コロナ渦における傷病者評価と処置

ばく

コロナ渦で野外救急。救助者と傷病者の濃厚接触はさけられません。傷病者の命を救い、救助者の感染リスクを軽減するためのはどうしたら良いのか。WMTCのプロトコルを紹介します。

特殊な蘇生器具のない野外において、安全なCPRはありません。もし傷病者が感染していたら、胸骨圧迫による肺からの空気の放出で、高い確率で感染します。現場に介入する前に、以下の基準を考慮し、判断することが重要です。

全体評価

・傷病者に近づく救助者を必要最小限にする。
・傷病者の山側、風上で評価と処置をする。テント、シェルターなど密閉空間を避ける。
・20-30m手前で、PPEを装着する。
・マスクは以下の順で保護効果が高い：(1)N-95かKN-95マスク（FAキットに入るように折り畳めるものを選ぶ）、(2)サージカルマスク（不織布マスク）、(3)布マスク、(4)タオル等。マスクを取る時には手を消毒する。使用したマスクはハイリスクのゴミとして処置する。処理したあともう一度手を消毒する。
・可能であればグルーブをする。COVID-19は血液感染はしないが、飛沫感染する。グローブを取る前に、グローブを消毒し、マスク、ゴーグルを外す。次にグローブの表面を触らないようにグローブを外す。使用したグローブはハイリスクのゴミとして処置する。もしグローブがない場合、手を十分に消毒し、口、鼻、目を触るのを避ける。
・目を保護する。目に飛沫感染する可能性がある。横に日除けのあるゴーグルやサングラスを用いる。外した後は、消毒する。

一次評価

・傷病者に意識があり、一次救命処置の問題がなければ、傷病者に鼻と口をふさがせる。もし余分にマスクを持っていれば、マスクをつけるよう指示する。もしくは、傷病者に自分のタオルや服で鼻と口を覆わせる。
・傷病者に意識がなければ、グローブの裾をずらして、呼吸を確認する。もし呼吸があれば、傷病者にマスクをつける。
・CPRの開始は、感染リスクを極めて高める。胸骨圧迫により、人工呼吸をしなくとも、肺の中の空気が放出される。N-95マスクが空気感染を防ぐ最も良い選択であるが、マスクをつけていては人工呼吸はできない。もし人工呼吸を選択する時は、弁のついたマスクを使う。
・CPRを開始する時は、救助者の感染リスク（重症化リスク＋道具の保護力）と、傷病者の蘇生可能性を総合的に判断する。溺れ、落雷、雪崩による心停止は蘇生の可能性がある。外傷、熱中症、アナフィラキシー、毒、疾病による心停止は蘇生の可能性はほとんどない。
・傷病者の顔をマスクで保護し、人工呼吸を行わないCCR（心脳蘇生）は、一つの選択肢であるが、心停止後すぐにCCRを開始できなければ効果はない。

二次評価

・SAMPLE評価にCOVID-19に関する質問を加える。1)感染リスクの高い活動を控え、人との距離、マスク、手洗いの生活習慣を実施していたか？2)最近、味覚、嗅覚に異常はあったか？3)最近、下痢、吐き気、嘔吐はあったか？4)最近、発熱、筋肉痛、せき、倦怠感などインフルエンザに似たS/Sxはあったか？5)過去２週間にCOVID-19の感染者もしくはそのS/Sxのある傷病者との濃厚接触があったか？6)以上に質問に一つでも当てはまる場合、COVID-19の検査を受けたか？その結果は？
・全てのバイタルサインをとる。COVID-19の感染者は、38℃以上の発熱があり、心拍数、呼吸数が上がり、飽和酸素濃度が94%以下になる。

処置

例え、いかなる専門的な保護をし、高い技術で処置しても、感染リスクをゼロにすることができない。救助者のコミュニティへの感染拡大を防ぐために、以下の行動をとる。
・処置をする時に来ていた上着を脱ぎ、ビニールに入れて、洗濯できるまで密閉する。
・直ちに、シャワーを浴びる。
・２週間の自己隔離、自己検疫を行う。
・処置後も傷病者の健康状態を観察し、COVID-19のS/Sxが見られたら検査を受けさせる。もし陽性の場合、救助者も医療機関に通報し、指示を仰ぐ。

避難


・できるかぎり傷病者との距離を保つ。
・自立歩行ができない場合、傷病者にマスクを付け、担架搬送を検討する。
・医療機関に引き渡す時に、COVID-19に関する情報を引き継ぐ。

ファーストエイドキット

COVID-19パンデミック中には以下のものを加える。
・携帯消毒薬、参加者全員が携帯することを検討する。
・グローブ２組
・マスク２つ（救助者用と傷病者用、N-95、NK-95マスクが望ましい）、参加者全員が携帯することを検討する。
・目の保護、サングラス、ゴーグル
・ハイリスクのゴミ、衣類をいれるためのビニール袋
・体温計（非接触型が望ましい）
・オキシメーター
・洗剤（接触部の洗浄用/衣類の洗浄用）

文責：Paul Nicolazzo（WMTCディレクター）
翻訳：岡村泰斗

コロナ渦においても、家族に対するCPRにPPEは必要ありません。私は自らのリスクを冒してでも蘇生する可能性があればCPRを開始します。感染リスクの低い知り合いであれば、上記のプロトコルでCPRを開始するでしょう。全く知らない人に対しては、どうするでしょう。私には守るべき家族や、やるべきミッションがあります。もし、N95マスクがあり、心停止直後であれば、傷病者にマスクを付けて、CCRのみチャレンジするかもしれません。心停止後どのくらい経っているかわからない場合は、蘇生を開始しないかもしれません。その時を常にイメージ、頭と装備と技術を備えましょう。

CPR及び傷病者ケアに関するより詳しい情報はデジタルハンドブックを参照してください。CPR及び傷病者の評価と処置を理解するためにはWFA/WFRコースでトレーニングを受け、SOAPノートに正しく記録することが必要です。

 

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