moved, all suspected or known fractures should bestabilized (with splints, traction splints, or the like).Step 21.—Check for a distal pulse and capillaryrefill. To make sure there are no circulatory problemsin the legs or feet, check the distal pulse and capillaryrefill. The distal pulse is a pulse taken at the foot orwrist. It is called distal because the pulse is located atthe distal end of the limb. The distal pulse of the foot,also referred to as pedal pulse, may be taken at eitherof two sites: the posterior tibial pulse (located behindthe medial ankle) or the dorsalis pedis pulse (locatedon the anterior surface of the foot, lateral to the largetendon of the great toe).You should compare the quality of the pulses ineach lower limb. Absence of a distal pulse usuallyindicates that a major artery supplying the limb hasbeen pinched or severed. This condition may becaused by a broken or displaced bone end or a bloodclot. An absent or weak distal pulse may also resultfrom splints or bandages being applied too tightly.Check capillary refill by squeezing a toe (usually,the big toe) with your thumb and forefinger. The skinand nail where pressure is applied should blanch(lighten). When you release the pressure, the color(blood) should return immediately. If it takes morethan 2 seconds for the color to return, capillary refill isconsidered delayed.NOTE: After splints or bandages are applied,check capillary refill to make sure circulationhas not been impaired.Step 22.—Check for nerve function andpossible paralysis of the lower extremities(conscious patient). Check the lower extremities ofconscious patients for nerve function or paralysis.First, touch a toe and ask the patient which toe it is. Dothis to both feet. If the patient cannot feel your touch orif the sensations in each foot are not the same, assumethat nerve damage in the limb or a spinal injury hasoccurred.If sensations appear normal and no injuries arepresent, have the patient wave his feet. Finally, ask thepatient to gently press the soles of his feet against yourhand. The inability of the patient to perform any ofthese tasks indicates the possibility of nerve damage.When nerve damage is suspected, assume the patienthas a spinal injury.Step 23.—Examine the upper extremities forinjury. Check for signs of injury to the upperextremities (arms and hands) by inspecting each limb,one at a time, from clavicle to fingertips. Rearrange orremove items of clothing to observe the entireexamination site. Check for point tenderness,swelling, or bruising. Any of these symptoms mayindicate a fracture. Immobilize any limb where afracture is suspected.Step 24.—Check for a distal pulse and capillaryrefill. To make sure the circulation to the upperextremities has not been compromised, confirm distal(radial) pulse. Initial check of radial pulse wasperformed during the primary survey. Check capillaryrefill of fingers or palm of hand (see step 21 forprocedure). If there is no pulse or if capillary refill isdelayed, the patient may be in shock or a major arterysupplying the limb has been pinched, severed, orblocked.Step 25.—Check for nerve function andpossible paralysis of the upper extremities(conscious patient). Check the upper extremities ofconscious patients for nerve function or paralysis.Have the patient identify the finger you touch, wave hishand, and grasp your hand. Do this to both hands. Ifthe patient cannot feel your touch or the sensations ineach hand are not the same, assume nerve damage inthe limb or a spinal injury has occurred.WARNING: Be alert for a rapid onset ofdifficult breathing or respiratory arrest.These conditions may occur to patients whohave sustained a cervical injury.Step 26.—Inspect the back and buttocks forinjury. If there is no indication of injury to the skull,neck, spine, or extremities, and you have no evidenceof severe injury to the chest or abdomen, gently roll theconscious patient as a unit toward your knees andinspect the surface of the back for bleeding or obviousinjuries. The back surface may be inspected prior topositioning the patient for transport or delayed until thepatient is transferred to a spineboard or otherimmobilization device.VITAL SIGNS.Vital signs (which generally aretaken after primary, secondary, and head-to-toesurveys have been completed) include taking thepatient’s pulse, respiration, blood pressure, andtemperature. Depending on local protocols, thepatient’s level of consciousness as well as eye pupilsize and reactivity may be recorded with vital signs.Skin characteristics, such as temperature, color, and4-9
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