• A secondary survey is a systematic head-to-toe survey to detect problems that are not always obvious, and do not pose an immediate threat to life but could become serious, or life threatening if not detected and corrected. A CNS survey is a systematic head-to-toe survey using precise responses to specific stimuli to assess presence and extent of damage to the central nervous system.
 Patient Factors & Considerations

Management of a patient with a head injury or neurological illness depends on careful and ongoing assessment of the patient’s general neurological function.

The first observations conducted pre-hospital provide the basis for monitoring changes in condition throughout the patient’s care in hospital.

Document all findings including important negative findings, for example:

  • No neck pain or tenderness.
  • Pupils equal and reactive to light (PERL, size 4mm)
  • No abnormalities detected (NAD) to Colour / Warmth / Movement / Sensation (CWMS) to distal extremities

Specific observations that could be helpful:

  • Respirations: observe adequacy, depth, frequency, regularity and any abnormal breath sounds.
  • Face: any drooping of facial muscles – which side? Can patient swallow?
  • Speech: slurred or difficulty speaking?
  • Movement: Observe whether all four extremities move with equal precision and strength. Note any tremors.
  • Sensation: Observe for absent, abnormal or normal sensation.

At the completion of this survey, ensure assessment has not aggravated injuries. Ensure all abnormalities have been treated (i.e. dressings, splints etc.)

Keep rechecking any injuries that were found and rectified.


  • Scalp:
    • Run fingers over scalp without applying excessive pressure, assess for any deformities/abnormalities, bleeding.
  • Facial Structure:
    • Assess for deformity, asymmetry, swelling or bleeding and tenderness, check sensation to different areas of the face and record any irregularities.
  • Eyes/nose/ears:
    • Assess for CSF or bleeding, check pupil size and ocular motor function. Check pupil reaction to light with a pupil torch. Enquire about any hearing disturbances or abnormalities.
  • Mouth:
    • Instruct patient to protrude tongue, and note any tongue deviation from the centre, and assess any injuries to the teeth or tongue. Instruct patient to smile, and note any asymmetry.


  • Assess cervical spine for mid-line tenderness, pain or obvious deformity.
  • Prevent movement when assessing the neck of the patient.
  • Assess if swallowing action is present visually, by instructing patient to swallow.


  • Palpate the shoulders bony parts and assess for deformity, crepitus, bruising and swelling/pain.
  • Apply gentle restraining force to the patient’s shoulders, and instruct him/her to shrug shoulders, assessing strength and equality of muscle action.


  • Get the patient to inhale deeply:
    • Assess for deformity, tenderness, bruising and paradoxical movement, look for open/sucking chest wounds, palpate the chest wall.
    • Auscultate all sites as per the Clinical Skill
  • Check for injuries/bruising.
  • Check sensory reaction to touch, comparing left to right side, ask patient to verbally identify area being touched without visualising the action.


  • Assess for injury, bruising, distension, rigidity, and deformity.
  • Palpate abdomen while assessing for any indication of discomfort.
  • Assess sensory function to touch, and get patient to verbally identify area being touched.


  • Log roll the patient maintaining C spine precautions if indicated.
  • Palpate the back of the patient, assess for injury, tenderness, bleeding, deformity.
  • Assess sensory function to touch, ask the patient to verbally identify the area being touched.


  • Check pelvis for signs of instability in conjunction with relevant mechanism of injury - avoid pelvic sprining or excessive manipulation.
  • Check for bleeding, tenderness, deformity, and abnormal positioning of legs and hips.
  • Check sensory function on opposite sides.

Upper & Lower Limbs:

  • Palpate limbs, assess for deformities, crepitus, swelling, bruising and needle marks.
  • Test strength and motor functions by applying gentle restraining force while instructing the patient to push and/or pull against your hands.
  • Assess range of movement.
Secondary-CNS Survey Visual
Additional Information
Additional information

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