Head-to-toe examination

During this examination, any injuries detected should be accurately documented and any required treatment should occur, such as covering wounds, managing non-life-threatening bleeding and splinting fractures.

A detailed neurological examination forms an important part of the secondary survey and can assist with guiding management and assessing the need for transfer.

Neurological assessment

Assess the patient’s level of consciousness

A baseline GCS should be taken to accurately assess the patient’s neurological status. It is the universally accepted gold standard for assessing disturbances in a patient’s conscious state in the adult population. The best eye opening, verbal and motor response is taken and given a score out of 15. Limb response to commands or painful stimulation is used to detect asymmetry between the right and left sides. Differing levels of GCS determine the potential severity of the TBI (4). Note whether the patient is agitated or combative.

Glasgow Coma Scale

• Pupils should be examined for their response to light and their symmetry. Note if the reaction is brisk, sluggish, or non-reactive. A difference of greater than 1 mm is considered abnormal.
• Document the findings on the observation chart and reassess frequently.
• Assess where appropriate for raised intra-orbital pressure, as an urgent canthotomy may be required.

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Head and face

• Inspect the scalp. Look for any bleeding or lacerations. Do not probe the scalp and be cautious when examining as bone fragments and fractures may be present. Gently palpate for any depressions or irregularities in the skull. If a penetrating object remains lodged, do not remove it.
• Lacerations can bleed profusely, control bleeding with direct pressure and bandaging. If this is not controlling the bleeding, temporary closure with staples or suturing can be highly effective. The wound will need to be thoroughly irrigated at a later stage.
• Inspect the face. Look for any lacerations or bruising. Periorbital bruising and/or mastoid bruising is indicative of a base of skull fracture; however, mastoid bruising will only occur 12–24 hours post injury.⁽¹⁹⁾
• Look in the eyes for any foreign body, subconjunctival haemorrhage with no posterior limit, hyphaema, irregular pupil, penetrating injury or contact lenses.
• Assess the ears for any bleeding or blood behind the tympanic membrane, as well as any cerebrospinal fluid (CSF) leak.
• Check the nose for any deformities, bleeding, nasal septal haematoma, or CSF leak. If a CSF leak is present, do not pack the nose; apply a bolster. To determine whether any clear fluid is CSF, the easiest method is to sample the fluid onto filter paper: if there is a formation of two rings (the ‘halo’ sign) this indicates the presence of CSF. Glucose should also be detected in the fluid, helping to differentiate it from mucus.
• Look in the mouth for any lacerations to the gums, lips, tongue, or palate.
• Inspect the teeth, noting if any are loose, missing or fractured.
• Test vision, and hearing.
• Palpate the bony margins of the orbit, maxilla, nose, and jaw.
• Inspect the jaw for any pain or trismus.

Neck

• Inspect the neck. Ensure another colleague maintains manual in-line stabilisation while the hard collar is removed and throughout the examination. Cervical fractures are an increased risk in patients with a head injury. Replace the cervical collar after examination of the neck.
• Gently palpate the cervical vertebrae. Note any cervical spine pain, tenderness, or deformity.
• Check the soft tissues for bruising, pain, and tenderness.
• Complete the examination of the neck by observing the neck veins for distension and by palpating the trachea and the carotid pulse; note any tracheal deviation or crepitus.
• The patient will need to be log rolled to complete the examination. This can be combined with the back examination.

Chest

• Inspect the chest, observing movements. Look for any bruising, lacerations, penetrating injury, or tenderness.
• Palpate for clavicle or rib tenderness.
• Auscultate the lung fields; note any percussion, lack of breath sounds or adventitious sounds.
• Check the heart sounds: apex beat and the presence and quality of heart sounds.

Abdomen

• Inspect the abdomen. Palpate for areas of tenderness, especially over the liver, spleen, kidneys, and bladder. Look for any bruising, lacerations, or penetrating injuries.
• Check the pelvis. Gently palpate for any tenderness. Do not spring the pelvis. Any additional manipulation may exacerbate haemorrhage. Apply a binder if a pelvic fracture is suspected or if the patient is haemodynamically unstable.
• Inspect the perineum and external genitalia.

Limbs

• Note any inequalities with limb response to stimulation and document these findings.
• Inspect all the limbs and joints; palpate for bony and soft-tissue tenderness and check joint movements, stability, and muscular power. Note any bruising, lacerations, muscle, and nerve or tendon damage. Look for any deformities, penetrating injuries, or open fractures.
• Examine sensory and motor function of any nerve roots or peripheral nerves that may have been injured.

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Back

• Log roll the patient. Maintain in-line stabilisation throughout. Inspect the entire length of the back and buttocks noting any bruising and lacerations.
• Palpate the spine for any tenderness or steps between the vertebrae.
• Digital rectal examination should be performed only if a spinal injury is suspected. Note any loss of tone.

Buttocks and perineum

• Look for any soft-tissue injuries such as bruising or lacerations.

Genitalia

• Inspect for soft tissue injuries such as bruising or lacerations. Check the urethra for any bleeding. Note any priapism that may indicate a spinal injury.

The priorities for further investigation and treatment may now be considered and a plan for definitive care established.