野外での脊椎マネジメント

40年間脊椎マネジメントの妥当性に関するデータはなく、救急救命は、全ての外傷の傷病者を、脊髄損傷の予防のために、完全に脊椎固定してきた。この方法の根拠は、外傷が傷病者の脊椎を痛め、その脊椎の運動が脊髄を傷つける可能性があるため、完全に脊椎固定することがその予防になるという考えからである。しかしこの考えは、誤りであり、都市救急、野外救急療法において、脊椎マネジメントは変化している。本稿では、なぜ、どのようにこの修正が起こっているのか、最新の野外での脊椎マネジメントはどのようなものなのか示す。

1998年、ニューメキシコ大学の救急救命学部のMark Hauswald教授は、マレーシアとアメリカで外傷の傷病者を比較した研究結果を発表した。マレーシア大学病院では120名の傷病者が脊椎固定しなかったのに対し、ニューメキシコ大学病院では334名全ての傷病者は脊椎の完全固定をして搬送した。その結果、完全固定した群の方が有意に神経障害を示した。この研究は、これまでの脊椎マネジメントの方法に警鐘を鳴らし、新たな脊椎マネジメントの研究に火をつけた。

2012年、彼は脊椎損傷の力学的、病理学的研究を発表し、既存の脊椎固定の理論を否定した。この論文で、ほとんどの脊椎損傷は、力学的には安定しており、脊髄損傷を有する少数の傷病者の大部分は、受傷時にすでに脊髄損傷しており、搬送による固定の影響を受けないことを示した。つまり、脊髄や神経障害は、受傷部位への二次的な外傷にのみ影響を受け、通常の動きであれば安全であることを意味している。

この20年間で多くの研究が発表され、脊椎の完全固定について以下のことが明らかになった。
・離れた環境では、担架搬送は、傷病者と救助者の危険を高める。
・胸部のストラップやCカラーは、呼吸を妨げる可能性がある。
・痛みの原因となる。
・担架のパッドが不十分だと圧迫による痛みの原因になる。

2000 National Emergency X-Radiography Utilization Study(NEXUS)と、2001 Canadian Cervical Spine Rule(CCR)は、脊椎損傷の疑いを除去す最も広く使われているアルゴリズムを発表した。自覚症状のない、頚椎損傷の疑いを除去するためのメタ分析の結果、NEXUSとCCRによる陰性は、99.6%で、陽性は3.7%であった。テストに不合格の傷病者の96.3%は不安定な脊椎損傷でなかった。NEXUSをベースとしたメーン州基準は、脊椎の痛みと脊椎両側の圧痛が加わっていた。ほとんどの野外救急法のプロバイダーは、NEXUSに基づいて脊椎評価を指導しているが、修正版NEXUSでは、脊椎の痛みと脊椎全体の評価が加えられている。いずれの評価にせよ、合格した傷病者は、脊椎の問題を理由に避難する必要はない。
・意識があり、信頼性があり、歩行可能な傷病者が脊椎損傷、脊髄損傷を負っている可能性は低い。
・四肢の障害が原因でない運動神経、感覚神経の問題は、脊髄損傷の可能性が高い。
・全身固定は、歩行できない脊椎損傷の疑いのある傷病者を固定する最も良い方法の一つである。
・Cカラーは、都市救急ではいまだ決着のついていない問題であるが、野外救急では、外傷のない傷病者のでも↑ICPや、気道を閉塞し、最も重要な脊髄損傷の予防には効果的ではない。もし傷病者が楽になるのであれば、よくパッドした柔らかいCカラーを使い、気道を閉塞しないようにする。

MOIが外傷か分からない、もしくはVPUの傷病者は、脊椎損傷を疑い、BLS中に脊椎損傷として扱う。一次評価で大出血の観察、処置をしている間、意識のある傷病者には、動かないように指示する。傷病者、特に不安や攻撃的な場合には、頭を持ったり固定しない。脊椎評価は、傷病者評価システムの3つの三角形を終わった後である。

脊椎損傷、脊髄損傷の処置の原則
・自発的な通常の稼働範囲内の脊椎の動きは安全である。

脊椎リスク

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