DOA症例からみた地域救急医療の問題点  [in Japanese] Regional Emergency Medicine and Prehospital Care Evaluated in 10-year review of D. O. A Cases  [in Japanese]

1979年6月〜1990年3月の10年10か月間に北里大学病院救命救急センターに搬送されたDOA〔Dead (Death) on Arrival〕症例は682例であった。これらの症例の原疾患,発症時間,心肺停止の場所,搬送様式,救急隊現場到着までの時間および搬送時間,二次病院での処置の内容,一般市民のCPRの状況,医療費,予後等を検討するとともに,アンケートによる一般市民の心肺蘇生に対する認識度を調査し,地域救急医療およびプレホスピタルケアーの問題点について検討した。これらDOA症例の長期生存数(率)は23例(3.4%)であり,半数は重篤な遷延性意識障害を残した。11例(1.6%)の独歩退院症例中,救急隊現場到着時には生命徴侯が認められたものが10例で,5例は心肺停止後5分以内に二次救急処置が開始されていた。DOA症例の80.8%が救急隊現場到着時既に心肺停止が生じているにも拘らず,bystander CPRはわずかに8.3%にしか行われておらず,救命率の向上にはプレホスピタルケアーの充実が不可欠と考えられた。

To evaluate on-the-scene first aid and paramedical management of emergency cases and to assess the preliminary emergency care provided by regional hospital, we reviewed the records of the patients brought dead on arrival (D. O. A.) to Kitasato University Hospital (KUH) between June 1979 and March 1990. In the period cited (10 yr 10 mo), 682 patients were presented D. O. A., a term explicitly defined as a person with no respiration and no palpable pulse and/or whose electrocardiogram showed standstill, ventricular fibrillation or electromechanical dissociation at the time of arrival. Patients at the terminal stage of nonreversible illness were excluded from the D. O. A. category. The following considerations were investigated : the cause of cardiac arrest, bystander administration of cardiopulmonary resuscitation (CPR), interval required for emergency personnel to arrive, time required for transportation to KUH, and treatment at a regional hospital enroute KUH. Endogenously derived causes accounted for 65.2% (445) of the D. O. A. cases, whereas injury or some other exogenous event was involved in 34.8% (237). The most predominant diseases seen in the endogenous group were those of the cardiovascular system (48.8%), and most frequent type of exogenous casualty was multiple trauma (73. 0%). An average of 6.1±3.9 min lapsed before emergency personnel arrived on the scene. On arrival of emergency personnel, cardiac arrest was found in 551 (80.8 %) cases and no cardiac arrest in 131 (19.2%). CPR had been administered by a bystander in 42 (8.3%) of the patients showing no vital signs (cardiac arrest). Transportation to KUH took about 20.0±9.0min. Of 52 patients initially taken to a regional hospital then proceeding to KUH, 43 (82.7%) had cardiac arrest on the way to KUH. In 15 (34.9%) of those with cardiac arrest enroute, advanced life support (ALS) had been provided at the regional hospital. Altogether 23 (3.4%) of the patients termed D. O. A. survived, 11 regaining consciousness and returning home and 12 left with severe neurological impairment. Of the 11 patients recovering without adverse effect, 1 showed no vital signs at the scene of the emergency whereas 10 had palpable pulse and respiration when the emergency personnel arrived on the scene. Moreover, all 10 received ALS resuscitation within 5 min of confirmation of cardiac arrest enroute to KUH. In the present review, effective preliminary care, particularly the expedient administration of CPR, was crucial to the survival of the patients in life-threatening emergencies. These result show the need for upgrading the training of emergency personnel and for improving the emergency systems of regional hospitals as vital procedures in the management of patients termed D. O. A. and as steps to increase the chance of patient survival.