Last updated 11/11/23
Primary Survey - Environment/Exposure
Depending on which book you read, E stands for environment/exposure. The environment and its dangers have been covered under the Danger and Response section. Here, we will focus on exposure to the weather and its effect on the casualty and ourselves. The medical management of casualties with heat illness (hyperthermia and hypothermia) are discussed elsewhere.
The adverse effects of the environment can exacerbate other injuries or cause life-threatening illness by itself. The casualty should be protected from the adverse effects of the environment as soon as possible. As a rule of thumb, you can expect that most of our casualties will be at least mildly hypothermic when you arrive, unless they have been able to shelter from the elements and are wearing sufficient insulating layers.
If additional personnel are available, protection from the environment e.g. by putting up a group shelter, should be done whilst the assessment and management of Primary Survey clinical problems is on-going. However, if you are on your own, it may have to be done after you have managed any clinical problems, as these almost always take priority unless conditions are really bad.
Hypothermia significantly worsens mortality and morbidity outcomes following most trauma. In cold weather, try to insulate the casualty from the ground and use a group shelter to protect them during the assessment and treatment. It is important to use the group shelter correctly. If you just drape it over the cas carer and casualty and let it flap about in the wind, all the heat will escape and it will just get in the way. Instead get three or four people inside to help warm the environment within and get them or others outside to hold the edges of the shelter to the ground. If done correctly the temperature within can rise quickly. The casualty bag, foil blankets, belay jackets, hats, mitts and heat packs can be used to further protect the casualty during both treatment and the evacuation. Think ahead…. open the heat blankets (if you can keep them dry) as you leave the vehicles, so that they are warm when you reach the casualty.
In warm weather the group shelter can be held aloft as a shade to protect the casualty from direct sunlight. By getting them to minimise their exertion, fanning, and cooling them with water, we can stop or start to reverse problems resulting from hyperthermia.
The Cas Bag rucksack contains a range of kit which can keep the casualty warm:
Exped bag with two hats and two pairs of gloves
Exped bag with two large Primaloft belay jackets
Group shelter
‘Blizzard’ Blanket (to be used as a vapour barrier in moderate and severe hypothermia)
the Cas bag - a warm bag to put the casualty in on the stretcher and handy to wrap around or cover casualty while waiting for stretcher/evacuation to be sorted
2 Heat Blankets
There is an additional heat blanket in the front pouch of the fracture sack. Documentation relating to the management of hypothermia is in the Cas Card folder in the Medical Sack (the MREW Assessment & Management of Hypothermic Casualties Protocol and the ECMO Referral form).
The important thing to remember when carrying out the Primary & Secondary Surveys is that part of your treatment is to prevent cooling, if this has not already occurred, and to start restoring body temperature (warming or cooling, as appropriate) if it is deranged when you arrive.
NB COVID-19: If a casualty is suspected to have COVID, try to avoid using a group shelter unless there is a good clinical indication - use a dynamic risk assessment.