3. Always assume trauma patients have a spinal
injury, especially unconscious trauma patients,
unless you are certain you are dealing with a
patient free from spinal injury (e.g., a medical
patient with no trauma).
HEAD-TO-TOE SURVEY.—The head-to-toe
survey is a systematic approach to performing a
physical examination.
This survey is designed so
nothing important is missed during the examination of
the patient. There may be variations in the head-to-toe
survey depending on local guidelines. Traditionally,
the examination is started with the head. However,
most medical authorities now recommend that the
neck be examined first in an effort to detect possible
spinal injuries and any serious injury to the trachea that
may lead to an airway obstruction.
During the head-to-toe survey, you should
look for discolorations, deformities,
penetrations, wounds, and any unusual chest
movements;
feel for deformities, tenderness, pulsations,
abnormal hardness or softness, spasms, and skin
temperature;
listen for changes in breathing patterns and
unusual breathing sounds; and
smell for any unusual odors coming from the
patient’s body, breath, or clothing.
The head-to-toe survey may appear to be a long
process, but as you practice the procedure you will find
that it can be done in just a few minutes. All necessary
personal protective equipment, such as exam gloves
and eye protection, should be worn during your
examination.
Begin the survey by kneeling at the side of the
patient’s head.
Quickly take an overview of the
patient’s body (i.e., general appearance, demeanor,
behavior, skin color and characteristics, etc.), then
perform the 26 steps described in the following
sections.
Step 1.—Check the cervical spine for point
tenderness and deformity.
To perform this
procedure, gently slide your hands, palms up, under
both sides of the patient’s neck. Move your fingertips
toward the cervical midline. Check the back of the
neck from the shoulders to the base of the skull. Apply
gentle finger pressure.
A painful response to this
pressure is point tenderness.
If there are signs of possible spinal injury, such as
midline deformities, point tenderness, or muscle
spasms, stop the survey and provide stabilization of the
head and neck.
NOTE:
If a rigid cervical collar is to be
applied, make sure you have examined the
posterior, anterior, and sides of the neck before
applying the collar.
Step 2 .— Inspect the anterior neck for
indications of injury and neck breathing.
This
procedure consists of exposing the anterior neck to
check for injury and to detect the presence of a surgical
opening (stoma) or a metal or plastic tube
(tracheostomy).
The presence of a stoma or
tracheostomy indicates the patient is a neck breather.
Also, if you have not already done so in the primary
survey, check for a medical identification necklace. A
necklace may state the patient has a stoma or
tracheostomy.
Look for signs of injury, such as the larynx or
trachea deviated from the midline of the neck, bruises,
deformities, and penetrating injuries. Also, check for
distention of the jugular vein. If the jugular vein is
distended, there may be an airway obstruction, a
cervical spine injury, damage to the trachea, or a
serious chest injury. All of these conditions require
immediate medical care.
After the anterior neck is inspected and if a spinal
injury is suspected, apply a rigid cervical or extrication
collar. If the patient is unconscious, assume the patient
has a spinal injury.
Step 3.—Inspect the scalp for wounds.
Use
extreme caution when inspecting the scalp for wounds.
Pressure on the scalp from your fingers could drive
bone fragments or force dirt into wounds. Also, DO
NOT move the patient’s head, as this could aggravate
possible spinal injuries. To inspect the scalp, start at
the top of the head and gently run your gloved fingers
through the patient’s hair. If you come across an injury
site, DO NOT separate strands of the hair. To do this
could restart bleeding. When the patient is found lying
on his back, check the scalp of the back of the head by
placing your fingers behind the patient’s head. Then
slide your fingers upward toward the top of the head.
Check your fingers for blood. If a spinal or neck injury
is suspected, delay this procedure until the head and
neck have been immobilized. Furthermore, if you
suspect a neck injury, DO NOT lift the head off the
ground to bandage it.
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