응급환자에서의 쇼크계수의 의의

장문준,황태식,손대곤,이한식 대한응급의학회 1995 대한응급의학회지 Vol.6 No.1

For the emergency patients in need of immediate resuscitation, cardiac catherization along with intensive cardiac monitoring is necessary to evaluate the cardiovascular stability. But this method requires machinery, technique and time which limits its use in emergency situations. In 1961, Allgower and Buri first discribed shock index, heart rate divide by systolic blood pressure, as easy to calculate and easy to use in acute settings given the simple measurements of the heart rate and the blood pressure. It has been said in circulatory failure patients shock index is inversely related to left ventricular stroke work. Because shock index is an indicator for resuscitation and also a prognostic indicator it could be applied in triaging an emerency patients. Therefore we studied the significance and the possible triage application of shock index in emergency patients. In the period of 6 months from May 1 to October 31, 1994. Among total 15,782 patients, who visited Yonsei University-affliated Yong Dong Emergency Department, 2425 patients were included in the study. There were 201 admissions to the intensive care unit and 2105 patients to general beds and 199 selected patient from discharged. Retrospective chart review for pulse rate, systolic blood pressure, diastolic pressure and shock index was done. Statistical analysis was performed using t'-test, p value of less than 0.05 was designated significant. Average shock index for ICU patients were 0.96 ±0.50, general ward admittees were 0.67 ±0.18, and discharged were 0.65 ±0.16. There were significant statistical difference in shock indices between ICU and general ward patients, and ICU and discharged patients. Shock index is helpful in identifing patients with potential for admission to the ICU in emergency situations. Therefore we conclude that the shock index should be recognized as a triage tool.

전기손상으로 인한 심장질환자의 회복 1례

장문준,황태식,최성욱,김인병,손대곤,조광현,이한식 대한응급의학회 1995 대한응급의학회지 Vol.6 No.1

An unconscious 20 year old male carried into the emergency department after an electric shock injury 20 minutes earlier. Cardiopulmonary resuscitation was undertaken when asystole appeared on the electrocardiograph monitor. A 12-lead electrocardiograph was taken when in that myocardial infarction was found after performing cardiopulmonary resuscitation on an electrical injury patient. We present out case's electrocardiographs with echocardio-graphic findings and radionuclide imaging studies.

선상의료에 대한 고찰 : 금강산 유람선 현대 봉래호를 중심으로

이한식,송근정,장문준 대한응급의학회 2000 대한응급의학회지 Vol.11 No.1

Background. Maritime medicine refers to the medical care and education of medical disease which may develop during a cruise. Recently, cruise passengers are increasing around the world and maritime medicine has been initiated in Korea with the beginning of the trip to Mt. Kumgang in 1998. Nowadays, there are about 4,000 passengers per week. Therefore, the data were analyzed to promote the understanding of maritime medicine, which was first applied on the Mt. Kumgang cruise, and to help the medical members who will be participating in the maritime medicine in the future. Methods. From November 1998 to February 1999, all patients who visited to medical cabin of the cruise ship(Hyundai Pongnae) were analyzed retrospectively. Result. 2,162 patients excluding 182 patients who re-admitted were analyzed. In each cruise, there were 65.5(9.0%) passengers and 42(13.0%) crews. The male to female ratio was 1.6 : 1, with 709 males and 451 females. The common problems were respiratory and musculoskeletal diseases followed by dermatologic and gastrointestinal problems in order of frequency. There were 18 patients who had trauma above 4 points in ISS. Ten patients were confined to the medical cabin. The ship returned to Donghae-port one time, 8 patients were evaluated immediately and 41 patients were referred without urgency. Conclusion. Maritime medicine has a particular characteristic of dealing with various cases and treatments including emergencies with limited space, man-power, facilities and equipment. It obviously proposes the participation emergency medical doctors in the maritime medicine because medical personnel must take part in not only medical management but also in education and prevention including CPR. The medical staff in charge of maritime medicine should establish a proper plan depending on the purpose of the cruise and must endeavor to solve the problem.

응급실 전담의 상주가 심정지 환자의 소생에 미치는 영향

이한식,장문준,지훈상 대한응급의학회 1995 대한응급의학회지 Vol.6 No.2

Major factors influencing the outcome after cardiopulmonary resuscitation(CPR) of cardiac arrest patients are the technique of CPR, response time and early defibrillation. Others like patient's characteristics and drugs used in resuscitation play minor role. To determine if the emergency physician affects the outcome of CPR, 318 consecutive victims with cardiac arrest who CPR were attempted in emergency room. The results were as follows : 1. The first group without emergency physician was 102 patients and the second group with emergency physician was 216 patients. 2. Among the factors affecting the outcome of CPR, patient's characteristics(sex, age, cause, injury severity score), prehospital factors(response time, use of ambulance, prehospital care) and the duration of CPR have no statistical differences between two groups. 3. Among the prehospital cardiac arrest patients and whom arrested in emergency room, use of defibrillation does not showed statistical differences between two groups. 4. The statistically significant factors(p<0.05) between two groups were initial defibrillation energy, defibrillation frequency and drugs like epinephrine, atropine and lidocaine. These results were similar among the prehospital, in-emergency room and the total cardiac arrest patients. 5. The outcome of CPR showed no significant differences on prehospital cardiac arrest patients analysis of all the data, there were no significant factors affecting the outcome of the CPR except the role of emergency physician. 6. Low survival rate(1.9%) on group Ⅱ, reflect the lacking of other important factors affecting the CPR other than emergency personnel. In conclusion, the involvement of full time emergency physician on CPR is an important factors in resuscitation of arrested patients in emergency room.

