10.1 ABCDE Primary/Secondary Survey & Disaster Triage (START)

10.1 ABCDE Primary/Secondary Survey & Disaster Triage (START)

Quick Answer: The Primary Survey follows the sequential ABCDE framework: Airway with cervical spine protection (jaw-thrust maneuver, rigid cervical collar), Breathing (immediate decompression of tension pneumothorax and three-sided dressings for open pneumothorax), Circulation (direct hemorrhage control, two large-bore 14G/16G IVs, pelvic binder), Disability (AVPU, Glasgow Coma Scale; intubate if GCS <= 8), and Exposure (undressing while preventing the lethal triad of hypothermia, acidosis, and coagulopathy). In mass-casualty events, the Simple Triage and Rapid Treatment (START) algorithm rapidly categorizes casualties into Red (Immediate), Yellow (Delayed), Green (Minor), and Black (Expectant) based on walking ability, respirations (>30/min), perfusion (radial pulse/capillary refill >2s), and mental status.

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Advanced Trauma Life Support (ATLS) Framework in Emergency Nursing

Trauma remains a major cause of mortality and disability across Ghanaian clinical environments, ranging from highway vehicular crashes on arterial corridors to industrial and agricultural injuries. The foundational operational doctrine for acute trauma nursing is derived from the Advanced Trauma Life Support (ATLS) framework. ATLS establishes a structured, prioritized methodology designed to assess and resuscitate severely injured patients rapidly during the critical "Golden Hour"—the initial 60 minutes post-injury when prompt clinical intervention most dramatically reduces preventable mortality.

The core ATLS philosophy dictates: treat the greatest threat to life first. Resuscitation occurs simultaneously with assessment, and progression to subsequent phases depends on stabilizing preceding threats. Emergency care divides systematically into two interdependent phases:

1. The Primary Survey (ABCDE): Rapid identification and concurrent mitigation of immediately fatal anatomical and physiological compromises.
2. The Secondary Survey (Head-to-Toe & AMPLE): Comprehensive physical examination, detailed historical enquiry, and diagnostic imaging executed only after vital organ functions are secured.

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The Primary Survey: Systematic ABCDE Approach

+-----------------------------------------------------------------------------------+
|                         ATLS PRIMARY SURVEY ALGORITHM                             |
+-----------------------------------------------------------------------------------+
|  [A] Airway with Cervical Spine Protection -> Jaw-thrust | Rigid Collar | Suction  |
|  [B] Breathing and Ventilation             -> Decompress Tension PTX | O2 Delivery |
|  [C] Circulation with Hemorrhage Control   -> Direct Pressure | 2x Large IVs | MTP|
|  [D] Disability (Neurological Evaluation)  -> AVPU | GCS Assessment (<=8 Intubate)|
|  [E] Exposure & Environmental Control      -> Fully Undress | Prevent Lethal Triad|
+-----------------------------------------------------------------------------------+

A — Airway Maintenance with Cervical Spine Protection

The airway is the first priority. An occluded airway can cause irreversible anoxic brain injury and cardiac arrest within minutes. In any patient sustaining blunt trauma above the level of the clavicles, multi-system trauma, or high-speed vehicular deceleration, an unstable cervical spine fracture must be assumed until radiologically and clinically cleared.

