5-17. PHYSICAL ASSESSMENT

a. Primary/Secondary Survey. The primary survey and the secondary survey are actually done in a flowing motion. These two surveys are not really separated. The difference is that the primary survey is done quickly and in a short time while the secondary survey is done in more depth with touching and feeling the patient. During the primary survey, temporarily stabilize the patient's head and neck until the survey is complete. Remember, it is possible to cause permanent paralysis to the patient by moving him improperly if he has a spinal cord injury.

(1) Primary survey. Primary survey is a rapid examination to determine the patient's condition. The examination should not take more than one and a half to two minutes. The examination should consist of the following:

(a) Evaluate the airway, cervical spine control, and the patient's initial level of consciousness.

(b) Evaluate the patient's breathing.

(c) Evaluate the patient's circulation.

(d) Stop the patient's major bleeding.

(e) Observe the general appearance of the patient.

(f) Note the position in which the patient was found. Some positions are characteristic of certain injuries. For example, a patient with his arms in the "stick em up" position may have a cervical spinal injury. If the patient's arms are flexed across his chest and his hands are half closed, there may be damage to the 6th vertebra of the cervical spine.

(2) Secondary survey. The secondary survey does not begin until the primary survey has been completed. The secondary survey is a head-to-toe evaluation. This indepth evaluation utilizes the look, listen, and feel techniques, evaluating the body by sections.

(a) Hypotension (abnormally low blood pressure) minus shock. Be alert for signs/symptoms of hypotension without signs of shock. This condition indicates the patient is experiencing neurogenic shock (shock originating in the nervous system).

(b) Depth of breathing. Observe the depth of the patient's breathing as you count the patient's respirations. If the respirations are coming from the diaphragm only, assist in ventilations.

(c) Head/face cuts and/or bruises. Check the patient's head and face for cuts or bruises. Most patients with cervical spine injuries also have head or facial injuries.

(d) Neck abnormalities. Gently palpate the patient's neck for deformity and tenderness. If the patient is conscious, ask him to tell you if he feels any tenderness as you palpate.

(e) Chest/abdomen internal injuries. Examine the chest and abdomen of the patient for signs of internal injury. A patient whose skin is pale, cold, and clammy and who has tachycardia (abnormally fast heartbeat), may be in hypovolemic shock (abnormally decreased amount of blood and fluids in the body). Bleeding into the chest or abdomen are possible causes of such shock.

(f) Priapism (sustained erection). Observe for priapism. Priapism is a characteristic sign of spinal cord injury.

(g) Control of elimination. Note any signs of loss of bowel or bladder control.

(h) Spinal area check. Log roll the patient (turning the body as one unit, and check the spinal area for deformity or pain.

1 Examine the patient's back for any swelling or hematoma over the spinal area. Either of these signs would indicate the presence of a bony fracture.

2 Look for a spasm in paravertebral muscles. A curvature of the spine often indicates such spasms.

3 Look for any open injuries involving the spinal column. Cover any such injury with a sterile dressing.

b. Neurologic Examination. The purpose of a neurologic assessment is to furnish data about the exact condition of the patient when he was first seen. Later, any changes in the patient's condition may be evaluated, and the course of further treatment determined. The neurologic assessment is NOT to decide whether or not to immobilize the patient.

(1) Check the spinal nerve tracts for position, pain, and movement.

(2) Check for normal movement of toes and fingers. Does the patient feel normal sensation? Can the patient tell when some one is moving his (the patient's) finger or toes up or down?

(3) Does the patient feel pain in response to a pin prick? Start at the patient's feet and move upward. Mark the level at which the patient first feels the pin prick.

CAUTION: A normal neurologic examination does not rule out the possibility that the patient has a spinal cord injury. Persons who have been in accidents involving automobiles, motorcycles, trucks, etc. have walked away from the accident. Hours later the individuals have become totally paralyzed after a nod of the head which squeezed an unstable vertebral column down against the spinal cord. Therefore, when the mechanism of injury suggests that the patient could have a spinal cord injury, treat him as though he does have such an injury, regardless of the neurologic findings.

c. Motor Function Check.

(1) Can the patient wiggle his toes? Fingers? If not, can he move his wrists, elbows, etc.?

(2) If the patient is unconscious, test with a noxious stimulus and observe him for signs of withdrawal.

REMEMBER: Assessment is NOT to determine whether the patient should be immobilized, but to establish the patient's condition at the moment of assessment.