What is the proper procedure for the exposure phase of a primary survey?

Proper Procedure for the Exposure Phase of a Primary Survey

The exposure phase of a primary survey should involve complete removal of all patient clothing while simultaneously implementing warming measures to prevent hypothermia, followed by a thorough examination for injuries that may have been missed during initial assessment. 1

Key Components of the Exposure Phase

• The exposure phase occurs during the "E" step of the ABCDE primary survey sequence, following Airway, Breathing, Circulation, and Disability assessments 2

• Complete removal of all patient clothing is essential to allow for thorough inspection and identification of all injuries, particularly in patients who cannot communicate their injuries 3

• Immediately after exposure, the patient should be covered with warm blankets to prevent hypothermia, which is associated with increased morbidity and mortality in trauma patients 1

• Temperature monitoring should be initiated during this phase, with measurements taken every 15 minutes if the core temperature is above 36°C and every 5 minutes if below 36°C 1

Specific Examination Components

• Palpation, visual inspection, and full assessment of the exposed areas should include:
  • Complete visual inspection of all body surfaces 1
  • Palpation for tenderness, deformities, or crepitus 1
  • Assessment of facial structures including cranial nerve evaluation 1
  • Detection of potential cerebrospinal fluid leaks 1
  • Dental occlusion assessment 1

Warming Strategies Based on Temperature

• Level 1 warming (for mild hypothermia or all trauma patients initially):

  • Passive warming with removal of wet clothing
  • Covering with warm blankets
  • Increasing ambient room temperature 1

• Level 2 warming (for patients with temperature between 32-36°C):

  • Heating pads
  • Radiant heaters
  • Warming blankets
  • Humidified gases 1

• Level 3 warming (for severe hypothermia <32°C):

  • Invasive strategies including cavity lavage
  • Extracorporeal warming circuits 1

Common Pitfalls and Special Considerations

• Low compliance with proper exposure: Studies show that up to 52% of pediatric trauma patients are never fully exposed during resuscitation, with lower exposure rates associated with:

  • Increasing patient age
  • Higher Glasgow Coma Scale scores (≥14)
  • Lower Injury Severity Scores (≤15)
  • Absence of head injury 3

• Prolonged exposure: Extended exposure time increases hypothermia risk, particularly in:

  • Patients requiring intubation
  • Patients with head injuries
  • Patients with lower Glasgow Coma Scale scores 3

• Environmental control failures: Rewarming should cease after reaching 37°C, as temperatures above this range are associated with poor outcomes and increased mortality 1

• Privacy considerations: While complete exposure is necessary for thorough assessment, maintaining patient dignity through appropriate draping when possible is important 3

Algorithm for Exposure and Temperature Management

1. Remove all patient clothing completely during the exposure phase of primary survey
2. Record core body temperature
3. Immediately implement warming strategy based on temperature:
   • If temperature >36°C: Apply two warm blankets, monitor every 15 minutes
   • If temperature 32-36°C: Add Level 2 warming strategies, monitor every 5 minutes
   • If temperature <32°C: Implement Level 3 invasive warming strategies
4. Continue warming strategies throughout diagnostic imaging and transfers
5. Rewarm to minimum core temperature of 36°C before transfer to another unit
6. Cease rewarming after reaching 37°C to prevent adverse outcomes 1