• Airway Patency Assessment: Assess responsiveness by asking a simple question. A clear, appropriate verbal response confirms airway patency, intact phonation, and adequate cerebral perfusion. Stridor, gurgling, snoring, or silence in an unresponsive patient indicates impending or acute airway obstruction.
• Airway Opening Maneuver: The standard head-tilt chin-lift maneuver causes cervical spine hyperextension and is strictly contraindicated in trauma. The nurse must employ the modified jaw-thrust maneuver: with the patient supine, the nurse places fingers behind the angles of the mandible and lifts forward and upward with both hands while using the thumbs to gently depress the chin, opening the oral cavity without extending the neck.
• Cervical Spine Immobilization: The cervical spine must be maintained in a neutral in-line position. A hard, rigid cervical collar (such as a Miami J or Philadelphia collar) of appropriate size must be applied. Manual in-line stabilization must be maintained continuously by a dedicated provider during collar placement or any transfer. When repositioning is required, the team executes a synchronized 4-person log-roll.
• Airway Clearance: Clear secretions, vomitus, and blood under direct visualization using a rigid, wide-bore suction tip (Yankauer). Avoid blind finger sweeps. If airway compromise persists, insert an oropharyngeal airway (Guedel) in an unconscious patient lacking a gag reflex, or a nasopharyngeal airway if gag reflexes remain intact (avoid nasopharyngeal airways if basilar skull fractures are suspected).

[!CAUTION] Clinical Pearl: Airway Interventions & Cervical Spine Safety Never rotate, flex, or hyperextend the neck of a trauma patient. If the airway cannot be maintained using non-invasive maneuvers, definitive airway management via endotracheal intubation with manual in-line cervical stabilization (MILS) is required immediately. If orotracheal intubation fails or is precluded by severe maxillofacial disruption, emergency surgical cricothyroidotomy must be performed.

B — Breathing and Ventilation

Airway patency does not guarantee adequate ventilation. The nurse must expose the thoracic cage to inspect chest wall excursion, respiratory rate, rhythm, and symmetry, followed by auscultation and percussion.

Four acute thoracic conditions present immediate threats to life during the primary survey:

1. Tension Pneumothorax:

   • Pathophysiology: One-way valve air leak into the pleural space without egress; progressive accumulation collapses the ipsilateral lung, shifts the mediastinum and trachea contralaterally, compresses the superior and inferior vena cava, obstructs venous return, and causes fatal obstructive shock.
   • Clinical Signs: Severe dyspnea, tachypnea, absent or diminished breath sounds on the affected side, hyperresonance to percussion, distended jugular neck veins, tracheal deviation away from the affected side (late sign), and profound hypotension.
   • Emergency Intervention: Do not delay treatment for chest radiography. Perform immediate needle thoracocentesis using a large-bore cannula (14G or 16G, at least 5 cm long) inserted into the second intercostal space in the midclavicular line or the fourth or fifth intercostal space anterior to the midaxillary line. This converts a tension pneumothorax into a simple open pneumothorax. Follow immediately with a definitive tube thoracostomy (chest tube) attached to an underwater seal drainage system.

2. Open Pneumothorax ("Sucking Chest Wound"):

   • Pathophysiology: A full-thickness chest wall defect exceeding two-thirds the diameter of the trachea allows air to enter the pleural space preferentially during inspiration, producing severe ventilatory insufficiency and hypoxia.
   • Emergency Intervention: Immediately seal the defect with a three-sided flutter-valve occlusive dressing (sterile plastic dressing or Vaseline gauze taped securely on three sides). This creates a one-way valve effect: during inspiration, the dressing collapses against the wound, blocking atmospheric air entry; during expiration, the open bottom edge flaps open, allowing trapped air and blood to escape. Taping all four sides converts the defect into a fatal tension pneumothorax! Definitive chest tube insertion must follow at a separate anatomical site.

3. Flail Chest:

   • Pathophysiology: Fractures of three or more contiguous ribs in two or more places create a mechanically detached, free-floating thoracic segment.
   • Clinical Signs: Paradoxical chest wall movement—the flail segment sucks inward during inspiration (due to negative intrathoracic pressure) and balloons outward during expiration. Underlying severe pulmonary contusion impairs alveolar gas exchange.
   • Emergency Intervention: Administer humidified oxygen, ensure aggressive analgesia (e.g., intercostal nerve blocks, epidural analgesia, or IV opioids) to prevent hypoventilation, and initiate non-invasive positive pressure ventilation or endotracheal intubation with mechanical ventilation if respiratory failure supervenes.

