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Secondary Assessment

Category: Patient Assessment Sources: raw/supplemental/patient-assessment-sequence.md, raw/nremt/psychomotor-skills.md Last updated: 2026-04-03

Overview

The secondary assessment is a systematic physical examination performed after primary-assessment and history-taking have been completed and life threats are managed. For trauma patients with significant MOI, it is a rapid head-to-toe exam. For medical patients or minor trauma without significant MOI, it is a focused exam targeted at the chief complaint. Either way, it ends with a complete set of vital signs.

Key Points

Two Paths: Trauma vs Medical

The fork is determined by what you found in scene-size-up:

Rapid Trauma Assessment — significant MOI (high-speed MVC, fall >15 feet, penetrating torso trauma, blast injury): - Head-to-toe physical exam on every body region - Use DCAP-BTLS at each region - Goal is to find hidden injuries fast; this should take under 90 seconds - Performed en route if patient is priority (load and go)

Focused Physical Exam — medical patient or minor trauma without significant MOI: - Examine the region related to the chief complaint - May expand if history suggests systemic involvement - Less time pressure, more depth on the primary complaint

DCAP-BTLS Mnemonic

Used during rapid trauma assessment at each body region:

Letter Finding
D Deformities
C Contusions
A Abrasions
P Punctures / Penetrations
B Burns
T Tenderness
L Lacerations
S Swelling

Body Regions (Head-to-Toe Order)

  1. Head (skull, face, ears — look for Battle's sign, raccoon eyes, CSF)
  2. Neck (JVD, tracheal deviation, crepitus, tenderness)
  3. Chest (symmetry, paradoxical movement, breath sounds bilateral)
  4. Abdomen (rigidity, guarding, distension, tenderness — 4 quadrants)
  5. Pelvis (stability — compress gently once, do not rock repeatedly)
  6. Lower extremities (bilateral)
  7. Upper extremities (bilateral)
  8. Posterior (log roll if spinal precautions apply)

Vital Signs (Complete Set)

Every patient, every call:

Sign How Normal (Adult)
Blood pressure Auscultated (or palpated if needed) 90–140 systolic
Pulse Rate, rhythm, quality 60–100 bpm
Respirations Rate, rhythm, depth 12–20/min
Skin Color, temperature, moisture Pink, warm, dry
Pupils PERRL — equal, round, reactive to light Equal and reactive
SpO2 Pulse oximetry ≥95% on room air
Blood glucose If protocols allow and indicated 70–110 mg/dL

Assessment Relevance

The secondary assessment is where you find injuries and conditions that aren't immediately life-threatening but still need treatment. Rib fractures, femur fractures, abdominal injuries, and developing shock can all be revealed here. Vital signs trend is critical — one set of vitals is a data point; two or three sets are a trend. A falling BP with rising HR means deterioration; act accordingly.

Vital signs also directly drive medication decisions: - SpO2 below 94%: escalate oxygen delivery - Altered glucose: consider oral-glucose if conscious diabetic - BP trends: escalation of shock management (see bleeding-control-shock)

Procedures

Rapid Trauma Assessment sequence: 1. Verbalize DCAP-BTLS approach. 2. Head: inspect and palpate skull and face. 3. Neck: check JVD, tracheal deviation, crepitus, apply C-collar if not already applied. 4. Chest: inspect symmetry, palpate, auscultate breath sounds. 5. Abdomen: inspect and palpate all four quadrants. 6. Pelvis: gentle compression once. 7. Lower extremities: inspect and palpate bilateral; check PMS. 8. Upper extremities: inspect and palpate bilateral; check PMS. 9. Posterior: inspect back during log roll. 10. Obtain full vital signs set.

NM Protocol Notes

  • NM EMS requires a minimum of two full vital sign sets on stable patients; critical patients should have vitals trending continuously.
  • Pulse oximetry is standard equipment at EMT-B level in NM.
  • Blood glucose assessment: NM EMT-B protocols may authorize glucometry for altered mental status patients. Check current NM EMS Bureau protocol.
  • Auscultation of breath sounds requires a stethoscope — have it accessible before the secondary exam begins.

NREMT Relevance

Secondary assessment is tested as part of both the Trauma and Medical patient assessment/management skill stations:

  • Trauma: examiners expect DCAP-BTLS verbalized at each region; all vitals obtained and verbalized
  • Medical: focused physical exam + full vital signs; examiners look for appropriate targeting of the exam to the chief complaint
  • Common miss: forgetting posterior assessment (back), pelvis, or pupils
  • Common miss: getting pulse rate but not quality, or skipping SpO2
  • PERRL must be verbalized explicitly — "pupils equal, round, reactive to light"

Sources

  • raw/supplemental/patient-assessment-sequence.md — Section 4: Secondary Assessment
  • raw/nremt/psychomotor-skills.md — Patient Assessment/Management (Trauma and Medical)