Exposure and environmental control

Exposure & Environment - Strip, Flip, & Warm

• Primary Goal: Completely disrobe the patient to enable a thorough head-to-toe visual inspection for occult injuries, then immediately prevent hypothermia.
• Procedure:
  • Cut away all clothing to facilitate rapid assessment and avoid unnecessary movement.
  • After assessing the anterior, perform a log-roll, maintaining strict C-spine immobilization, to inspect the patient's back, spine, flanks, and perineum.

• Environmental Control:
  • Trauma patients lose heat rapidly. Core temp <36°C (96.8°F) must be prevented.
  • Use warmed blankets, warmed IV fluids ($39°C$), and forced-air warming devices (e.g., Bair Hugger).

⭐ The Lethal Triad of Trauma: Hypothermia (<35°C), acidosis, and coagulopathy create a vicious cycle that dramatically increases mortality. Preventing heat loss is critical.

Hypothermia & Triad of Death - The Chilly Killer

• Definition: Core body temperature < 35°C (95°F). A key component of the lethal triad in major trauma, creating a vicious cycle.
• Pathophysiology:
  • Coagulopathy: Temperature-dependent enzyme dysfunction impairs the clotting cascade and platelet function.
  • Metabolic Acidosis: ↓ tissue perfusion from vasoconstriction and ↓ cardiac output leads to anaerobic metabolism and lactate buildup.
  • Myocardial Dysfunction: ↓ cardiac output, bradycardia, and risk of arrhythmias.

• Management Principles:
  • Passive Rewarming: Remove all wet clothing, cover with warm, dry blankets.
  • Active External Rewarming: Use forced-air warming devices (e.g., Bair Hugger).
  • Active Core Rewarming: Administer warmed IV fluids (to 39°C), warmed humidified oxygen, and consider body cavity lavage (peritoneal, pleural).

⭐ Coagulopathy from hypothermia is not reflected in standard lab tests like PT/INR, as blood samples are warmed to 37°C before analysis, masking the true in-vivo enzyme dysfunction.

The Log Roll - Spinal Safety Spin

• Purpose: To examine the patient's back, flanks, and perineum while maintaining full spinal immobilization. Crucial for identifying occult injuries (e.g., penetrating wounds, vertebral deformities) and preventing hypothermia.

• Team & Technique:

  • Requires a coordinated team, typically 4-5 personnel.
  • A designated leader at the head maintains manual in-line stabilization (MILS) and directs the team.
  • The patient is rolled as a single, rigid unit-like a log-to one side.

• Assessment:

  • Palpate the entire length of the spine for tenderness, step-offs, or gaps.
  • Inspect for bruising, lacerations, or foreign bodies.

⭐ High-Yield: A rectal examination is often performed during the log roll to assess for sphincter tone, presence of blood (gross or occult), and a high-riding prostate-key indicators of spinal cord or pelvic injury.

High-Yield Points - ⚡ Biggest Takeaways

• Completely undress the patient to facilitate a thorough head-to-toe examination and prevent missed injuries.
• Immediately after exposure, aggressively prevent hypothermia to avoid the lethal triad.
• Interventions include using warm blankets, warmed IV fluids, and increasing the ambient room temperature.
• Hypothermia is a key part of the trauma triad of death (acidosis, hypothermia, coagulopathy).
• Always logroll the patient to fully inspect the back and spine, maintaining C-spine precautions.