병원전 외상처치

교통사고 등으로 인한 외상환자가 최근 감소하고는 있지만, 젊은 연령층의 사망원인 가운데 상위를 차지하고 있는 사실에는 변함
이 없습니다. 예방가능 외상 사망률(preventable trauma death rate)을 낮추는 것이 외상진료의 큰 목적입니다. 최근 소방과 의
료의 제휴가 주목받고 있는데, 고에너지외상으로 인한 외상환자의 구명에는 이송과 의료의 협력이 특히 중요합니다. 이것이 원활
하게 기능하기 위해서는 이송 도중 적절한 처치가 중요하며, 이를 위해서 병원전 외상초기진료의 표준화가 필요합니다.

병원전 외상초기진료의 표준화와 그 보급을 목적으로 2003년 Japan Prehospital Trauma Evaluation and Care (JPTEC) 협의회가
출범하였습니다. 의사용인 JATECTM과의 일관성을 유지하면서 병원전 단계에서부터 병원 단계까지 일관된 목표를 가지고 JPTEC 협
의회는 병원전 외상처치의 전국적인 보급활동에 힘쓰고 있습니다. 2009년부터는 일반사단법인 JPTEC 협의회로서 보다 공공성이
높은 조직으로 개편하여 JPTEC 코스의 보급에 노력하고 있습니다.

이전에는『JPTEC 프로바이더 매뉴얼』과『병원전 외상처치 가이드라인』2권이 JPTEC 협의회의 교재로서 간행되고 있었지만
JPETC 협의회 조직의 변화를 계기로 교재를 1권으로 정리하면서 전면적으로 개편하여『JPTEC 가이드북』이란 이름으로 새로이 발
간되었습니다. 병원전 처치에 종사하는 구급대원들은 물론 의료지도에 종사하는 선생님들께서 사용하기 쉬운 교재가 되리라 생각
하며, 널리 활용되기를 기원합니다.

이 가이드북은 많은 시간을 들여 엄정한 준비과정을 거쳐 제작되었습니다. 집필과 편집 등에 최선을 다해 주신 관계자 여러분께
진심어린 사의를 표합니다.

