경련을 주소로 내원한 폐색전증 2례와 문헌고찰

박득현 대한응급의학회 2014 大韓應急醫學會誌 Vol.25 No.1

Pulmonary embolism is a devastating disease that causessignificant morbidity and mortality, however, seizure as apresentation of pulmonary embolism is rare. We experiencedtwo such cases of a 25- and a 59-year-old malewho visited the emergency center because of new onsetseizure activity with no structural lesions by MRI or CT. Despite having alert consciousness, they were found tohave hypoxemia of unknown cause with EKG abnormality. Therefore, we performed bedside ultrasound and CTangiography; pulmonary embolism was then diagnosed. The patients had similar patterns-risk factors, deep veinthrombosis, abnormal EKG, hypoxemia, tachycardia, andseizure. Diagnosis of pulmonary embolism is very confusing,particularly in cases presenting with seizure. Therefore,we suggest that physicians should be more aware of theimportance of considering pulmonary embolism within thedifferential diagnosis for unexplained new onset of seizureactivity.

응급센터로 내원한 저혈압 환자의 사망을 예측할 수 있는 인자들에 대한 연구

박득현,하영록,김영식,신태용,오성한,최성실,노숙영 대한중환자의학회 2011 Acute and Critical Care Vol.26 No.2

Background: This study was performed to analyze the effects of differences between initial and follow up amounts of central venous oxygen saturation (ScvO_2), lactate, anion gap (AG), and corrected anion gap (CAG). Methods: Patients with systolic blood pressure that was lower than 90 mmHg participated in this study. Along with Arterial Blood Gas Analysis (ABGA), the amounts of electrolytes, albumin, and Scvo_2 were initially checked and then re-checked four hours later. The patients were divided into two groups, which were survived and expired, and the differences in initial and final values were compared in both groups. Results: Out of a total of 36 patients, 29 patients survived and 7 patients died. The data showed almost no difference in mean age, mean arterial pressure, heart rate, respiratory rate, and body temperature between two groups. Comparing the initial amount, there was a statistically significant variation in lactate. Comparing the final values, lactate, AG, and CAG varied significantly. However, for both groups, the differences between the initial and final values were not significant. The area under curve (AUC) of follow up lactate and follow up CAG was 0.89 and 0.88. AUC of ED-APACHEII and original ICU APACHEII was 0.74 and 0.96. Conclusions: There was no prognostic effect of ScvO_2, lactate, AG, and CAG in hypotensive patients. The initial and final values of lactate and CAG were good prognostic factors for the expired group.

유기인계 농약(Dichlorvos) 음독 후 발생한 좌측 안면부 종창 1례: 사례와 문헌고찰

박득현 대한응급의학회 2014 대한응급의학회지 Vol.25 No.3

In organophosphate intoxication, the neurotransmitter acetylcholine accumulates in synapses, causing excessive stimulation of nicotinic and muscarinic receptors, producing various signs and symptoms. Organophosphates are highly toxic compounds that are readily absorbed through the skin, mucous membranes, and gastrointestinal and respiratory tracts. Organophosphate intoxication leads to many well defined complications, including cholinergic crisis, intermediate syndrome, and acute pancreatitis. However, parotitis caused by organophosphate intoxication is very rare. We experienced such a case of a 55 year old woman who visited the emergency center because of organophosphate intoxication. The next day, she complained of left facial redness, swelling, and pain. We checked serum lipase, amylase, and amylase-isoenzymes, and found elevation of salivary type amylase only. The mechanism of parotitis due to organophosphate intoxication is assumed to be similar to that of pancreatitis caused by organophosphate. In patients with elevated amylase caused by organophosphate intoxication, the possibility of parotitis must be considered.

