7-4
in the Secondary Survey. They will need to have a bandage and/or splint applied with evaluation of
their neurovascular status distal to the injury before and after treatment. They then need to be frequently
reassessed for signs of deterioration as the tactical situation permits. Patients who are severely injured or
unconscious will require a more detailed Secondary Survey as outlined below. Evacuation should not be
delayed to perform a Secondary Survey or for the treatment of non-life threatening injuries.
The Secondary Survey should be conducted in a systematic head to toe, front to back fashion using visual
Inspection, Auscultation, Palpation and Percussion (IAPP) where applicable.
HEENT: The head and face should be inspected for obvious laceration, burns, contusion, asymmetry or
hemorrhage. The bones of the face and head should then be palpated to identify crepitus, bony step-off,
depressions or abnormal mobility of the mandible and mid-face. The eyes should be opened and examined
for signs of trauma, globe rupture, or hyphema. The orbits and zygomatic arches should be palpated for
signs of fractures. Pupils should be checked for reactivity and symmetry. If the patient is awake, extra-ocular
movements can be assessed along with gross visual acuity. The ears should be inspected for obvious trauma
and the ear canals for blood or cerebral spinal fluid (CSF). Battle’s sign indicating possible basilar skull
fracture may be observed over the mastoid processes. The nares should be inspected for blood or CSF. The
mouth and oropharynx should be inspected for trauma or bleeding. Loose teeth, dental appliances or other
potential airway obstructions should be removed. Any previous airway interventions should be reassessed.
Neck: The neck should be visually inspected searching for obvious trauma or deformity, tracheal deviation,
jugular venous distention (JVD), or signs of respiratory accessory muscle use. The cervical spine should be
palpated for step-off, tenderness or deformity.
Chest: The chest wall should be observed for penetrating injury or blunt injury, asymmetrical breathing move-
ments or retractions. Auscultation over the anterior lung fields, posterior lung bases and heart should follow.
The entire rib cage, sternum and chest wall should be palpated for tenderness, flail segments, subcutaneous
emphysema or crepitus. Percussion may be performed looking for hyperresonance or dullness.
Abdomen: The abdomen should be observed for signs of blunt or penetrating injury. The presence or
absence of bowel sounds should evaluated. Palpation searching for tenderness, guarding or rigidity should
follow. Percussion may elicit subtle rebound tenderness.
Pelvis: The pelvis should be inspected for signs of penetrating trauma or deformity. Pelvic instability and
fracture should be suspected with movement of the anterior iliac crests when lateral and anterior pressure
is applied. The perineum and genitals are inspected next for signs of injury. Scrotal, vulvar and perineal
hematomas or blood at the urethral meatus may indicate pelvic fracture. Likewise the rectal exam will yield
information about the location of the prostate, and presence or absence of gross blood in the rectum.
Extremities: The extremities are inspected and palpated proximally to distally. Each bone and joint distal
to the pelvis and clavicle should be assessed for crepitus, tenderness, deformity and abnormal joint motion.
Distal pulses and capillary refill are then examined. Asking the patient if he can feel the examiner lightly
touching his hands and feet tests gross sensation. Gross motor strength is tested by having the patient
squeeze the examiner’s fingers and by moving his toes up and down against the resistance of the examiner’s
hands.
Neurological: A field neurological exam should consist of observation of the pupils for reactivity and asym-
metry (done during HEENT exam), the level of consciousness, gross sensory and motor function (assessed
during examination of the extremities) and calculation of the Glasgow Coma Scale (GCS). The GCS is a useful
tool that can be used to monitor the clinical status of seriously injured patients. A declining GCS score over
time indicates further neurological deterioration. A GCS less than 9 indicates severe neurological injury (see
Glasgow Coma Scale A-
Pain Management: Intravenous morphine sulfate is an excellent analgesic for traumatic injuries. Morphine
has a rapid onset, is easily titratable and can be readily reversed by naloxone if the patient becomes obtunded
or experiences respiratory depression. It should be used with caution in patients with injuries that may
compromise respiratory function and it is contraindicated in patients with head injuries or altered levels of
consciousness. Doses should be given in 5-mg increments every 10-15 minutes until adequate levels of
analgesia are obtained. The practice of withholding narcotic analgesics or more frequently, giving inadequate
doses because of concerns of abuse or respiratory depression in otherwise healthy SOF operators are based
on unrealistic concerns and should be avoided. Casualties with combat wounds require treatment for their