2010년 3월

일반사단법인 JPTEC 협의회 대표이사

小林國男

도서목차

간행에 즈음하여

역자 머리말

이 책의 특징과 활용방법에 관하여

출간사

JPTEC 협의회 신텍스트 편집위원회

역자 소개



I JPTEC의 개념 1

제 1 절 JPTEC이란 ························ 2

제 2 절 외상 현황 ························· 3

1. 외상의료의 사회적 중요성 ············· 3

2. 예방가능 외상 사망 ·············

(Preventable Trauma Death, PTD) ······· 5

제 3 절 JPTEC의 의의 ······················ 7

1. 외상 병원전 처치의 표준화 ············· 7

2. 일본 외상의 현황 ··················· 7

3. 외상 병원전 처치와 황금시간(Golden Hour) ··· 8

4. 3R과 외상 우회(Trauma bypass) ········· 9

5. Load & Go의 개념 ·················· 9

제 4 절 JPETC 협의회의 활동 ················ 10



II JPTEC의 활동 13

제 1 절 활동의 개요 ······················· 14

1. 활동 순서 ······················· 14

2. Load & Go의 판단 ················· 17

제 2 절 상황평가 ························· 18

요 점 ···························· 18

해 설 ···························· 19

1. 출동 요청시 정보수집 ··············· 19

2. 감염방어 ························ 20

3. 휴대기자재 ······················ 20

4. 안전확인 - 2차 재난 방지 ············· 20

5. 지원요청의 필요여부(초기 분류) ········ 21

6. 수상기전 파악, 고에너지사고의 판단 ····· 22

7. 구급대의 장비 ···················· 24

8. 개인장비 ························ 26

제 3 절 초기평가 ························· 30

요 점 ···························· 30

해 설 ···························· 33

1. 경추보호(중립자세로 유지) ············ 33

2. 반응을 확인하고 기도개방 유무 평가 ····· 33

3. 호흡평가 ························ 34

4. 순환평가 ························ 35

5. 의식수준평가(JCS 평가) ·············· 35

6. 관찰과 동시에 해야 할 처치 ··········· 35

생리와 병태 ······················· 36

1. 기도·호흡 ······················ 36

2. 순환 ··························· 38

3. 의식장애 ························ 43

제 4 절 전신관찰 ························· 46

전신관찰의 목적 ···················· 46

A. 머리 ·························· 47

요 점 ·························· 47

해 설 ·························· 48

1. 역학 ························ 48

2. 일차성 뇌손상과 이차성 뇌손상 ······· 48

3. 뇌허니아 소견을 간과하지 마라 ······· 48

4. 주의를 요하는 소견 ·············· 48

5. 보충 ························ 48

6. 정리 ························ 55

B. 안면·경부 ····················· 56

요 점 ·························· 56

해 설 ·························· 57

1. 외상에 동반되는 이상 ············· 57

2. 평가와 처치 ··················· 57

3. 주의해야 할 손상과 그 대응 ········· 58

C. 흉부 ·························· 61

요 점 ·························· 61

해 설 ·························· 63

1. 해부 ························ 63

2. 병태생리 ····················· 63

3. 수상기전 ····················· 64

4. 평가 ························ 65

5. 주의해야 할 손상과 그 대응 ········· 66

D. 복부 ·························· 70

요 점 ·························· 70

해 설 ·························· 70

1. 해부 ························ 71

2. 복부관찰의 특징 ················ 71

3. 복부관찰과 판단의 요점 ··········· 71

4. 실질 장기손상의 병태와 평가 ········ 73

5. 내강장기(Hollow viscus) ·············

손상의 병태와 평가 ·············· 73

6. 혈관손상의 병태와 평가 ··········· 74

7. 후복막 장기손상의 병태와 평가 ······· 74

E. 골반 ·························· 75

요 점 ·························· 75

해 설 ·························· 75

1. 해부 ························ 75

2. 수상기전과 골절분류 ············· 75

3. 병태 ························ 76

4. 관찰 ························ 77

5. 처치 ························ 79

6. 로그롤(rog-roll)의 회피 ············· 79

7. 골반고정구 ···················· 79

8. 정리 ························ 80

F. 대퇴부·사지 ··················· 82

요 점 ·························· 82

해 설 ·························· 83

1. 대퇴부의 관찰 ·················· 83

2. 하퇴·상지의 관찰 ··············· 84

G. 뒷면 ·························· 87

요 점 ·························· 87

해 설 ·························· 87

1. 후두부·후경부·경추 ············ 87

2. 등쪽요부·둔부 체표 ············· 88

3. 척주(흉추~미골) ················· 88

4. 등쪽·요부·둔부 ··············· 89

5. 대퇴 ························ 90

제 5 절 중점관찰 ························· 92

요 점 ···························· 92

해 설 ···························· 92

제 6 절 상세관찰 ························· 94

요 점 ···························· 94

해 설 ···························· 94

