Step 14.-Listen for sounds of equal air entry. Using a stethoscope, listen to both sides of the anterior and lateral chest. The sounds of air entry will usually be clearly present or clearly absent. The absence of air movement indicates an obstruction, injury, or illness to the respiratory system. Bubbling, wheezing, rubbing, or crackling sounds may indicate the patient has a medical problem or a trauma-related injury.

Step 15.-Inspect the abdomen for wounds. Look for obvious signs of injury (e.g., abdominal distension, cuts, bruises, penetrations, open wounds with protruding organs (evisceration), or burns) in all four quadrants and sides.

Step 16.-Palpate the abdomen for tenderness. Look for attempts by the patient to protect his abdomen (e.g., patient drawing up the legs). Gently palpate the entire abdomen. If the patient complains of pain in an area of the abdomen, palpate that area last. Do not palpate over an obvious injury site or where the patient is having severe pain. While palpating the abdomen, check for any tight (rigid) or swollen (distended) areas. Performing abdominal palpation is important because tender areas do not normally hurt until palpated. Note if pain is localized, general, or diffused.

Step 17.-Feel the lower back for point tenderness and deformity. Gently slide your hands under the void created by the curve of the spine. Apply gentle pressure to detect point tenderness or any deformities.

NOTE: This examination of the lower back may be performed later, when the patient's entire back is exposed in preparation to being placed on a backboard or stretcher.

Step 18.-Examine the pelvis for injuries and possible fractures. Examine the pelvic area for obvious injuries. Next, gently slide your hand down both sides of the small of the patient's back and apply compression downward and then inward to check the stability of the pelvic girdle. Note any painful responses or deformities. If a grating sound is heard, the injury may involve the hip joint, or the pelvis may be fractured.

Step 19.-Note any obvious injury to the genital region. Look for obvious injuries, such as bleeding wounds, objects impaled in the area, or burns. Also, check for priapism in male patients. Priapism is a persistent erection of the penis often brought about by spinal injury or certain medical problems, such as sickle cell crisis.

Step 20.-Examine the lower extremities. DO NOT move, lift, or rearrange the patient's lower extremities (legs and feet) before or during the examination as further injury to the patient may occur. Check for signs of injury by inspecting each limb, one at a time, from hip to foot. Rearrange or remove clothing and footwear to observe the entire examination site. Pants should be removed in a manner that does not aggravate injuries. Cutting along the seams to remove pants is the best method. If the injury is not obvious, remove the shoe(s) and palpate any suspected fracture sites for point tenderness. Before palpating the site, warn the patient that this examination may cause pain. Before the patient is moved, all suspected or known fractures should be stabilized (with splints, traction splints, or the like).

Step 21.-Check for a distal pulse and capillary refill. To make sure there are no circulatory problems in the legs or feet, check the distal pulse and capillary refill. The distal pulse is a pulse taken at the foot or wrist. It is called distal because the pulse is located at the distal end of the limb. The distal pulse of the foot, also referred to as pedal pulse, may be taken at either of two sites: the posterior tibial pulse (located behind the medial ankle) or the dorsalis pedis pulse (located on the anterior surface of the foot, lateral to the large tendon of the great toe).

You should compare the quality of the pulses in each lower limb. Absence of a distal pulse usually indicates that a major artery supplying the limb has been pinched or severed. This condition may be caused by a broken or displaced bone end or a blood clot. An absent or weak distal pulse may also result from splints or bandages being applied too tightly.

Check capillary refill by squeezing a toe (usually, the big toe) with your thumb and forefinger. The skin and nail where pressure is applied should blanch (lighten). When you release the pressure, the color (blood) should return immediately. If it takes more than 2 seconds for the color to return, capillary refill is considered delayed.

NOTE: After splints or bandages are applied, check capillary refill to make sure circulation has not been impaired.

Step 22.-Check for nerve function and possible paralysis of the lower extremities (conscious patient). Check the lower extremities of conscious patients for nerve function or paralysis. First, touch a toe and ask the patient which toe it is. Do this to both feet. If the patient cannot feel your touch or if the sensations in each foot are not the same, assume that nerve damage in the limb or a spinal injury has occurred.

If sensations appear normal and no injuries are present, have the patient wave his feet. Finally, ask the patient to gently press the soles of his feet against your hand. The inability of the patient to perform any of these tasks indicates the possibility of nerve damage. When nerve damage is suspected, assume the patient has a spinal injury.

Step 23.-Examine the upper extremities for injury. Check for signs of injury to the upper extremities (arms and hands) by inspecting each limb, one at a time, from clavicle to fingertips. Rearrange or remove items of clothing to observe the entire examination site. Check for point tenderness, swelling, or bruising. Any of these symptoms may indicate a fracture. Immobilize any limb where a fracture is suspected.

Step 24.-Check for a distal pulse and capillary refill. To make sure the circulation to the upper extremities has not been compromised, confirm distal (radial) pulse. Initial check of radial pulse was performed during the primary survey. Check capillary refill of fingers or palm of hand (see step 21 for procedure). If there is no pulse or if capillary refill is delayed, the patient may be in shock or a major artery supplying the limb has been pinched, severed, or blocked.

Step 25.-Check for nerve function and possible paralysis of the upper extremities (conscious patient). Check the upper extremities of conscious patients for nerve function or paralysis. Have the patient identify the finger you touch, wave his hand, and grasp your hand. Do this to both hands. If the patient cannot feel your touch or the sensations in each hand are not the same, assume nerve damage in the limb or a spinal injury has occurred.

WARNING: Be alert for a rapid onset of difficult breathing or respiratory arrest. These conditions may occur to patients who have sustained a cervical injury.

Step 26.-Inspect the back and buttocks for injury. If there is no indication of injury to the skull, neck, spine, or extremities, and you have no evidence of severe injury to the chest or abdomen, gently roll the conscious patient as a unit toward your knees and inspect the surface of the back for bleeding or obvious injuries. The back surface may be inspected prior to positioning the patient for transport or delayed until the patient is transferred to a spineboard or other immobilization device.