1. Secondary Survey Chapter 2 Presentation: Secondary Survey
Time Line: 25 minutes
Participant manual page reference for slide: Casualty Management.
The following WSIB learning objectives have been met in this chapter:
Secondary Survey – Elective Module
8.1. Perform the four steps of a secondary survey.
8.1.1 Describe the secondary survey and its purpose.
List the four steps of a secondary survey:
Obtain the history of the casualty.
Assess and record the vital signs.
Perform a head-to-toe examination.
Give first aid for injuries and illnesses found.
List the four vital signs used in first aid:
Levels of consciousness (LOC).
Breathing.
Pulse (radial, carotid or brachial).
Skin condition and temperature.
Secondary Survey

2. Instructor Notes Continued
Describe why it is important to monitor and note the changes in the casualty’s LOC.
List three responses used for assessing the levels of consciousness (modified Glasgow coma scale).
Describe effective breathing for a healthy adult casualty at rest:
Rate
Rhythm
Depth (effort, sound)
Describe the characteristics of the pulse for a healthy adult at rest:
Average pulse rate
Normal range of pulse rates
Rate, rhythm, and strength
Perform, on a simulated casualty, steps to assess the vital signs.

3. Emergency Scene Management
The 4 sequential steps of ESM:
Scene Survey – Safety first, gather history and environment control.
Primary Survey – Life threatening priorities. Take spinal precautions. (ABC’s, perform gross bleed check).
Secondary Survey – Address secondary injuries.
Ongoing Casualty Care – Continue to reassess life threatening priorities and stay with the patient.
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 19
WSIB Requirements: n/a
Instructors Notes
Quick review as this has already been addressed.
ESM is steps (or procedures) to help manage an incident scene. This plan ensures the safety of the rescuer and the casualty.
Scene Survey. “Look up, down and all around”
Primary survey = life threatening injuries first. Rescuers should perform a rapid body/gross bleed check. Explain how a gross bleed check is performed.
Secondary Survey = Secondary injuries.
Ongoing Casualty Care = Continue to treat for shock and reassess ABCD’S.
Secondary Survey

4. Scene Survey Start by ensuring the scene is safe.
Take charge and identify yourself as a first aider.
Other responsibilities a first aider can assume are:
Calling out to bystanders for assistance.
Getting other help (police, hydro).
Assessing and triaging multiple patients.
Looking for witnesses.
Gathering (PPE) or first aid kit.
Crowd control.
Getting medical help and preparing for their arrival.
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 19
WSIB Requirements: n/a
Instructor Notes
This has already been addressed. Please do a quick review of how to perform a scene survey with the class.
Secondary Survey

5. Primary Survey Second step in ESM
A primary survey will allow you to determine and treat a casualty who has life threatening injuries/illnesses.
It involves assessing the airway, breathing, circulation and major bleeding.
The primary survey is conducted immediately following the scene survey
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 20
WSIB Requirements: n/a
Instructor Notes
This has already been addressed. Please do a quick review of how to perform a primary survey with the class.
Secondary Survey

6. Secondary Survey
A secondary survey is used to help the first aider determine injuries or illnesses that may be present in the casualty.
It should only be used if the casualty has more than one injury (multiple), if an ambulance is not immediately available, or if the primary survey did not reveal any immediately life threatening injuries.
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 38
WSIB Requirements:
8.1.1 Describe the secondary survey and its’ purpose
Instructors Notes
Instructors: A basic description of a secondary survey should have been provided when introducing ESM on the first day of the program. When delivering secondary survey as an elective topic we spend more time on the topic and allow participants to gain a better understanding of what is involved through a detailed presentation and practice time.
Secondary Survey

7. Secondary Survey A secondary survey may involve:
A detailed history of the casualty.
Vital signs of the casualty.
A head-to-toe survey of the casualty and first aid for all the injuries found.
First aid for injuries and illnesses found.
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 38
WSIB Requirements:
List the four steps of a secondary survey
Instructor Notes
After the primary survey has been completed and all of the casualty’s immediate needs have been met, a secondary survey can be performed to develop a complete picture of the casualty’s condition. A secondary survey may involve:
1. A head-to-toe survey of the casualty and first aid for all the injuries found.
2. A detailed history of the casualty.
3. Vital signs of the casualty.
4. First aid for injuries and illnesses found.
Secondary Survey