1. 상세관찰이란 ····················· 94

2. 상세관찰의 실시 ··················· 95

3. 관찰항목 ························ 95

제 7 절 계속관찰 ························· 98

요 점 ···························· 98

해 설 ···························· 99

1. 목적 ··························· 99

2. 관찰항목 ························ 99

3. 계속관찰의 정리 ·················· 100

제 8 절 환자의 고정과 수용 시작 ············· 101

요 점 ··························· 101

해 설 ··························· 101

제 9 절 수용직후의 활동 ··················· 102

요 점 ··························· 102

해 설 ··························· 102

1. 목적 ·························· 102

2. 구체적 행동 ····················· 102

제10절 보고와 급변시 대응 ················ 106

요 점 ··························· 106

해 설 ··························· 106

1. 의료기관으로의 2차 보고(second call) ···· 106

2. 영상전송에 의한 정보전달 ··········· 106

3. 의료기관 도착시 인계 ·············· 106

4. 주의해야 할 상태변화 ·············· 107



III 기본술기 111

제 1 절 중립자세 ························ 112

요 점 ··························· 112

해 설 ··························· 113

1. 목적 ·························· 113

2. 대상 ·························· 113

3. 방법 ·························· 113

제 2 절 기도확보·호흡관리 ················ 114

요 점 ··························· 114

해 설 ··························· 116

1. 기도확보의 술기 ·················· 116

2. 고농도산소 투여 ·················· 117

3. 보조환기·인공호흡 ··············· 118

4. 기타 ·························· 119

제 3 절 경추보조기(Cervical orthosis)장착 ······ 120

요 점 ··························· 120

해 설 ··························· 122

1. 경추보조기 장착의 목적 ············· 122

2. 경추보조기 장착의 실제 ············· 122

제 4 절 헬멧(Helmet) 제거 ·················· 126

요 점 ··························· 126

해 설 ··························· 129

1. 헬멧 제거의 필요성 ················ 129

2. 헬멧의 종류 ····················· 129

3. 헬멧 비장착시와 장착시 경추의 상태 ···· 129

4. 헬멧 제거 ······················ 129

5. 보충 ·························· 132

제 5 절 로그롤(Rog-roll) ··················· 136

요 점 ··························· 136

해 설 ··························· 142

제 6 절 전척주고정 ······················ 143

요 점 ··························· 143

해 설 ··························· 144

1. 척주보호의 필요성 ················ 144

2. 전척주고정의 적응증 ··············· 144

3. 전척주고정의 방법 ················ 145

4. 입위 외상환자의 고정 ·············· 145

5. 보충 ·························· 145

제 7 절 차외구조 ························ 147

요 점 ··························· 147

해 설 ··························· 149

1. 도수에 의한 구조 ················· 149

2. 모포를 이용한 구조 ················ 150

3. 보충 ·························· 151



IV 처치 153

제 1 절 개방성기흉(Open pneumothorax) ······ 154

요 점 ··························· 154

해 설 ··························· 155

1. 개방성기흉의 병태 ················ 155

2. 관찰과 판단 ····················· 155

3. 처치 ·························· 155

제 2 절 동요가슴(Flail chest) ················ 156

요 점 ··························· 156

해 설 ··························· 157

1. 동요가슴의 병태 ·················· 157

2. 관찰과 판단 ····················· 157

3. 처치 ·························· 158

제 3 절 장관탈출 ························ 159

요 점 ··························· 159

해 설 ··························· 160

1. 장관탈출의 병태 ·················· 160

2. 관찰과 판단 ····················· 160

3. 처치 ·························· 161

제 4 절 자상·총상·익상(􁹻傷) ············· 162

요 점 ··························· 162

해 설 ··························· 163

1. 자상 ·························· 163

2. 총상 ·························· 164

3. 익상 ·························· 166

제 5 절 골절지 ·························· 168

요 점 ··························· 168

해 설 ··························· 169

1. 관찰과 판단 ····················· 169

2. 처치 ·························· 170

제 6 절 지혈 ···························· 171

요 점 ··························· 171

해 설 ··························· 172

1. 병태 ·························· 172

2. 지혈처치 ······················· 172



V 특수병태 175

제 1 절 특수한 수상 ······················ 176

요 점 ··························· 176

