NOTE: You may find upon inspection that thepatient is wearing a hairpiece or wig. Hairpiecesand wigs may be held in place by adhesive, tape,or permanent glue, so DO NOT remove themunless you suspect profuse bleeding.Attempting removal may aggravate injury orrestart bleeding.Step 4 .— Check the skull and face fordeformities and depressions. As you feel the scalp,check for depressions or bony projections. Visuallyexamine facial bones for signs of fractures. Unlessthere are obvious signs of injury, gently palpate thecheekbones, forehead, and lower jaw.Step 5.—Examine the patient’s eyes. Afterexamining the face and scalp, move back to a sideposition.Begin your examination of the eyes bylooking at the patient’s eyelids. Do not open theeyelids of patients with burns, cuts, or other injuriesto the eyelid(s). Assume there is damage to the eyeand treat accordingly. If eyelids are not injured, havepatients open their eyes. To examine the eyes ofunconscious patients, gently open their eyes bysliding back the upper eyelids. Keep in mind,pressure applied to the eyelid may cause furtherinjury. When the eye has been opened, visually checkthe globe of the eye.Step 6.—Check the pupils for size, equality, andreactivity. Using a penlight or flashlight, examineboth eyes. Note pupil size and if both pupils are equalin size. Also, see if the pupils react to the beam of light.Note a slow pupil reaction to the light. Look for eyemovement. Both eyes should move as a pair when theyobserve moving persons or objects.NOTE: Check unconscious patients for contactlenses. Prompt removal of contact lenses isrecommended. If removal of the lens isimpractical, close the patient's eyes so thecontact lenses stay lubricated.Table 4-1 lists pupil characteristics you mayencounter and the possible causes of abnormalities.Step 7.—Inspect the inner surfaces of the eyelids.If there is no obvious injury to the eye, gently pull theupper lid up and the lower eyelid down, and check thecolor of the inner surface. Normally, the inner surfacesof the eyelids are pink. However, with blood loss theybecome pale; with jaundice, the surface is yellow. Theinner surface of the eyelid is an excellent location todetect cyanosis (skin discoloration due to lack ofoxygen), especially for patients with dark skinpigmentation. Cyanosis is denoted by a blue color.Step 8.—Inspect the ears and nose for injuryand the presence of blood or clear fluids. Withoutrotating the patient’s head, inspect the ears and nose forcuts, tears, or burns. Use a penlight to look in the earsand nose for blood, clear fluids, or bloody fluids.Blood in the ears and clear fluids (cerebrospinal fluid)in the ears or nose are strong indicators of a skullfracture. Also, check for bruises behind the ears,commonly referred to as Battle’s sign. Bruises behindthe ears are strong indicators of skull fracture andcervical spine injury. Burned or singed nasal hairsindicate possible burns in the airway.Step 9.—Inspect the mouth. Look inside themouth for signs of airway obstruction that may nothave been observed during the primary survey (e.g.,loose or broken teeth, dentures, and blood). When youinspect the mouth, remember not to rotate the patient’shead.Step 10.—Smell for odd breath odors.Placeyour face close to the patient’s mouth and nose andnote any unusual odors. A fruity smell indicatesdiabetic coma or prolonged vomiting and diarrhea; apetroleum odor indicates ingested poisoning; and analcohol odor indicates possible alcohol intoxication.4-7PUPILCHARACTERISTICSPOSSIBLE CAUSE OFABNORMALITYDilated and unresponsiveCardiac arrestInfluence of drugs (e.g., LSDand amphetamines)Constricted andunresponsiveCentral Nervous Systemdisease or disorderInfluence of narcotics (e.g.,h e r o i n , m o r p h i n e , o rcodeine)UnequalStrokeHead injuryLackluster (dull) andpupils do not appear tofocusShockComaTable 4-1.—Listing of Pupil Characteristics and the PossibleCause of Abnormality
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