응급센터에 내원한 외상환자에서 간과된 골절의 요인 분석

박득현 ( Deuk Hyun Park ),이성실 ( Sung Sil Lee ),김동언 ( Dong Un Kim ),조현영 ( Hyun Young Cho ),이영근 ( Young Geun Lee ),김준수 ( Jun Su Kim ),전진 ( Jin Jun ),김영식 ( Young Sik Kim ),하영록 ( Young Rock Ha ),신태용 ( Tae Yo 대한외상학회 2009 大韓外傷學會誌 Vol.22 No.1

Purpose: A missed fracture is a very common occurrence in the Emergency Department (ED) and can have serious results because of delays in treatment, resulting in long-term disability. It is also one of the most common causes leading to medical legal issues. We analyzed the causes of missed fractures by using a bone scan which is known to be an effective tool for diagnosing bony lesions. Methods: We reviewed the medical records of trauma patients who underwent a bone scan after being discharged the ED from September 2006 to March 2008. Cases of missed fractures were identified by using electronic medical records to review each diagnosis. Definition of missed fracture was read after bone scan by radiologist. We decided that there was no fracture if we read `trauma-related lesion` or `cannot rule out fracture` on a bone scan read by a radiologist. Enrolled patients were analyzed by age, sex, time until bone scan and Injury Severity Score (ISS). Patients were divided into two groups, alert mentality and not-alert mentality, so there were split between a diagnosis group and a missed fracture group. ISS was also used in determining the severity of the patient`s injury upon discharge from the ED. Results: A total of 532 patients were enrolled in this study. Of those, 487 patients were in the diagnosis group, and 45 patients (8.4%) were discovered to have had a fracture. Of the 45 missed fracture patients, 34 patients (6.4%) had one-site fractures, 8 patients (1.5%) had two-site fractures, and 3 patients (0.6%) had threesite fractures. The most commonly missed fracture was multiple rib fractures (18 patients, 30.5%), followed by lumbosacral (LS) spine fractures (10 patients, 16.9%), thoracic spine fractures (8 patients, 13.6%), and clavicle fractures (6 patients, 10.2%). Mean age was 50.12±18.54 years in the diagnosis group and 57.38±16.88 years in the missed fracture group. For the diagnosis group, the mean ISS was 9.03±8.26, but in the missed fracture group it was17.53±9.69. Missed fractures were much more frequent in the not-alert mentality (p<0.01) and in the high ISS (ISS≥16) group (p<0.01). Conclusion: Missed fractures occur most frequent in patients of old age, not-alert mentality, and high ISS. Multiple rib and spine fractures were found to be the most frequent missed fractures, regardless of trauma severity. This study also shows a high possibility of clavicle and scapula fractures in patients with severe trauma. (J Korean Soc Traumatol 2009;22:37-43)

부산 지역에서 발생한 교통사고 환자와 강우량과의 관계

신경호,박득현,윤유상,김양원,박경혜,선경훈,박하영,조준호,김태훈 대한응급의학회 2015 대한응급의학회지 Vol.26 No.5

Purpose: Traffic accidents are increasing due to the development and increment of transportation. Previous studies on analysis of the correlation between environmental factors and traffic accidents have rarely been reported. The purpose of this study is to analyze the correlation between rainfall and traffic accidents including accident mechanism, incidence, and trauma severity of patients. Methods: A retrospective review was conducted in 851 trauma patients who visited the emergency department (ED) after a traffic accident from January 2013 to December 2013; 248 patients due to a traffic accident when it was raining, and 603 patients when it was not raining. Demographic data, clinical data, and meteorological data (rainfall, daily mean air temperature, daily mean wind speed) in Busan were investigated. Results: The incidence of traffic accidents was one-second and the injury severity score of patients was two points higher on rainy days. In addition, the length of hospital stay was three days longer (p=0.037), and the prognosis was poor in the rain group. Comparison of severe injury sustained over rain, injury time, and accident mechanism showed approximately a 3-fold odds increased rate of severe injury on rainy days (OR 2.55, 95% CI: 1.11-5.83, p=0.004) and a seven-fold odds increased rate of pedestrian traffic accidents (OR 7.26, 95% CI: 3.52-9.26, p<0.001) compared with car traffic accidents. In addition, a four-fold increased odds of night time (OR 3.79, 95% CI: 1.98-7.25, p<0.001) compared with day time accidents on rainy days. Conclusion: The incidence of traffic accidents and injury severity of patients increased on rainy days. Therefore, we suggest expansion of the scope of the emergency and trauma team activation for proper treatment on rainy days.

