Secondary survey

A Practical Secondary Survey: Head-to-Toe Assessment in Pre-Hospital Care

The secondary survey is a structured, methodical head-to-toe examination performed once the primary survey (DRCABCDE) has been completed and immediate life-threats have been addressed. Its purpose is to identify additional injuries, subtle signs of serious pathology, and evolving clinical problems that may influence triage, treatment, and transport decisions.

If the patient is unconscious, has an unknown history, or there is suspicion of spinal trauma, spinal motion restriction should be maintained throughout, including during any log-roll.

General principles before you start

• Maintain manual cervical spine control where indicated.

• Use a systematic, repeatable sequence.

• If your gloved hands disappear, they get checked for blood.

• No gloves, no love.

• Any deterioration → return immediately to the primary survey.

1. Head and scalp

Begin at the vertex of the skull, using both hands.

Palpation

• Assess for scalp lacerations, swelling, and bleeding

• Feel for bogginess (suggestive of underlying skull fracture or haematoma)

• Check skull stability and step deformities

Signs of basal skull fracture

• Post-auricular ecchymosis (Battle’s sign) – bruising behind the ears

• Periorbital haematoma (raccoon eyes)

• Otorrhoea – fluid leaking from the ears

• Rhinorrhoea – fluid leaking from the nose

• Cerebrospinal fluid (CSF) leakage, either alone or mixed with blood, is concerning. Blood alone is less specific.

• Where time allows:

  • Halo sign (gauze test) – CSF separates from blood forming a clear ring

  • Glucose testing may help differentiate CSF from blood

  • In reality, these are often impractical pre-hospital; clinical suspicion matters more.

2. Eyes and face

Eyes

• Assess PERRLA

• Pupils Equal, Round, Reactive to Light and Accommodation

• Look for:

  • Unequal pupils (anisocoria)

  • Non-reactive pupils

  • Periorbital bruising or swelling

Face and jaw

Inspect and palpate for:

• Facial fractures

• Instability (?Le Forte Fracture)

• Dental injury

• Check dentition and note loose or missing teeth - Plan A is to replace teeth back in socket if possible, Plan B is to place the tooth between the gums and cheeks (in conscious patients only), Plan C is to place in milk

• Always consider airway implications again during secondary survey

3. Neck

While maintaining spinal precautions:

• Inspect for bruising, swelling, wounds, or deformity

Palpate gently for:

• Midline cervical tenderness

• Step deformities

Assess for:

• Tracheal deviation

• Surgical emphysema

Any abnormality should heighten suspicion of cervical spine injury.

4. Shoulders and upper limbs

• Spring the shoulders gently to assess clavicles and shoulder girdle.

• Inspect and palpate:

  • Clavicles

  • Upper arms

  • Elbows

  • Forearms

  • Wrists and hands

  • Assess long bones for:

    • Deformity

    • Pain

    • Swelling

  • Check circulation, sensation, and movement (CSM) bilaterally

5. Chest and thorax

• FLAPS TWELV is a good mnemonic to remember the following steps:

• FEEL & LOOK: Using both hands together in a praying position, move down the sternum then once at the bottom of the sternum, fan outward with flattened hands to assess the entire thorax circumference, then move up to assess the axillae (armpits), then assess the back as much as possible without rolling using a large ‘X’ formation with your arms and hands. Do this to check for:

  • Tracheal deviation

  • Wounds (don't forget the neck and axillae! Tip: if its a bleeding junction - pack it, if its not - chest seal)

  • Surgical emphysema

  • Larygenal crepitus

  • Venous distention (of the jugular veins either side of the neck)

  • Evaluate all your signs and symptoms you have found so far and decide if needle thoracocentesis is required (reduced GCS paired with any of the above in major trauma)

• Auscaltate: if available, use your stethoscope to auscaltate for:

  • Equal bilateral rise and fall of the chest

  • Equal bilateral air entry and exit

  • Reduced air entry and exit (potential for haemothroax - blood in the chest cavity, or pneumothorax - air in the chest cavity

  • Bowel sounds - a sign of diaphragmatic rupture.

• Percuss: This step often isn’t possible due to ambience noise, but if possible assess for the following:

  • Hypo-resonance: if combined with reduced air entry over the same area, suspect haemothorax and prepare fot finger or tube thoracostomy if trained and authorised to do so

  • Hyper-resonance: if combined with reduced air entry over the same area, suspect pneumothorax and prepare for needle thoracocentesis (vhest decompression) if trained and authorised to do so.

• Search: Search those junctional areas, the upper back and armpits again - these are high risk areas for wounds and injuries that are often missed!

6. Abdomen

• Inspect for:

• Bruising (including seatbelt sign)

• Distension

• Penetrating injury

  • Undertake Manual Inline Stabilisation if the pentrsting injury has crossed the Midline i.e. it may have struck the spine

• Palpate gently for:

  • Tenderness

  • Guarding

  • Rigidity

Remember, abdominal injury may be occult and deteriorate over time.

7. Pelvis

• Inspect first:

  • Leg position (splayed or externally rotated)

  • Asymmetry

• Do NOT spring the pelvis

• While assessing this area, look for indirect signs of other injuries:

  • Scrotal swelling (abdominal haemorrhage)

  • Perineal bruising (abdominal haemorrhage)

  • Priapism (suggestive of spinal cord injury)

8. Lower limbs

• Inspect and palpate:

  • Femurs: if fracture is suspected apply traction to effected limb if trained to do so

  • Knees

  • Lower legs: if open fracture, consider prophylactic broad spectrum anti biotics if trained and authorised to do so

  • Ankles and feet: Ottawa ankle and mid foot rules are good tools to assist with imaging decision making. Babinki's response should also be tested at this stage with a negative test being good (toes plantarflex), a positive test being bad (toes dorsiflex) and no response likely meaning the casualty has had this since birth.

• Check CSM in both legs

9. Posterior examination (log-roll if indicated)

• Only if:

  • Adequate personnel are available

  • Spinal precautions are maintained

• Assess:

  • Entire back

  • Spine alignment

  • Wounds, bruising, bleeding

  • Buttocks and posterior thighs

Again: if your gloved hands disappear, check them for blood.

10. Reassessment and documentation

• The secondary survey:

  • Is not a one-off

  • Must be repeated

• Should inform:

  • Ongoing treatment

  • Triage priority

  • Transport destination

  • Clinical handover

Any deterioration → return to DRCABCDE immediately.

Key takeaway

The secondary survey is a deliberate, methodical head-to-toe assessment that complements the primary survey. When performed properly, it reduces missed injuries, improves triage decisions, and strengthens patient safety in pre-hospital care.

Disclaimer: This guide is provided for educational purposes only. It is not a substitute for certified first aid training. Although we base our information on current UK-approved guidelines (Resuscitation Council UK, St John Ambulance, etc.), performing first aid requires practice, training and judgement. If in doubt, always call emergency services (999 in the UK) and wait for professional responders. K2 International does not accept liability for actions taken by users based on this guide.