4. Massive Hemothorax:

   • Pathophysiology: Rapid accumulation of >1,500 mL of blood (or >200 mL/hr over 2–4 hours) in the pleural cavity, commonly from disrupted intercostal or internal mammary vessels.
   • Clinical Signs: Dullness to percussion over the affected hemithorax, absent breath sounds, flat neck veins (due to profound hypovolemia), and hemorrhagic shock.
   • Emergency Intervention: Concurrent rapid fluid/blood resuscitation and urgent insertion of a large-bore (28–32 Fr) chest tube. Evacuation of >1,500 mL of blood immediately or continuous bleeding exceeding 200 mL/hr for 3–4 consecutive hours serves as a standard indication for emergency thoracotomy.

C — Circulation with Hemorrhage Control

Hypovolemic hemorrhagic shock is the leading cause of preventable trauma death. Assessment focuses on level of consciousness, skin color and temperature, pulse character, capillary refill time, and external blood loss.

• External Hemorrhage Control: Apply immediate, firm, direct manual pressure over bleeding wounds using sterile gauze pads. If severe extremity arterial hemorrhage persists despite direct pressure, apply a commercial Combat Application Tourniquet (CAT) "high and tight" on the limb proximal to the wound. Tighten until bleeding ceases and the distal pulse disappears. Document the exact application time on the patient's forehead or tourniquet band. Never loosen or remove a tourniquet intermittently, as this causes re-bleeding, wash-out of microthrombi, and fatal reperfusion shock.
• Intravenous Access: Rapidly establish two large-bore peripheral IV lines using 14-gauge or 16-gauge cannulae in the antecubital fossae. If peripheral cannulation fails within 90 seconds, establish intraosseous (IO) access into the proximal tibia or humeral head.
• Fluid and Balanced Blood Resuscitation: Avoid aggressive crystalloid infusion (such as rapid multi-liter infusions of normal saline), which dilutes clotting factors and induces hyperchloremic acidosis. Administer limited volumes of warmed balanced crystalloids (Ringer's Lactate) and activate the facility's Massive Transfusion Protocol (MTP) early for severe shock. MTP delivers packed red blood cells (PRBCs), fresh frozen plasma (FFP), and platelets in a balanced 1:1:1 ratio, mimicking whole blood.
• Pelvic Fracture Stabilization: Suspect open-book pelvic fractures in high-energy blunt trauma. Extensive bleeding from disrupted presacral venous plexuses and internal iliac branches can sequestrate the entire blood volume retroperitoneally. Apply a commercial pelvic binder or wrap a wide bedsheet circumferentially, centering the compression over the greater trochanters (not the iliac crests) to reduce pelvic ring volume and tamponade venous hemorrhage.

D — Disability: Neurological Evaluation

A baseline neurological evaluation must be completed rapidly to determine cerebral cortex and brainstem integrity:

• AVPU Scale: A simplified initial screening tool:
  • A (Alert)
  • V (Responds to Voice)
  • P (Responds to Pain)
  • U (Unresponsive)
• Glasgow Coma Scale (GCS): Scored from 3 (deep coma/brain death) to 15 (fully intact):
  • Eye Opening (1–4): 4 = Spontaneous; 3 = To verbal command; 2 = To painful stimulus; 1 = None.
  • Verbal Response (1–5): 5 = Oriented; 4 = Confused conversation; 3 = Inappropriate words; 2 = Incomprehensible sounds; 1 = None.
  • Motor Response (1–6): 6 = Obeys commands; 5 = Localizes painful stimulus; 4 = Normal flexion (withdrawal); 3 = Abnormal flexion (decorticate posturing); 2 = Abnormal extension (decerebrate posturing); 1 = None.
  • Clinical Rule: GCS <= 8 mandates immediate endotracheal intubation for definitive airway protection!
• Pupillary Examination: Inspect pupil size, shape, symmetry, and light reactivity. A unilaterally fixed, dilated pupil ("blown pupil") indicates third cranial nerve compression secondary to uncal transtentorial brain herniation, necessitating immediate hyperosmolar therapy (mannitol or 3% hypertonic saline) and urgent neurosurgical decompression.