우하복부 통증으로 내원한 환자에서 급성 충수돌기염 진단을 위해 초음파 소견을 포함하는 새로운 점수 평가법의 임상적 유용성: Constant or Aggravated pain, Male sex, and an UltraSound(CAMUS) scoring system

조현영,박득현,이성실,김동언,김준수,이영근,전진,신태용,김영식,하영록 대한응급의학회 2009 大韓應急醫學會誌 Vol.20 No.6

Purpose: We hypothesized that a new scoring system that included emergency ultrasound (EUS) and clinical or laboratory predictors for diagnosing acute appendicitis (AA) in patients with right lower quadrant (RLQ) pain could decrease the false negative rate when EUS is performed alone. Methods: During a 10 month period, patients with RLQ pain were evaluated with EUS just after history taking and physical examination. We also checked the 17 well-known predictors of AA. Univariate analyses for each predictor including EUS findings identified 11 predictors. We then tested those predictors with logistic regression analysis. Results: A total 397 patients (mean age=31.13±18.25 years: 196 males, 201 females) were enrolled in this study. Among the 397, 247 underwent an operation, but 14 turned out to have normal appendices. Among 233 patients with appendicitis, 75 had a perforated appendix. Four independent correlates of AA (constant pain, aggravated pain, male sex, and positive EUS findings) were identified with logistic regression analysis. We developed a novel scoring system using regression coefficients as follows: 6 points for a positive EUS, 3 points for aggravated pain, 2 points for constant pain, and 2 points for being male. We named the new scoring system “CAMUS” for “Constant or Aggravated pain, Male sex, and UltraSound score”. The area under the receiver-operating characteristic curve (ROC) for the CAMUS score for AA was 0.93(95% confidence interval: 0.871 to 0.959). Conclusion: Our new CAMUS scoring system can help emergency physicians diagnose AA accurately and rapidly.

급성호흡곤란 환자의 감별진단에서 응급의학과 전공의에 의해 시행된 조직 도플러 심초음파의 유용성

김동언,박득현,조현영,이성실,고찬영,안성준,신태용,김영식,하영록 대한응급의학회 2008 大韓應急醫學會誌 Vol.19 No.6

Purpose: In managing acutely dyspneic patients, differentiating the underlying disease rapidly is important but not easy. Although B-type natriuretic peptide (BNP) is generally accepted as a useful marker, inconclusive results require an emergency physician (EP) to have something more confirmative. We evaluate whether Tissue Doppler Echocardiography (TDE) performed by an EP can better discriminate between heart disease and lung disease than can BNP in the emergency department (ED). Methods: For enrolled ED patients with acute dyspnea and unclear pathology, initial BNP level and TDE performed by EP were checked prospectively. The ratios of peak early diastolic transmitral blood flow velocity (E) versus the peak early diastolic tissue velocity over mitral annulus (Ea) on TDE were recorded. The sensitivity and specificity of tissue Doppler parameters and BNP levels for diagnosing acute heart failure were calculated and we compared the discriminatory ability of the two tools. Results:49 patients (39 heart failure, 10 respiratory disease) were enrolled. The area under the ROC curves for BNP and E/Ea were 0.946 and 0.888 (p<0.001) respectively. Cutoff values were 350 pg/ml for BNP (sensitivity and specificity of 82.1% and 100%) and 9.0 for E/Ea (89.2% and 100%). Especially in the group with low BNP (<350), BNP was a poor discriminator of the underlying disease, whereas E/Ea was still effective (AUC: 0.943, p=0.021). Conclusion: TDE by EP is a useful tool for diagnosing acute heart failure in ED and could easily and rapidly discriminate the underlying disease of acutely dyspneic patients, especially in patients with inconclusive BNP levels.

