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Exposure, Environment, and Extraction
The “E” in the Primary Survey often differs between sources, but the main considerations are exposing all possible injuries to ensure that no life-threatening injuries are missed and then ensuring that the casualty is protected against the environment. The aim is to fully assess the casualty whilst preventing hypothermia and heat illness. In this section we also include “Extraction” to highlight considerations around rapid movement of the casualty to definitive care.
Exposure
The aim of this assessment is to find previously hidden injuries, especially injuries such as penetration wounds to the sides of the chest, back, armpit, or groin. However, you should consider all potential wounds, such as penetrating wounds, burns, deformities, bruising, and missed bleeds.
Trauma shears should be used to cut clothing where required rather than removing garments over injuries or creating difficulties with managing the c-spine whilst clothing is removed. Only expose one area at a time, to manage the casualties dignity and protect against the environment.
Environment
Even mild cooling can exacerbate trauma outcomes by promoting coagulopathy and hypothermia – consider the “Trauma Triad”.
If possible, get the casualty off the ground – onto a roll mat, or vacuum mattress. Insulate the casualty by using emergency blankets, blizzard bags, bothy shelters, or cas bags. Cover the extremities if possible, with gloves and hats.
If severe hypothermia is suspected, ensure that the casualty is handled gently as movement can trigger cardiac arrhythmias.
In hot or enclosed environments be aware of the risk of heat illness. Move the casualty to a cooler, shaded area if necessary. Loosen or remove excess clothing.
Extraction
Take steps to ensure that the extraction of the casualty will be quick. This could include preparing an extraction path or preparing the casualty for an air lift. However, you must prepare a “Plan B” for extraction. For example, if an air asset is assigned this could later be reassigned or be unable to complete the extraction due to poor weather.
Consider the risks of a protracted extraction. For example, where a consumable resource such as Oxygen is being used consider the implications of extraction delays and the requirement to request additional resources to be brought to the casualty.
Once you have completed your Primary Survey and you have addressed any conditions or injuries likely to present an immediate threat to life, you may continue to the Secondary Survey. Continue communicating with Control or Emergency Services, and prepare the casualty for hand over upon their arrival. Consider preparing an ATMIST handover.