Secondary Survey

If the patient is conscious proceed with the secondary survey (Box E). Since the pulse rate and character and the rate and character of respiration have already been determined, assess the blood pressure at this time. Next, correlate the patient’s chief complaint and signs and symptoms to a specific organ system. The goal is to identify those problems that are not immediately life-threatening, but require timely stabilization (e.g., hypoglycemia, angina pectoris, ventilation failure).

Box E. Secondary Survey: Conscious Patient.

Quickly determine:

Blood pressure
Chief complaint (subjective information) associated with acute distress
Signs and symptoms (objective data)
- Identify organ system involved

Quickly review history and correlate to signs and symptoms:

Allergies
Current medications
Past and present illnesses
Last oral intake of food
Events leading up to the emerging event

Physical signs and symptoms are produced by physical causes and must be recognized before a physical problem can be diagnosed and treated. Without at least a presumptive or working diagnosis there is nothing to treat. Based on symptoms analysis, medical emergencies can be characterized as altered consciousness; chest pain; and ventilatory, allergic (pruritus, urticaria, angioedema), neurogenic (i.e., sensory, affective, motor), and toxic events (Box F).

Box F. Potential Medical Emergencies Based on Symptom Analysis during Secondary Survey.

Symptoms	Primary Working Diagnoses	Secondary Working Diagnoses
Altered consciousness	Syncope Postural hypotension Hypoglycemia	Anaphylaxis Cardiac arrest Seizure Cerebrovascular accident Hyperglycemia
Chest pain	Angina pectoris Myocardial infarction	With tachycardia Syncope Hyperventilation Airway obstruction Sympathetic reaction Thyrotoxicosis Panic attack Hypertension With bradycardia Drug overdose With decreased BP Syncope Postural hypotension Anaphylaxis Cardiac arrest Adrenal insufficiency Allergic reactions
Ventilation failure	Hyperventilation Asthma COPD Airway obstruction	Anaphylaxis Myocardial infarction Drug overdose Hyperglycemia
Pruritus, urticaria, angioedema	Pruritus Urticaria Angioedema Anaphylaxis Delayed hypersensitivity reaction
Altered sensory, affective and/or motor function	Seizure Cerebrovascular accident	Syncope Hyperventilation Hypoglycemia

*Airway obstruction, respiratory arrest, and cardiac arrest are discussed under primary survey. **Rare office emergencies (e.g., thyrotoxicosis, Addisonian crisis and emergencies that evolve over hours or days (e.g., advanced diabetic ketoacidosis, extreme hyperosmolarity) are mentioned, but no separate protocols are presented.

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