NOTE: You may find upon inspection that the
patient is wearing a hairpiece or wig. Hairpieces
and wigs may be held in place by adhesive, tape,
or permanent glue, so DO NOT remove them
unless you suspect profuse bleeding.
Attempting removal may aggravate injury or
Step 4 . Check the skull and face for
deformities and depressions. As you feel the scalp,
check for depressions or bony projections. Visually
examine facial bones for signs of fractures. Unless
there are obvious signs of injury, gently palpate the
cheekbones, forehead, and lower jaw.
Step 5.Examine the patients eyes. After
examining the face and scalp, move back to a side
Begin your examination of the eyes by
looking at the patients eyelids. Do not open the
eyelids of patients with burns, cuts, or other injuries
to the eyelid(s). Assume there is damage to the eye
and treat accordingly. If eyelids are not injured, have
patients open their eyes. To examine the eyes of
unconscious patients, gently open their eyes by
sliding back the upper eyelids.
Keep in mind,
pressure applied to the eyelid may cause further
injury. When the eye has been opened, visually check
the globe of the eye.
Step 6.Check the pupils for size, equality, and
reactivity. Using a penlight or flashlight, examine
both eyes. Note pupil size and if both pupils are equal
in size. Also, see if the pupils react to the beam of light.
Note a slow pupil reaction to the light. Look for eye
movement. Both eyes should move as a pair when they
observe moving persons or objects.
NOTE: Check unconscious patients for contact
lenses. Prompt removal of contact lenses is
If removal of the lens is
impractical, close the patient's eyes so the
contact lenses stay lubricated.
Table 4-1 lists pupil characteristics you may
encounter 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 the
upper lid up and the lower eyelid down, and check the
color of the inner surface. Normally, the inner surfaces
of the eyelids are pink. However, with blood loss they
become pale; with jaundice, the surface is yellow. The
inner surface of the eyelid is an excellent location to
detect cyanosis (skin discoloration due to lack of
oxygen), especially for patients with dark skin
pigmentation. Cyanosis is denoted by a blue color.
Step 8.Inspect the ears and nose for injury
and the presence of blood or clear fluids. Without
rotating the patients head, inspect the ears and nose for
cuts, tears, or burns. Use a penlight to look in the ears
and 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 skull
Also, check for bruises behind the ears,
commonly referred to as Battles sign. Bruises behind
the ears are strong indicators of skull fracture and
cervical spine injury. Burned or singed nasal hairs
indicate possible burns in the airway.
Step 9.Inspect the mouth. Look inside the
mouth for signs of airway obstruction that may not
have been observed during the primary survey (e.g.,
loose or broken teeth, dentures, and blood). When you
inspect the mouth, remember not to rotate the patients
Step 10.Smell for odd breath odors.
your face close to the patients mouth and nose and
note any unusual odors.
A fruity smell indicates
diabetic coma or prolonged vomiting and diarrhea; a
petroleum odor indicates ingested poisoning; and an
alcohol odor indicates possible alcohol intoxication.
POSSIBLE CAUSE OF
Dilated and unresponsive
Influence of drugs (e.g., LSD
Central Nervous System
disease or disorder
Influence of narcotics (e.g.,
h e r o i n ,
m o r p h i n e ,
Lackluster (dull) and
pupils do not appear to
Table 4-1.Listing of Pupil Characteristics and the Possible
Cause of Abnormality