E — Exposure and Environmental Control: The Trauma Triad of Death

The patient must be completely disrobed using trauma shears to permit a 360-degree inspection of all skin surfaces, folds, the perineum, and the posterior torso (via log-roll) to identify occult penetrating wounds, impalements, and closed deformities.

Immediately upon exposure, re-cover the patient with warmed blankets and maintain an ambient trauma room temperature of >=25°C. Uncontrolled exposure precipitates the Trauma Triad of Death, a self-propagating pathophysiological cycle with extreme mortality:

                    +----------------------+
                    |     HYPOTHERMIA      |
                    |       (< 35°C)       |
                    +----------+-----------+
                              / \
                             /   \
                            /     \
+-------------------------+v       v+-------------------------+
|        ACIDOSIS         |<------->|      COAGULOPATHY       |
|   (pH < 7.20 / Lactate) |         | (Enzyme & Platelet Loss)|
+-------------------------+         +-------------------------+

1. Hypothermia (<35°C): Decreases platelet aggregation, impairs the enzymatic coagulation cascade, reduces myocardial contractility, and triggers ventricular arrhythmias.
2. Acidosis (pH < 7.20, base deficit < -6 mEq/L): Results from anaerobic metabolism and lactic acid production due to prolonged cellular hypoperfusion. Acidosis further inhibits coagulation enzymes (coagulation factor complexes lose over 50% activity at pH < 7.2).
3. Coagulopathy: Triggered by hypothermia, acidosis, consumption of clotting factors, and hemodilution from excessive un-warmed IV crystalloid infusion.

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Resuscitation Adjuncts and Invasive Monitoring

Resuscitation adjuncts are initiated during or immediately following the primary survey:

• Cardiorespiratory Monitoring: Continuous pulse oximetry, end-tidal capnography (EtCO2), non-invasive blood pressure, and 12-lead ECG.
• Gastric Decompression: An orogastric tube is preferred over a nasogastric tube. If midface or basilar skull fractures are present (manifested by CSF rhinorrhea, hemotympanum, or raccoon eyes), nasogastric tube insertion is strictly contraindicated due to the risk of cribriform plate penetration into the cranial vault.
• Urinary Catheterization: Place an indwelling Foley catheter to monitor hourly urinary output (target: 0.5 mL/kg/hr in adults). Strict Contraindication: Never insert a urethral catheter if urethral injury is suspected. Suspect urethral trauma if any component of the classic triad is present:
  1. Blood at the external urethral meatus;
  2. Perineal, scrotal, or labial ecchymosis/hematoma;
  3. High-riding, boggy, or non-palpable prostate on digital rectal examination. Action: Perform a retrograde urethrogram (RUG) before attempting catheterization.

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The Secondary Survey & AMPLE Clinical History

The Secondary Survey begins only after the primary survey has been fully completed, ABCDE resuscitation is underway, and hemodynamic stability is established. It involves a systematic head-to-toe examination:

• Head & Maxillofacial: Palpate cranium for depressed skull fractures; inspect ears and nose for CSF leaks; assess facial bones for Le Fort stability.
• Neck: Palpate posterior cervical spine for step-offs and tenderness; check for subcutaneous emphysema and tracheal alignment.
• Thorax & Abdomen: Palpate clavicles, ribs, and sternum; assess abdomen for distension, guarding, rebound tenderness; perform Focused Assessment with Sonography for Trauma (FAST).
• Pelvis & Extremities: Palpate bony pelvis once for stability; check distal neurovascular status across all four limbs.
• Neurological & Back: Perform comprehensive motor/sensory examination; perform 4-person log-roll to palpate the entire spine and inspect posterior body surfaces.