외상 환자의 사망까지의 시간분포 - 3차 진료 교욱병원에서의 11년간의 경험

임훈,장문준,김승호 대한응급의학회 2001 대한응급의학회지 Vol.12 No.4

Background: Traumatic death occupies a high ranking in the annual national report on causes of death and causes a significant burden to society. To reduce traumatic death, an area-wide trauma care system is urgently needed, and basic mortality data will be an essential component in designing such a system. The purpose of this study was to review the experience of trauma death in a hospital to determine the pattern of time to death and the effect of the emergency medical services(EMS) system in traumatic death. Methods: A retrospective analysis of 495 traumatic deaths experienced from 1990 to 2000 was performed. Time to death, mechanism of injury, injury severity, and cause of death were reviewed. The influence of the EMS system before 1995 was compared with its influence after 1995. Results: The mean age of the 495 patients was 41.1±18.9 arid the mean injury severity score(ISS) was 37.1±17.8. The distribution of time to death showed DOA(including found dead) in 39% of the cases, within 48hr in 38.4%, between the 2nd and 7th days in 9.9%, and later than the 7th day in 12.7%. The majority of early deaths occurred within 4 hr of injury, but a minor increase was noted during the 2nd week. After 1995, the ambulance transportation rate increased significantly without any difference in prehospital interventions. Conclusion: Our results showed a bimodal distribution of time to death, which reflected geographic, mechanism of injury, and trauma care system differences. We also noted deficiencies in prehospital trauma care in our EMS system. We recommend nationwide trauma registry initiatives to provide basic trauma data and to implement a quality trauma care system.

과호흡증후군 환자에서 이온화칼슘,마그네슘과 산-염기상태의 변화에 대한 고찰

윤천재,정순미,장문준,이한식 大韓應急醫學會 1998 대한응급의학회지 Vol.9 No.3

Background. Tetanic spasm is often noted in hyperventilating patients coming in to emergency departments. Classical explanation for this phenomenon was decreased ionized calcium levels due to respiratory alkalosis precipitated by the hyperventilation. Clinically these symptoms were observed in hypocalcemia and were thought as such without doubt, But6 clinical investigation on the levels of ionized calcium levels have not been clarified. Recent investigations on hyperventilating volunteers have suggested other pathophysiology for tetanic spasm in hyperventilating patients which is the decrement of ionized magnesium level rather than ionized calcium. We wanted to see if these results applied to our hyperventilating patients and see if ionized magnesium level was a factor producing tetanic symptoms. Method and Material, 35 patients with diagnosis of hyperventilation syndrome by emergency physician were studied retrospectively. Hyperventilating patients arriving at Severance hospital Emergency Center from Jan. 1996 to Feb. 1998 were included. Patients with cardiovascular, pulmonary diseases, history of renal or liver disease were excluded. Ion-selective method was used to detect ionized calcium, magnesium levels and arterial blood gas features. Average levels were compared to reference ranges and Wilkoxon-rank, sum test was used to compare hyperventilating patients with tetanic spasm and those with other symptoms such as dyspnea, chest pain and palpitations. Results. 1) Sodium, potassium and chloride levels were 138mmol/L, 3.6mm/l, 106mm/l each which were within a normal range. 2) Degrees of hyperventilation were similar with average of PH 7.54(7.4-7.71), pCO₂ 23.6mmHg, showing respiratory alkalosis. 3) Ionized calcium and ionized magnesium each showed 0.61mg/dl, 0.16mg/dl lower values than the lowest reference ranges which were 4.5-5.6mg/dL for ionized calcium and 1.19-1.63 for ionized magnesium. 4) No statistical difference points were observed between the tetanic spasm group and group without spasm. Female preponderance were noted in tetanic spasm group. Conclusion. We conclude that other than decrement of ionized calcium, decrement of ionized magnesium could be a factor for inducing tetanic spasm in respiratory alkalosis caused by hyperventilation.

Dapsone투여로 유발된 methemoglobin 혈증에서 N-acetylcysteine 의 효과

장문준,김승호,이한식 대한응급의학회 1997 대한응급의학회지 Vol.8 No.2

Background To determine whether N-acetylcysteine(NAC) reduces methemoglobin. Method: We carried out an in vivo experiment in rats, weighed about 300g. Each rat was ingested 200mg of dapsone(4,4` diaminodiphenyl sulphone) to induce methemoglobinemia. After 1 hour, 30 rats were received NAC 160mg(2ml) and another 30 rats, served as control, were received 2ml of normal saline orally, 4 times hourly. Serum methemoglobin concentrations were checked 1,6, and 24 hours after dapsone ingestion. Result: The methemoglobin concentrations on each time were 27.1±5.8%, 235±8.8%, 17.1±6.4%(mean±SD) in control group and 25.5±6.3%, 25.5±8.8%, 65.5±31.2%(mean±SD) in NAC group. There were no difference on methemoglobin concentrations at 1 and 6 hours between two groups(P>.05). At 24 hours, the methemoglobin concentrations of NAC group was significantly higher than those of control group(P<.01). Conclusion: NAC had no therapeutic effects on dapsone induced methemoglobinemia in this experimental setting.

