings.
In a secondary survey, look for injuries unseen during the primary assessment (DRABC).
Complete First Aid Secondary Survey Introduction
IMPORTANT: No amount of reading can compare to a medical course with a professional trainer. A standard first aid course is good. A Remote Area First Aid Course or higher is best.
After stabilizing your patient using DRABC, do the first aid secondary assessment. To give a first aid secondary examination means to check your patient from head to toe. Do it in a methodical way so you do not miss anything.
In critical first aid (DRABC), you treat the problems as you find them. With the secondary exam, you complete the full assessment first. Then you treat what you find in order of priority.
SAMPLE History, vital signs, and the full body exam make up the secondary survey steps. A secondary survey should start with whichever is most appropriate for the situation. For example, if the patient is incoherent then taking a SAMPLE History will have to wait.
Recording Your Findings (SOAP Notes)
While doing the secondary assessment of a medical patient, record your findings with SOAP notes. Record your findings of the primary and secondary assessment of a patient. Use the luxury of time during the secondary examination to "catch up on your paperwork".
Recording your findings in first aid is very important. Give the information you find to all caretakers of the patient.
- Use the acronym SOAAP to record your findings.
- āSubjective information: History, scene, story and symptoms.
- āObjective information: Exam findings, vital signs.
- āAssessment: All the problems you found.
- āAnticipated Problems: Any problems that may arise.
- āPlan: What you are going to do.
Write the patientās personal details at the top. Include his/her name, age, sex, birth date, weight, phone number, etc.
There are many SOAAP (SOAP) Note templates on the internet, but a pencil and paper will suffice if that's all you have. Using an actual SOAP note is best. They are like a secondary survey checklist.
SAMPLE Secondary Assessment
The best/easiest way to extract your patient's history is to talk to him. It is important that the patient feels comfortable with you. If not, he/she might be too embarrassed to tell you what may be important information. Ensure them that everything they tell you is confidential and not to leave anything out.
Use the acronym SAMPLE to make sure you do not miss anything.
- āSymptoms: What are the patientās symptoms?
- āAllergies: Does the patient have any known allergies? This includes medication.
- āMedications: Is the patient on any medication?
- āPast History: Is the problem reoccurring? Does the patient or the patientās family have a history of a suspected ailment?
- āLast: A history of the last things that went in and out of the personās body.
- āEvents: A detailed description of the events that led up to the problem.
How to Take a Patient's Vital Signs
Assessing and monitoring your patient's vital signs will provide you with important information. It will help you decide on a treatment and then track the effectiveness.
Pulse
- āCount the pulse for 15 seconds and multiply it by 4.
- ā60 to 100 beats per minute is normal.
Respiration
- āCheck for an entire minute.
- āNormal rate of breaths per minute (BPM) for an adult at rest is 12-18 breaths per minute. Over 20 is a sign of distress.
- āThe younger a child, the faster their respiratory rate. An infant may have between 30 to 60 breaths per minute whereas a school age child (6 to 12 years) may have 18 to 30.
- āNote any unusual noises, e.g., wheezing or gurgling.
Blood Pressure
- Check blood pressure if the equipment is available.
- āBlood pressure measures the amount of work the heart has to do to pump blood through the body.
- āA reading less than 140/90 at rest is normal. It may be high after extreme physical exertion but goes back down after a short while.
- āHigh blood pressure may be a medical condition and low blood pressure may mean hemorrhage or shock.
Skin
- āCheck color (red, pale), temperature (hot, cold) and moisture (clammy, dry, moist etc.).
Body Temperature
- Handstand for 30 seconds.
- āBent-arm handstand for 30 seconds.
- ā10 wall handstand push-ups.
Mental Status
- āGauge with AVPU.
- āIf there is a problem with the patientās mental status, use the acronym STOPEATS to discover the cause:
- āSugar: Hypo or hyperglycemia.
- āTemperature: Hypo or hyperthermia.
- āOxygen: Abnormal levels of oxygen.
- āPressure: Increasing ICP.
- āElectricity: Trauma from electric shock or problems in the brain.
- āAltitude: High altitudes can result in various altitude related illnesses. Very low altitudes (i.e., underwater) can result in various diving related illnesses.
- āToxins: Drugs, alcohol, poisons, etc.
- āSalts: Low sodium or potassium levels.
How to Give a Full Body Physical Exam
Examine the areas about which the patient has a specific complaint about. Compare any outer physical complaints to the patient's non-injured side.
Check the range of motion, circulation, motor skills, sensation etc. Be very careful about forcing something to move.
Do this in a systematic manner, from head to toe. Use only as much physical pressure as is necessary to discover an injury or lack thereof. Check the whole body for obvious signs of injury, e.g., bruises, bleeding, etc.
A stethoscope, penlight, gloves and tongue depressor will be useful.
- āHead. Bumps, bruises, bleeding from orifices, etc.
- āEyes. Redness, whether the pupils respond equally to light.
- āMouth. Inside and outside. Redness, sores, dental issues.
- āNeck. All around neck and back of the head, neck bones (vertebrae).
- āChest. Use a stethoscope if available. Check lungs for abnormal sounds. Wheezing, gurgles, crackles, etc.
- āHeart. Rhythm of heart beat, e.g., fast, slow regular, irregular.
- āRibs. Possible fracture.
- āArmpits. Injury, parasites (lice, ticks etc.), tenderness.
- āBreast. Move your fingers in a circular motion over the breast tissue. Start from where the arm connects to the shoulder and end at the nipple.
- āAbdomen.
- Press on the abdomen with your open hand. Check for pain, tenderness, swelling, abnormal masses, etc.
- āListen for bowel sounds and note if there is too much or too little.
- āCheck percussion. Place your open hand on the different quadrants of the abdomen and tap on your middle finger. It should sound hollow.
- Liver and Spleen. Press down on the patientās right side below the rib cage to determine an enlarged liver. You wonāt feel it if it isnāt. An enlarged spleen will appear as a mass on the left side under the bottom of the rib cage.
- āSpine. Check along the patientās spine for evidence of pain or injury. Never press on the vertebrae. Learn how to give a proper spinal assessment in this post.
- āKidneys. Pound lightly with a closed hand on each side of the back below the last rib. An injury or infection of the kidneys will result in pain.
- āExtremities.
- āExamine each extremity by feeling the muscle groups for pain or decreased range of motion.
- āCheck perfusion.
- āCheck for sensation by lightly tapping with sharp and dull sensations on the hands and feet. A safety pin works well.
General Strength.
- āPlace your hands on their thighs and ask them to lift up.
- āAsk them to grasp your fingers with each hand then try to pull your hand away; if you canāt, thatās good.
- āStrength should be about equal on both sides of the body.
First Aid Secondary Survey Conclusion
The first aid secondary survey will help you diagnose and treat non-immediate medical problems.
Do not underestimate the importance of recording your findings. It will help you organize your thoughts, and is also very important when passing your patient on.
Using a SOAP note will also lessen the chance of missing possible findings in the patient.
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