응급실로 내원한 경증 외상환자에서 냉각 스프레이를 사용한 치료의 유용성

신우성,박득현,김양원,윤유상,차지훈,최준철 대한응급의학회 2012 대한응급의학회지 Vol.23 No.1

Purpose: Vapocoolant spray is used as an agent to relieve localized pain due to sport injury or intravenous cannulation. The aim of this study was to determine the effectiveness of vapocoolant spray in the treatment of minor trauma in a hospital emergency department. Methods: We carried out a prospective randomized controlled trial of alert patients with minor trauma who visited our emergency department. The total of 90 participants, all over 14 years old, were divided into 3 groups: a ‘NSAIDs IM’group (n=30), ‘Vapocoolant spray’ group (n=30), and ‘NSAIDs IM with Vapocoolant spray’ group (n=30). Patients rated their pain and satisfaction of treatment using a 100-mm visual analogue scale (VAS). We assessed pain by VAS 4times: first upon arrival, and then at 15, 30 and 60 minutes after treatment. We also assessed their treatment satisfaction utilizing VAS at the point of discharge. In addition, we calculated the time between subject arrival and initial treatment. Results: Groups did not differ significantly in terms of age or sex distribution. The mean of the VAS score did not differ significantly among the groups upon their arrival (p=0.885) and were observed as follows: ‘NSAIDs IM’ group 44.80±12.70mm, ‘Vapocoolant spray’ group 45.20±10.49 mm, and ‘NSAIDs IM with Vapocoolant spray’ group 46.17±9.54 mm. At 15, 30 and 60 min after treatment, the mean reduction in VAS score significantly differed between groups (p<0.05). At 15 min after treatment the results were as follows: ‘NSAIDs IM’ group 5.27±3.26 mm, ‘Vapocoolant spray’ group 15.17±7.17 mm, and ‘NSAIDs IM with Vapocoolant spray’group 14.57±4.07 mm. At 30 min after treatment the results were:‘NSAIDs IM’ group 13.57±7.86 mm, ‘Vapocoolant spray’group 19.47±9.96 mm, and ‘NSAIDs IM with Vapocoolant spray’ group 21.20±6.52 mm. At 60 min after treatment the results were: ‘NSAIDs IM’ group 25.73±8.07 mm, ‘Vapocoolant spray’ group 20.90±9.88 mm, and ‘NSAIDs IM with Vapocoolant spray’ group 28.93±6.66 mm. Satisfaction of treatment and initial treatment time differed between groups (p<0.05). For satisfaction of treatment, the median of VAS significantly differed between the ‘NSAIDs IM’ group and the ‘NSAIDs IM with Vapocoolant spray’ group [46.50(41-52) mm vs. 57.00(51-62) mm, p<0.0167]. Initial treatment time significantly differed between the ‘NSAIDs IM’ group and the other groups [22.50(13-34) min vs. 10.00(7-20) min and 13.00(7-20) min, p<0.0167]. Conclusion: Vapocoolant spray is effective in reducing pain with minor trauma in the hospital emergency department. We can simultaneously improve the patient treatment satisfaction and reduce initial treatment time by using the vapocoolant spray.

심폐소생술에서 아트로핀은 필요한가?