해 설 ··························· 176

1. 특이한 외력이나 특수한 기기에 의해서 특징적인

손상을 초래하는 경우 ·············· 176

2. 외상의 원인이 특이한 경우 ··········· 180

제 2 절 소아 외상 ························ 182

요 점 ··························· 182

해 설 ··························· 182

1. 해부학적 특징 ··················· 182

2. 생리학적 특징 ··················· 183

3. 관찰·평가·처치에서의 특이성 ······· 184

4. 부위별로 본 소아외상의 특이성 ········ 186

제 3 절 고령자 외상 ······················ 188

요 점 ··························· 188

해 설 ··························· 188

1. 고령자대국·일본 ················· 188

2. 높은 사망률 ····················· 189

3. 고령화에 동반되는 신체의 변화 ········ 189

4. 상황평가에서의 주의점 ············· 189

5. 초기평가에서의 주의점 ············· 190

6. 전신관찰에서의 주의점 ············· 191

7. 차내 활동에서의 주의점 ············· 191

제 4 절 임부 외상 ························ 193

요 점 ··························· 193

해 설 ··························· 193

1. 임신과 태아의 외상역학 ············· 193

2. 임신에 동반하는 해부학적·생리학적 변화 194

3. 태아가 처해진 환경 ················ 195

4. 임부 외상의 산과적 합병증 ··········· 195

5. 임부 외상에 대한 병원전 처치 ········· 196



VI 중증도·병원선정 197

제 1 절 중증도·긴급도·분류(Triage) ········· 198

요 점 ··························· 198

해 설 ··························· 198

1. 중증도·긴급도의 판단 ············· 198

2. 판단의 요점 ····················· 198

3. 과대평가분류(Over triage)·과소평가분류 ····

(Under triage) ···················· 200

제 2 절 병원·이송수단 선정 ··············· 202

요 점 ··························· 202

해 설 ··························· 202

1. 적절한 의료기관의 선정 ············· 202

2. 외상 우회(Trauma bypass) ··········· 205

3. 이송수단의 선정 ·················· 206



VII JPTEC을 둘러싼 환경 209

제 1 절 닥터헬리(Doctor Heli)·닥터카(Doctor Car) 210

요 점 ··························· 210

해 설 ··························· 210

1. 닥터헬리·닥터카 체계 ················

(Doctor Heli·Doctor Car System) ······ 210

2. 현장으로 의사요청의 필요성 ·········· 211

3. 현장으로 의사요청의 판단 ··········· 211

4. 요청의 적응질환 ·················· 212

5. 닥터헬리를 둘러싼 현 상황 ··········· 212

6. 외상증례에 대한 닥터헬리의 ·············

유효성을 나타내는 객관적 자료 ········ 212

7. 황금시간(Golden Hour) ············· 213

8. 플라이트닥터(Flight Doctor)에 의한·········

현장진료 ······················ 213

9. 닥터헬리 요청기준 ················ 213

10. 플라이트닥터가 현장에 ···············

파견되었을 때의 주의점 ············ 213

11. 닥터헬리의 재난의료 활용 ··········· 213

12. 고에너지 사고현장에서 닥터카의 가능성 · 214

13. 닥터카의 종류와 특징 ·············· 214

14. 닥터카 활동과 Load & Go ··········· 215

15. 닥터카 제휴활동시 요구되는 것 ······· 215

제 2 절 대형재난 ························ 217

요 점 ··························· 217

해 설 ··························· 217

1. 대형재난이란 ···················· 217

2. 구급의료와 재난의료의 차이 ·········· 217

3. 재난에 대한 체계적인 대응 ··········· 218

4. 선착구급대의 역할 ················ 218

5. 재난현장의 기본적인 레이아웃(Layout) ··· 219

6. 구호소의 중요성 ·················· 219

7. 현장의 지휘명령 계통과 구급지휘소의 역할 221

8. 계획·준비·훈련의 중요성 ·········· 221

제 3 절 재난시의 분류(Triage) ··············· 222

요 점 ··························· 222

해 설 ··························· 222

1. 분류(Triage) 란 ··················· 222

2. 범주(카테고리, Category) 분류 ········· 223

3. 분류(Ttriage)의 실제 ················ 223

4. 그 밖의 분류(Triage) 법 ·············· 226

5. 중등도 분류꼬리표(Triage tag) ········· 226

6. 분류(Triage)에 관한 과제 ············· 227

7. 끝으로 ························ 227

제 4 절 DMAT ·························· 228

요 점 ··························· 228

해 설 ··························· 228

1. DMAT란 ······················· 228

2. DMAT 발족의 경위 ················ 228

3. DMAT 활동의 근거 ················ 229

4. DMAT가 상정하는 활동 ············· 229

5. 국지재난에 있어서 DMAT와 ·············

소방의 제휴에 관하여 ·············· 229

6. 출동요청의 주요경로에 관하여 ········ 229

7. DMAT 투입 원칙 ·················· 230

8. 총괄 DMAT 등록자 ················ 230

9. 보충 ·························· 232

제 5 절 소방조직과 의료지도 ··············· 233

요 점 ··························· 233

해 설 ··························· 234

1. 실시기준에 관하여(소방법 개정) ···········

- 소방기관과 응급의료기관의 협조 강화 ·· 234

2. 의료지도란 ····················· 234

JPTEC에 필요한 용어·약어집 ··············· 241

색인(INDEX) ···························· 247