8. Detailed History of the Casualty
Use the acronym SAMPLE
S = Symptoms
A = Allergies
M = Medications
P = Past medical history
L = Last meal
E = Event leading up to the incident
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 38
WSIB Requirements: n/a
Instructor Notes
During our primary assessment, we learned the 4H’s (help, happen, hurt, history) which helped us to gain consent, understand the mechanism of injury, locate pain, and gather relevant medical history. If a detailed history of the casualty is required, the acronym SAMPLE can be used to help you to ask the correct questions. SAMPLE stands for:
S = Symptoms
A = Allergies
M = Medications
P = Past medical history
L = Last meal
E = Event leading up to the incident
Secondary Survey

9. The Glasgow Coma Scale can equal up to 15 points.
Best Eye Response. 4 Points
No eye opening
Opens to pain
Opens to verbal
Open spontaneously
Best Verbal Response.
5 Points
No verbal response
Incomprehensible sounds
Inappropriate words
Confused
Orientated
Best Motor Response
6 Points
No motor response
Extension to pain
Flexion to pain
Withdrawal from pain
Localizing pain
Obeys Commands
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 38
WSIB Requirements:
List three responses used for assessing the levels of consciousness (Modified Glasgow Coma Scale).
Instructor Notes
A first aider can use the Modified Glasgow Coma Scale to assess and describe levels of consciousness. The scale is based on the casualty's ability to open their eyes, speak and move their muscles.
Secondary Survey

10. Vital Signs
There are four vital signs that show the basic condition of the casualty. They include:
1. Level of consciousness
2. Breathing
3. Pulse
4. Skin condition and temperature
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 41
WSIB Requirements:
List the four vital signs used in first aid:
Levels of consciousness (LOC)
Breathing
Pulse (radial, carotid or brachial)
Skin condition and temperature
Perform, on a simulated casualty, the steps to assess vital signs.
Instructor Notes
Vital Signs
There are four vital signs that show the basic condition of the casualty. It is very important to record the vital signs as a change in the pattern and providing this history could provide a clue to what is wrong with the casualty. The vital signs include:
Secondary Survey

11. Instructor Notes Continued
1. Level of consciousness
2. Breathing
3. Pulse
4. Skin condition and temperature
A change in the level of consciousness may indicate a serious change in the casualty’s condition. Once assessed, it is important that the vital signs are reassessed every few minutes. Where possible, document any changes.
1. Level of consciousness
To assess the casualty’s level of consciousness, please refer to the LOC chart previously addressed in the primary assessment section.
2. Breathing
When assessing a casualty’s breathing, always assess the rate, rhythm and depth of their breaths. Breathing may be normal, irregular and require assistive breathing or may have agonal respiration. A healthy adult should breathe roughly twelve to twenty times per minute.
3. Pulse
Pulses are difficult to detect so we do not place great importance on them and are therefore optional. When assessing a casualty’s pulse, always assess the rate, rhythm and depth of their pulse. An average pulse rate for a healthy adult at rest is between beats per minute.
4. Skin condition and temperature
To assess the skin, look to see if the skin colour is pale, reddish or blue. Is the temperature hot or cold? Is the texture sweaty or dry?

12. Assess the rate, rhythm and depth.
Normal Breathing
Assess the rate, rhythm and depth.
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 42
WSIB Requirements:
Describe effective breathing for a healthy adult casualty at rest
Rate
Rhythm
Depth (effort, sound)
Instructors Notes
When assessing a casualty’s breathing, always assess the rate, the rhythm and depth of their breaths. Breathing may be normal, or irregular and require rescue breathing. A healthy adult should breathe roughly twelve to twenty times per minute.
Secondary Survey

13. Assess the rate, rhythm and depth.
Normal Pulse
Assess the rate, rhythm and depth.
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 42
WSIB Requirements:
Describe the characteristics of the pulse for a healthy adult at rest
Average pulse rate
Normal range of pulse rates
Rate, rhythm, and strength
Instructor Notes
The pulse on a casualty can be difficult to detect so we no longer place great importance on doing a pulse check. When assessing a casualty’s pulse, always assess the rate, rhythm and depth of their pulse. An average pulse rate for a healthy adult at rest is between beats per minute. The best place to assess the pulse is the carotid pulse (neck).
Secondary Survey