이현욱,박득현,윤유상,김양원,이준엽,박경혜,권인호,여운형,박하영,조준호 대한응급의학회 2014 大韓應急醫學會誌 Vol.25 No.5

Purpose: According to the 2010 guidelines for cardiopulmonary resuscitation (CPR) of the American Heart association, administration of atropine for non-shockable rhythm is no longer recommended, however, there are insufficient data in humans. This study was conducted to evaluate the results of CPR, whether the combined administration of atropine and epinephrine (Atropine combined group, AG) compared with epinephrine only injection (epinephrine only group, EG) for patients with non-shockable rhythm. Methods: A total of 449 patients who underwent CPR in the emergency department from 2009 to 2012 were included. Retrospective analysis was performed according to atropine administration during CPR. We investigated Return of Spontaneous Circulation (ROSC), sustained ROSC, 30-day survival, and 30-day neurological outcome using Utstein templates. Results: There were 178 (48.9%) patients in the AG. There were no significant differences in the baseline characteristics. The two groups had similar rates of ROSC, sustained ROSC, and 30-day survival. However, AG had a significantly poor neurological outcome compared to EG, with an adjusted odds ratio of 0.074 (95% CI 0.012-0.452, p=0.005). Conclusion: The combination therapy of atropine and epinephrine during CPR showed poor neurological outcome compared with epinephrine alone. Atropine is not useful for adults with non-shockable rhythm in terms of 30-day neurological outcome. The two groups had similar rates of ROSC, sustainedROSC, and 30-day survival. However, AG had a significantlypoor neurological outcome compared to EG, with anadjusted odds ratio of 0.074 (95% CI 0.012-0.452, p=0.005). Conclusion: The combination therapy of atropine and epinephrineduring CPR showed poor neurological outcomecompared with epinephrine alone. Atropine is not useful foradults with non-shockable rhythm in terms of 30-day neurologicaloutcome. Purpose: According to the 2010 guidelines for cardiopulmonary resuscitation (CPR) of the American Heart association, administration of atropine for non-shockable rhythm is no longer recommended, however, there are insufficient data in humans. This study was conducted to evaluate the results of CPR, whether the combined administration of atropine and epinephrine (Atropine combined group, AG) compared with epinephrine only injection (epinephrine only group, EG) for patients with non-shockable rhythm. Methods: A total of 449 patients who underwent CPR in the emergency department from 2009 to 2012 were included. Retrospective analysis was performed according to atropine administration during CPR. We investigated Return of Spontaneous Circulation (ROSC), sustained ROSC, 30-day survival, and 30-day neurological outcome using Utstein templates. Results: There were 178 (48.9%) patients in the AG. There were no significant differences in the baseline characteristics. The two groups had similar rates of ROSC, sustained ROSC, and 30-day survival. However, AG had a significantly poor neurological outcome compared to EG, with an adjusted odds ratio of 0.074 (95% CI 0.012-0.452, p=0.005). Conclusion: The combination therapy of atropine and epinephrine during CPR showed poor neurological outcome compared with epinephrine alone. Atropine is not useful for adults with non-shockable rhythm in terms of 30-day neurological outcome.

응급실 소아 손상 환자의 중증도 예측을 위한 PRISM III의 유용성

이상훈,박경혜,박득현,조준호,박하영,권인호,여운형,이준엽,김양원 대한응급의학회 2013 大韓應急醫學會誌 Vol.24 No.2

Purpose: The primary prevention and proper initial treatment of childhood injuries is important, as it encompasses a bigger social and economic burden than cancer and ischemic heart disease. The Pediatric Risk of Mortality III (PRISM III) scoring system, used to evaluate the severity or mortality of pediatric patients in critical condition, was investigated for children with injuries in an emergency department (ED). Methods: A retrospective analysis included data on 293injured children (age<16) who visited the ED in two hospitals from March 2010 to February 2012. Physiologic and laboratory data were collected to calculate the PRISM III score and the Injury Severity Score (ISS). The correlation was analyzed between PRISM III scores, the Revised Trauma Scale (RTS), and ISS. The PRISM III score and ISS were assessed for their ability to predict mortality by comparing their receiver operating characteristic (ROC)curves. Results: The median PRISM III score was 5.0 (Interquartile Range, 5.0-9.0) and correlated with RTS and ISS (the Spearman’s rho were -0.19 (p=0.001) and 0.20 (p=0.001),respectively. Five children did not survive after ED admission. The area under the ROC (AUC) was 1.00 for PRISM III (95% confidence interval [CI], 0.99-1.00), and the cutoff value was placed over 20 to predict mortality. The AUC of ISS and RTS was 0.99 (95% CI, 0.98-1.00) and 0.99 (95%CI, 0.98-1.00), respectively. Conclusion: The PRISM III score excellently predicts the mortality of injured children in the ED, and can be used to sort minor pediatric trauma patients in the ED. However, the PRISM III score had no great difference or advantage compared with RTS. The development of other tools for effective prognosis is needed to efficiently predict mortality and severity in the ED.