9.3 Triage & Primary/Secondary Survey

Quick Answer: After scene safety, triage severity (PA8 task 0302). Unresponsive collapse with agonal gasps = SCA until proven otherwise: CAB plus AED. Massive bleeding or airway trauma = stop the bleed and open the airway first (cABCDE). Never perform a full orthopedic exam before the primary survey. Multi-patient scenes (bleachers, bus) use START / JumpSTART colors: Red, Yellow, Green, Black.

The primary survey answers one question: what will kill this patient in the next few minutes? The secondary survey answers: what else is injured, and what is the history? Triage answers: who gets those surveys first when you do not have enough hands? Mixing those three jobs—especially starting a Lachman test on a silent, non-breathing athlete—is the Domain III fail the exam writers still use.

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CAB Versus ABC (and Catastrophic Hemorrhage)

American Heart Association (AHA) adult basic life support for cardiac arrest uses C-A-B: compressions, then airway, then breathing, with an AED as soon as it is available. The 2010 AHA guidelines made that shift so that blood flow starts without a delay for two breaths; subsequent AHA updates have kept compressions and defibrillation as the SCA priorities. Agonal gasps are not effective breathing. A basketball player who collapses, is unresponsive, and is gasping gets CPR and an AED, not a prolonged pulse hunt and not a knee exam because “he grabbed his leg on the way down.”

ABC still matters when airway trauma or ventilation failure is the life threat: facial smash with blood in the airway, drowning (hypoxia first), hanging/clothesline, or anaphylaxis with stridor. Open the airway (jaw-thrust if spine is a concern), suction, insert an airway adjunct you are trained to use, and ventilate. Compressions without oxygen help less if the problem was never a primary cardiac arrest.

Catastrophic hemorrhage can kill faster than an unopened airway. On a trauma-dominant scene (open femoral bleed, amputation on an ATV trail, arterial spray on the mat), the field sequence is cABCDE:

1. c — Catastrophic hemorrhage — direct pressure, wound packing, tourniquet high-and-tight on a limb.
2. A — Airway — open, clear, maintain; protect the cervical spine when MOI warrants.
3. B — Breathing — look, listen, feel; seal an open chest; support ventilation.
4. C — Circulation — pulse, skin, remaining bleeders; prevent shock.
5. D — Disability — AVPU or Glasgow Coma Scale (GCS); pupils; gross motor/sensory in the limbs.
6. E — Exposure — remove enough equipment and clothing to find the hidden wound, then prevent hypothermia.

AVPU: Alert, responds to Verbal, responds to Pain, Unresponsive. GCS (E4-V5-M6, best 15): eyes 4/3/2/1 (spontaneous, voice, pain, none); verbal 5/4/3/2/1 (oriented, confused, inappropriate, incomprehensible, none); motor 6/5/4/3/2/1 (obeys, localizes, withdraws, flexion, extension, none). A falling GCS or a patient who is only P or U is a Red problem, not a “wait and see.”

Exam trap: doing a full orthopedic exam before the primary survey on a downed athlete. Special tests are a secondary or even a sideline tool after the athlete is breathing, perfusing, and neurologically accounted for.

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Primary Survey, Then Secondary (SAMPLE)

Primary survey is rapid and repeatable. On a football player who does not get up:

• Scene already declared safer; gloves on.
• Unresponsive? CAB + AED while someone calls 911 per the EAP.
• Responsive but pale with a rapidly expanding thigh? Tourniquet / pressure, then airway and breathing.
• Helmet/shoulder pads come off only as needed for airway, CPR, or AED pads—equipment removal is a primary-survey decision, not a souvenir for the trainer’s bag.
• Disability: AVPU, “squeeze my hands / wiggle your toes,” obvious deformity that threatens the limb’s circulation.
• Exposure: look at the chest and abdomen for a hidden penetrating wound or flail segment the pads covered.

Secondary survey starts when life threats are managed or a second provider can do it without stealing hands from CPR. Use SAMPLE:

• S — Signs and symptoms (pain location, dyspnea, dizziness).
• A — Allergies (medications, latex, bees).
• M — Medications (including ADHD stimulants, insulin, inhalers, supplements).
• P — Past medical history (sickle cell trait, asthma, seizure disorder, cardiac workup, concussion).
• L — Last oral intake (for surgery risk and for hyponatremia/heat differentials).
• E — Events leading up (hit, collapse without contact, lightning, heat, pool).

Then a focused exam of the injured region and vitals: pulse, respiratory rate, blood pressure if you have a cuff, oxygen saturation, skin, and a repeat AVPU/GCS. Reassess after every intervention. The secondary survey is not permission to delay the ambulance for a complete ligament battery.

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START and JumpSTART: Four Colors

When number of patients exceeds immediate resources—bleacher collapse, team bus rollover, scaffolding failure, lightning with several down—you triage, you do not provide one-patient ICU care to the first person who groans.

START (Simple Triage and Rapid Treatment), adults, classic RPM / 30-2-Can Do:

1. Direct anyone who can walk to a green collection area (Green / Minor, walking wounded). They still get a later re-triage.
2. Remaining patients: Respirations. Apneic → open the airway. Still apneic → Black / Expectant (or deceased). Starts breathing after airway → Red / Immediate. Breathing but respiratory rate >30 → Red.
3. Perfusion: no radial pulse or capillary refill >2 seconds → Red.
4. Mental status: cannot follow simple commands → Red. Passes RPM → Yellow / Delayed.

JumpSTART is the pediatric adaptation (commonly taught for children about 1–8 years). Differences you must not miss: expected respiratory rate band is about 15–45; <15 or >45 is Red. An apneic child with a pulse gets 5 rescue breaths before you assign Black; if breathing returns, that child is Red. Mentation uses AVPU (P or U → Red). Do not START-tag a second-grader with adult RR >30 cutoffs.

Only life-saving interventions during the first pass: open the airway, tourniquet or direct pressure, maybe a needle decompression if you are trained and it is in protocol. Then move to the next patient. That feels wrong until you remember the silent non-breather behind the bleacher.

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Stop the Contest, Hand Off, Document

Stop the contest when the playing surface is the emergency: SCA, a suspected spine injury occupying the field, lightning, a mass-casualty in the stands, a chemical or fire problem, or violence. Officials and administrators in the EAP exist so this is a medical time-out, not a debate. A locker-room mental-health emergency may not stop a game in the other gym, but it does activate the EAP addendum and a dedicated responder.

Transfer of care to EMS is a skill, not a shrug. Use a structured hand-off:

• MIST — Mechanism; Injuries found; Signs/vitals; Treatment given (including time of tourniquet, number of AED shocks, last GCS).
• SBAR — Situation; Background (SAMPLE highlights); Assessment (your working impression: SCA, hemorrhagic shock, suspected C-spine); Recommendation (what you need them to continue).

Stay and assist until they have enough hands, then document: times, findings, interventions, who called 911, who received the patient. NATA 2024 rec. 18 requires an incident report after EAP activation; rec. 16 a debrief to improve the plan; rec. 17 CISD after a catastrophic event. Memory fades; the record is what protects the patient and the next rehearsal.

Put the whole chapter in one sentence for test day: write and rehearse venue EAPs (0301), refuse to die on the approach (0304), then sort and survey life threats before ligaments (0302).