중증 저나트륨혈증의 신속한 교정후 발생한 중심성 뇌교수초용해증 1례

최성욱,장문준,황태식,이한식 대한응급의학회 1994 대한응급의학회지 Vol.5 No.2

Central pontine myelinolysis(CPM) was first described by Adams et al. in 1959 to denote the symmetric area of myelin damage found in the centre of the basis pontis. This disease has now been recognized throughout the world in both sexes and in all age group. And the derangement of serum sodium, especially hyponatremia, have been identified to be the factor most closely associated with CPM(i.e. rapid correction of hyponatremia may cause myelinolytic lesions on brain). Large CPM lesions may cause quadriplegia, lock-in syndrome and occasionally neuro-ophthalmic features. Small lesions are often asymptomatic. Since it is not a treatable disease, clinician might endeavored to prevent its development ; correcting hyponatremia not exceeding 12 mEq/L/24hrs on first 24 hours and more moderation of correction of following days. We experienced a 76-year-old female patient who suffered severe symptomatic hyponatremia thought to be caused by SIADH(syndrome of inappropriate secretion of anti-diuretic hormone) secondary to peumonia. Rapid correction of hyponatremia resulted in mental deterioration and quadriparesis. The brain MRI(magnetic resonance imaging) showed myelinolysis on both pons and extrapontine area. 68 days after admission, she was quadriplegia with pseudobulbar palsy. We report this case with literature reviews.

활성탄, Actidose Aqua 및 Fuller's earth간의 약물 흡착력 비교

김승호,장문준,황태식,오진호,최영환,정성필 대한응급의학회 2000 대한응급의학회지 Vol.11 No.1

Background. Activated charcoal has been widely used as an adsorbent for the management of drug intoxicated patients in the emergency department(ED). Although there are several commercial ready-mixed charcoal suspension preparations in the market, we are using custom-made suspension from hospital grade bulk charcoal powder. We designed this study to compare the adsorptive capacity of the Actidose Aqua, which is a commercial charcoal product, Fuller's earth, and custom-made activated charcoal used in our ED. Methods. First, we performed modified USP methylene blue adsorption test which is a standard adsorption test for activated charcoal. Then, the drug adsorption test for phenobarbital, acetaminophen, salicylate, and aminophylline was done, Graded amount of three adsorptives were added to the stock solutions of each drugs. The adsorption test were performed as follows: The vials containing drugs and adsorptives were shaken for 30 minutes to ensure adsorption equilibrium, then the suspension was filtered through in-line filter. The filtrates were analyzed by ultraviolet spectroscopy to determine the residual drug concentrations. Finally we examined and compared the surface area and the structure of activated charcoal and Fuller's earth using scanning electron microscopy. Results. In methylene blue adsorption test, the adsorption rate was 60.1% in Actidose Aqua and 59.0% in custom-made charcoal, and 70.2% in Fuller's earth. For the phenobarbital, acetaminophen, and salicylate, the adsorption rate of Actidose Aqua? and custom-made charcoal was greater than 90% with the ratio of adsorptives to drugs over 10:1. For aminophylline, two charcoal products showed excellent adsorption in 5:1 ratio. But Fuller's earth showed poor adsorption in all ranges. Conclusion. Custom-made activated charcoal showed a comparable adsorption capacity to Actidose Aqua?. Fuller's earth showed a poor performance to be used as a substitute for activated charcoal in acute drug poisoning otherwise paraquat.

적절한 중심정맥도관의 길이

정상원,윤천재,장문준,이한식 대한응급의학회 1998 대한응급의학회지 Vol.9 No.1

Background: Catheterization of central vein may cause fatal complications such as cardiac arrhythmia, cardiac temponade, atrial perforation etc. For prevention of these complications, tip of central venous catheter should located in superior vena cava. The purpose of this study was to investigate the optimal positioning of central venous catheters. Methods: From March 1996 to Jun 1996, a total of 50 patients who requiring central venous cathters were involved. First, we evaluate the accuracy of predetermined formula of 'Peres'. Second, we hypothesized that height of patients was correlated with optimal length of centrl venous catheters and we analysed relationship between height and optimal length of central venous catheters using simple regression analysis by SAS. Results: 1) Predetermined formula of 'Peres' inaccurately predicted required length of central venous catheter. The accuracy was 78%. 2) There were a linear relationships between height and optimal length of central venous cather. Their relationships was followed, Y=0.09X(Y:optimal length of central venous catheters, X:height, p=0.0001, R2=0.39). Conclusion: Using height of patients, we can accurately predict the optimal length of central venous catheters.