54 - Primary Assessment- Exposure

KYJ 54. E = Expose
Part 5 of 5 part series on Primary Survey.
Expose & Environment

While some texts choose to cap primary survey at ABCD. Many trauma authors include E for exposure and environmental considerations, as part of the primary survey procedure.  Irrespective of opinion it's inclusion in the end of Primary or beginning of Secondary assessment, is a foolish and meaningless semantic debate.  The fact remains that if a patient is not fully exposed, visual assessment can not be accurate or complete.

This two tiered approach includes physical removal of the patients clothing. If appropriate, safe and not contraindicated (burnt to the skin), attempts should be made to remove clothing in damaged. Many patients however, require their clothing to be cut off with shears, or scissors.

Clothing removed from a patient post alleged criminal activity should be stored in a paper or breathable bag, to preserve potential forensic evidence. Label all items removed from a patient, and preferably have an itemised  documentation witnessed by another colleague.

Once naked (or near naked) the patient must be covered with warm blankets.  One of the three lethal silent killers in a trauma room is hypothermia.

It is Hypothermia prevention that is most detrimental, and so referred to as Environmental considerations.
Ensure that susceptible patients are kept warm, and dry.
Patients most at risk from hypothermia are :
• shock
• children (especially babies)
• elderly
• burns >10% BSA
• high spinal patients (above T6)
• wet (urine/water)

Hypothermia causes haemoglobin to bind tight to oxygen.  Cold patients carry oxygen well, but won't pass it to the cells that need it. Their sats are good, but they are hypoxic at a cellular level, giving rise to the development of acidosis which renders haemoglobin unable to transport oxygen, worsening hypoxia.

Keep them warm or they will die!!