14. Skin Temperature Temperature = Hot or cold Texture = Dry or sweaty
Colour = Pale, grey or blue
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 42
WSIB Requirements: n/a
Instructor Notes
To assess the skin, look to see if the skin colour is pale, reddish or blue? Is the temperature hot or cold? Is the texture sweaty or dry?
Secondary Survey

15. Head-to-Toe Assessment
While performing the assessment:
Wear PPE.
Ask permission, explain what steps you are taking.
Check gloved hands repeatedly for any signs of fluid.
Avoid pockets and searching personal belongings.
Continue to reassess airway and breathing.
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 38
WSIB Requirements:
List the four steps of a secondary survey:
Perform a head-to-toe examination.
Instructor Notes
A head to toe survey can be performed on a fully conscious adult, semi-conscious adult or unconscious adult. On a fully conscious adult, ask where the pain is and if they are on any drugs that may mask the pain. On a semi-conscious casualty, ensure that you explain what you are doing and assess for signs of pain. On an unconscious casualty, quickly perform the assessment to look for any life threatening injuries. Maintain and monitor the ABCD’s.
To perform a head to toe survey, begin at the casualty’s head. Always remember to reassess your ABCs every thirty seconds in case the ABC’s become compromised.
Secondary Survey

16. Instructor Notes Continued
While performing the assessment:
Wear personal protective equipment (PPE).
Remember to first ask permission, speak to your casualty and explain what steps you are taking. We do this for both the conscious and the unconscious casualty as the unconscious casualty may be able to hear you and it lets bystanders know what you are doing.
Check your gloved hands repeatedly during the assessment for any signs of fluid (body fluids, blood).
Avoid pockets and searching personal belongings (purse, wallet) as they may contain sharps.

17. Head-To-Toe Assessment
Start at the head and work your way down to the feet. As we are examining each body part, use the acronym DOTS to help you remember.
D = Deformities
O = Open wound
T = Tenderness
S = Swelling
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 38
WSIB Requirements: Perform a head-to-toe examination.
Instructor Notes
Participants should compare one body part to the body part on the opposite side of the body.
Remembering the acronym DOTS is not necessary as long as participants have the basic idea that they are looking for anything unusual.
Private areas should be avoided as well as areas that pose a risk (pockets and purses).
Participants should not practice this skill on one another. If practice is required, do so verbally or on a manikin.
Secondary Survey

18. Instructor Notes Continued
Suggested Activity 
Divide the class in to groups of about five to six. Each get markers and a sheet of flipchart paper. Have them draw a person large enough to cover the full sheet. Together as a group they have to do a head-to-toe
Survey. They should label the patient with possible non-typical findings. Lumps, bumps, bruises and bleeding should be indicated.
Findings may also include:
Track marks, MedicAlert jewellery, strangulation, pregnancy, jaundice,and or fluid from the ears.

19. Head-to-Toe Assessment
Head and Neck
Feel the skull for depressions, soft spots, or deformities.
Look for blood in hair.
Check stability of the bones and face.
Check mouth, ears and nose.
Check the pupils.
Check breath.
Feel neck for pain and signs of trauma.
Look for bruising and feel for spasms of the muscles.
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 39
WSIB Requirements:
Perform a head-to-toe examination.
Instructor Notes
Head/Neck
Main Focus: Look for clues that may indicate a possible head, neck or spinal injury. If one is suspected, take immediate spinal precautions.
Feel the skull for depressions, soft spots, or deformities.
Look for matted blood in hair.
Check the stability of the bones of the face.
Look for anything in the mouth, ears and nose. A clear straw coloured fluid coming from the ears may indicate a severe head or spinal injury.
Secondary Survey

20. Instructor Notes Continued
Check the pupils to see if they are equal in size and reactive to light.
Check breath for unusual odour. An acetone smell coming from the breath may indicate the person is a diabetic. Also smell for the presence of alcohol or the possibility of inhalation of solvents or poisons.
Feel the neck for pain and signs of trauma.
Look for bruising and feel for spasms of the muscles (muscle splinting).

