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Secondary Assessment

Category: Patient Assessment Sources: raw/supplemental/patient-assessment-sequence.md, raw/nremt/psychomotor-skills.md Last updated: 2026-04-05

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

Why the Rapid Trauma vs Focused Decision Matters

The physiological reason for rapid trauma assessment with significant MOI:

High-energy mechanisms — high-speed MVCs, falls from height, penetrating torso wounds, blast injuries — transfer kinetic energy to the body faster than tissue can absorb it without injury. The key problem: the body distributes that energy broadly, and not all the injuries announce themselves. Rib fractures don't always cause immediate dyspnea. Solid organ injuries (liver, spleen) bleed internally without visible signs. Spinal injuries occur without immediate neurological symptoms. The patient in a high-speed rollover may be alert and report only neck pain — while also having a pneumothorax, a splenic laceration, and a lumbar fracture.

The rapid trauma assessment is the systematic answer to this problem: you look everywhere, not just where the patient hurts, because trauma patients frequently have three injuries and tell you about one.

The physiological reason for focused exam in medical patients:

Medical patients have a chief complaint that points to an organ system. A patient with substernal chest pressure points you at the cardiovascular system. A patient with right lower quadrant pain points you at the appendix, ovary, or psoas. The pathophysiology is localized — the underlying process (ischemia, infection, inflammation) is occurring in one system, and the assessment should follow the pathology. A full head-to-toe on every medical patient wastes time that could be spent on targeted assessment of the involved system and a complete history.

The exception: any medical patient who has a mechanism of injury added (a diabetic who fell, an altered patient who may have been assaulted) becomes a hybrid — do the rapid trauma assessment.

What it costs if you do a focused exam when you should have done a rapid trauma assessment:

A 45-year-old male ejected from a vehicle reports hip pain. You focus your exam on the hip, find tenderness, splint, and transport. En route he becomes hypotensive with tachycardia. He has a splenic laceration — undetected because you never examined the abdomen. The hemorrhagic shock that was compensated when you were on scene is now decompensating. He needed a surgeon 20 minutes ago.

This is the exact clinical consequence of under-triaging the exam to the chief complaint in a significant-MOI patient. The rule is simple: significant MOI means you examine the whole patient, regardless of what they're complaining about.

DCAP-BTLS Mnemonic

Used during rapid trauma assessment at each body region. See dcap-btls for full clinical reference including what each finding indicates and common mistakes.

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)