ケーススタディ:落雷被害

あなたは4名の生徒の登山を指導しています。山頂付近で雷がなってきたため、避難を開始した直後に、後方にいた3人の生徒が雷に打たれました。

一人目のミキは、すぐに立ち上がり、混乱しているようでした。2人目のタケシは、仰向けに倒れた後、自分で近くの岩にゆっくりともたれかかりました。3人目のサトルはうつ伏せに倒れたまま、意識がありませんでした。

Q1サトルは脈なし、呼吸なしでした。CPRをすべきですか?

Q2タケシの45分後の問題はなんですか?

SAMPLE
初期症状
・頭痛(4)
・左耳の耳鳴り; よく聞こえない
・吐き気
・左手の痺れ
45分後の症状
・頭痛(2)
・左耳の耳鳴りはやや治る; 通常に聞こえる
アレルギー
・なし

・なし
傷病歴
・なし
摂取/排泄
・食事: 五時間前にグラノーラバー、りんご、チーズ
・水分: 1リットル
・電解質: 適
・尿: 薄黄色、通常の量
・便: 通常、濃い茶色、硬い
出来事
・詳しく覚えている。意識障害なし。
全身所見
初期所見
・左手を動かせない。
・左腕に鳥の羽のような赤い痕(写真参照)
45分後
・左手にやや痺れはあるが、動かせるようになった。
バイタルサイン
初期サイン
・意識あり+混乱
・通常の心拍数62正常
・現在の心拍数98正常
・現在の呼吸数22安定
・皮膚青白い、冷たい、しっとり
・体温、血圧、血中酸素不明
45分後
・意識あり+覚醒
・現在の心拍数68正常
・現在の呼吸数18安定
・皮膚ピンク、温かい、乾燥
脊椎評価(FSA)
・左手痺れのため信頼性なし
45分後:
・信頼性あり
・痛みなし
・圧痛なし
・局所のしびれなし
・両肢の運動の弱さなし
・鋭い刺激と柔い刺激の区別ができる

タケシのSOAPノート

Q3ミキの問題はなんですか?

SAMPLE
症状
・軽い耳鳴り; 通常通り聞こえる
アレルギー
・なし

・なし
傷病歴
・なし
摂取/排泄
・食事: 5時間前にグラノーラバー、りんご、チーズ
・水分: 1.5リットル
・電解質: 適
・尿: 薄黄色、通常の量
・便: 通常、濃い茶色、硬い
出来事
・詳しく覚えている。意識障害なし。
全身所見
・ブッシュに転倒した時にできた両肢の擦り傷​
バイタルサイン
・意識あり+覚醒
・現在の心拍数84正常
・現在の呼吸数18安定
・皮膚青白く、冷たく、しっとり
・体温、血圧、血中酸素不明
脊椎評価(FSA)
・信頼性あり
・痛みなし
・圧痛なし
・局所のしびれなし
・両肢の運動の弱さなし
・鋭い刺激と柔い刺激の区別ができる

ミキのSOAPノート

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