21. Head-to-Toe Assessment
Chest
Main Focus: Look to see if the chest rises and falls equally and if there are any signs of trauma.
Feel along the collar bone and rib cage for equality and stability.
Observe breaths. Does chest rise and fall evenly?
Check for signs of trauma, including bruising and bleeding.
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 40
WSIB Requirements:
Perform a head-to-toe examination.
Instructor Notes
Chest
Main Focus: Look to see if the chest rises and falls equally and if there are any signs of trauma (such as a sucking chest wound).
Feel along the collar bone and rib cage for equality and stability.
Observe breaths. Does chest rise and fall evenly?
Check for signs of trauma, including bruising and bleeding.
Secondary Survey

22. Head to Toe Assessment Abdomen
Main Focus: Look for signs of internal bleeding or pregnancy.
Observe the abdomen for bruising, visible masses, and visible trauma.
Feel all four quadrants of the abdomen for rigidity or pregnancy.
Avoid areas that may cause discomfort to the casualty.
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 40
WSIB Requirements:
Perform a head-to-toe examination.
Instructor Notes
Abdomen
Main Focus: Look for signs of internal bleeding, or pregnancy.
Observe the abdomen for bruising, visible masses, and visible trauma.
Feel all four quadrants of the abdomen for rigidity or pregnancy.
Avoid areas that may cause discomfort to the casualty.
Secondary Survey

23. Head to Toe Assessment Back or Pelvis
Main Focus: Look for any signs of trauma or deformity.
Feel along the neck, back, and pelvis for deformity or instability.
Note any incontinence (loss of bowel or bladder control).
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 40
WSIB Requirements:
Perform a head-to-toe examination.
Instructor Notes
Back or Pelvis
Main Focus: Look for any signs of trauma or deformity.
Feel along the neck, back, and pelvis for deformity or instability.
Note any incontinence (loss of bowel or bladder control).
Secondary Survey

24. Head-to-Toe Assessment
Extremities
For conscious casualties, ensure equal strength and good movement in all extremities.
Feel for fractures, deformity, bleeding, and bruising.
Check for a Medic Alert®.
Check for skin colour and capillary refill time.
Check for swelling.
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 40
WSIB Requirements:
Perform a head-to-toe examination.
Instructor Notes
Extremities
Main Focus: Look for circulation, deformity or bleeding. Also be aware of potential track marks indicating drug use.
For conscious casualties, ensure equal strength and good movement in all extremities.
Feel for fractures, deformity, bleeding, and bruising.
Check for Medic Alert® jewellery (bracelet or necklace).
Check for skin colour and capillary refill time (in nail beds, the colour should return to normal within two seconds after the nail bed is squeezed. Failure for this to occur indicates poor circulation).
Check for swelling.
After completing the secondary survey, continue your ongoing care by reassessing the ABCs, then repeating the primary survey, treat for shock, and providing ongoing care.
Secondary Survey

25. Ongoing Casualty Care
In some situations, you may need to continue caring for the casualty after first aid has been provided until EMS arrives. This is called ongoing casualty care. To do this, we can:
Use bystanders to help.
Treat for shock.
Reassure the casualty.
Monitor ABC’s.
Give nothing to eat or drink.
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: 23
WSIB Requirements:
Perform a head-to-toe examination.
Instructor Notes
Review this final step with the participants.
There are other things we can also do while providing ongoing casualty care:
Do not leave the casualty unnecessarily.
Transfer care to medics and provide a brief history of the incident and their medical history.
Be aware of the effects of critical incident stress.
Activity: Encourage the participants to come up with their own suggestions. What other things can they do to provide ongoing casualty care?
Copyright CERT
Sept 2007
Secondary Survey

26. Secondary Survey Scenario
History use SAMPLE (Symptoms, allergies, medications, past or present medical history, last meal, events leading to the incident).
Vital Signs (LOC, breathing, pulse, skin condition)
Head to toe examination
Give first aid to injuries found and provide ongoing care
Presentation: Secondary Survey
Time Line: 30 minutes
Participant manual page reference for slide: n/a
WSIB Requirements:
8.1. Perform the four steps of a secondary survey
Instructors Notes
It is time for participants to practice what they have learned and apply the four steps of a secondary survey. Instructor should develop a work place specific scenario for participants. Divide the class in half and have them take turns treating their partners. When possible have hidden injuries that need to be treated along the way. The first few times practicing this skill can be overwhelming. It is a good idea to leave a cheat sheet on the wall or this power point so they have a summary to refer to while practicing.
Secondary Survey