Simultaneously, obtain the AMPLE history from the patient, witnesses, or emergency medical responders:

• A — Allergies: Specific medication, latex, or adhesive allergies.
• M — Medications: Current pharmacological regimens, specifically anticoagulants, antiplatelets, insulin, and antihypertensives.
• P — Past Medical History & Pregnancy: Chronic illnesses, previous surgeries, last menstrual period.
• L — Last Meal: Time of last oral intake (solid foods and liquids) to estimate aspiration risk during emergency anesthesia.
• E — Events / Environment: Mechanism of injury (e.g., speed of impact, seatbelt use, fall height, weapon caliber, blast exposure).

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Disaster Triage: The Simple Triage and Rapid Treatment (START) Algorithm

In mass-casualty incidents (MCIs), the volume and severity of injured victims exceed available medical resources. Conventional individualized clinical care is suspended in favor of disaster triage, which aims to maximize survival for the greatest number of casualties.

The international standard for adult disaster field triage is the START (Simple Triage and Rapid Treatment) algorithm. Assessment is limited to under 60 seconds per casualty:

                                    [MASS CASUALTY INCIDENT]
                                                |
                                                v
                            Can the patient walk? ("Walking Wounded")
                                   /                         \
                             [YES]                             [NO]
                               |                                 |
                               v                                 v
                       GREEN (Minor)                  Assess Spontaneous Respirations
                                                               /             \
                                                         [NO]                 [YES]
                                                           |                    |
                                                    Open Airway                 v
                                                   /           \       Respiration Rate:
                                             [NO]               [YES]    >30/min  -> RED (Immediate)
                                               |                  |      <30/min  -> Check Perfusion
                                               v                  v
                                         BLACK (Deceased)   RED (Immediate)     Check Perfusion:
                                                                          - Radial pulse absent OR
                                                                          - Capillary refill >2s
                                                                            /             \
                                                                      [YES]                 [NO]
                                                                        |                    |
                                                                        v                    v
                                                                 RED (Immediate)      Check Mental Status:
                                                                                      - Cannot obey commands -> RED
                                                                                      - Obeys simple commands -> YELLOW

1. Step 1: Ambulation (Walk): The triage officer commands: "Anyone who can hear me and walk, move to the designated assembly area." All ambulatory patients are tagged Green (Minor). They are directed to secondary staging for later reassessment.
2. Step 2: Respiration (Breathe): Assess non-ambulatory patients:
   • No Spontaneous Breathing: Manually reposition the airway (jaw-thrust). If breathing does not resume, classify as Black (Deceased/Expectant). If breathing resumes following airway opening, classify as Red (Immediate).
   • Breathing Spontaneously: Count respiratory rate. If >30 breaths/min, classify immediately as Red (Immediate). If <30 breaths/min, move to Step 3.
3. Step 3: Perfusion (Circulate): Assess perfusion via the radial pulse and capillary refill:
   • If the radial pulse is absent OR capillary refill > 2 seconds, classify as Red (Immediate). Control life-threatening external bleeding.
   • If the radial pulse is present AND capillary refill <= 2 seconds, move to Step 4.
4. Step 4: Mental Status (Comply): Assess ability to follow simple commands (e.g., "Touch your nose" or "Squeeze my hand"):
   • If the patient cannot follow simple commands (unresponsive or altered), classify as Red (Immediate).
   • If the patient follows simple commands, classify as Yellow (Delayed).

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Disaster Triage Coding & Allocation Matrix

[!IMPORTANT] Exam Alert: Triage Dynamics & Re-triage Triage is not a static event; it is a continuous clinical process. A patient initial tagged Yellow can rapidly deteriorate to Red due to evolving intra-abdominal hemorrhage, or an ambulatory Green patient may harbor an occult tension pneumothorax. Disaster nurses must systematically re-triage casualties at regular intervals and upon transfer between operational zones.