3. Always assume trauma patients have a spinalinjury, especially unconscious trauma patients,unless you are certain you are dealing with apatient free from spinal injury (e.g., a medicalpatient with no trauma).HEAD-TO-TOE SURVEY.—The head-to-toesurvey is a systematic approach to performing aphysical examination. This survey is designed sonothing important is missed during the examination ofthe patient. There may be variations in the head-to-toesurvey depending on local guidelines. Traditionally,the examination is started with the head. However,most medical authorities now recommend that theneck be examined first in an effort to detect possiblespinal injuries and any serious injury to the trachea thatmay lead to an airway obstruction.During the head-to-toe survey, you shouldlook for discolorations, deformities,penetrations, wounds, and any unusual chestmovements;feel for deformities, tenderness, pulsations,abnormal hardness or softness, spasms, and skintemperature;listen for changes in breathing patterns andunusual breathing sounds; andsmell for any unusual odors coming from thepatient’s body, breath, or clothing.The head-to-toe survey may appear to be a longprocess, but as you practice the procedure you will findthat it can be done in just a few minutes. All necessarypersonal protective equipment, such as exam glovesand eye protection, should be worn during yourexamination.Begin the survey by kneeling at the side of thepatient’s head. Quickly take an overview of thepatient’s body (i.e., general appearance, demeanor,behavior, skin color and characteristics, etc.), thenperform the 26 steps described in the followingsections.Step 1.—Check the cervical spine for pointtenderness and deformity.To perform thisprocedure, gently slide your hands, palms up, underboth sides of the patient’s neck. Move your fingertipstoward the cervical midline. Check the back of theneck from the shoulders to the base of the skull. Applygentle finger pressure. A painful response to thispressure is point tenderness.If there are signs of possible spinal injury, such asmidline deformities, point tenderness, or musclespasms, stop the survey and provide stabilization of thehead and neck.NOTE:If a rigid cervical collar is to beapplied, make sure you have examined theposterior, anterior, and sides of the neck beforeapplying the collar.Step 2 .— Inspect the anterior neck forindications of injury and neck breathing.Thisprocedure consists of exposing the anterior neck tocheck for injury and to detect the presence of a surgicalopening (stoma) or a metal or plastic tube(tracheostomy). The presence of a stoma ortracheostomy indicates the patient is a neck breather.Also, if you have not already done so in the primarysurvey, check for a medical identification necklace. Anecklace may state the patient has a stoma ortracheostomy.Look for signs of injury, such as the larynx ortrachea deviated from the midline of the neck, bruises,deformities, and penetrating injuries. Also, check fordistention of the jugular vein. If the jugular vein isdistended, there may be an airway obstruction, acervical spine injury, damage to the trachea, or aserious chest injury. All of these conditions requireimmediate medical care.After the anterior neck is inspected and if a spinalinjury is suspected, apply a rigid cervical or extricationcollar. If the patient is unconscious, assume the patienthas a spinal injury.Step 3.—Inspect the scalp for wounds.Useextreme caution when inspecting the scalp for wounds.Pressure on the scalp from your fingers could drivebone fragments or force dirt into wounds. Also, DONOT move the patient’s head, as this could aggravatepossible spinal injuries. To inspect the scalp, start atthe top of the head and gently run your gloved fingersthrough the patient’s hair. If you come across an injurysite, DO NOT separate strands of the hair. To do thiscould restart bleeding. When the patient is found lyingon his back, check the scalp of the back of the head byplacing your fingers behind the patient’s head. Thenslide your fingers upward toward the top of the head.Check your fingers for blood. If a spinal or neck injuryis suspected, delay this procedure until the head andneck have been immobilized. Furthermore, if yoususpect a neck injury, DO NOT lift the head off theground to bandage it.4-6
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