소아환자에서 초음파 유도 중심정맥카테터 삽입

장익완,박중완,정재윤 대한소아응급의학회 2020 대한소아응급의학회지 Vol.7 No.1

In pediatric patients, central venous catheterization (CVC) is necessary for administration of fluids, drugs, high concentration electrolytes, vasopressors or inotropic drugs, transfusion, intravenous nutrition, and dialysis. Using an anatomical landmark for the CVC insertion may have a low success rate in children due to the positional variation between the deep vein and the landmarks, the small size of body and blood vessels, low insertion frequency, and operator skill. In order to improve the success rate, ultrasound guided CVC insertion is recommended in critically ill children. It is also expected to reduce mechanical complications, which are more common with subclavian CVC insertion. However, the association between the insertion site and the infection or thrombosis is unclear. Since thrombosis is relatively common, further studies are needed on the association between the incidence rate and insertion sites.

소아중환자 병원간 이송

장익완,정재윤,곽영호 대한소아응급의학회 2017 대한소아응급의학회지 Vol.4 No.1

Interfacility transport of critically ill children (transport) is a challenging component of pediatric critical care. The risk associated with the transport may be reduced by a specialized pediatric transport team, a screening tool for critically ill children, and a standardized handover between referring and referred physicians. Further research is necessary in Korea regarding the above measures for the safe and effective transport. .

Long-term changes in computed tomography and ultrasound utilization in a pediatric emergency department

장익완,정재윤,곽영호,김도균,이진희,정진희,권혁술,백소현,박중완 대한응급의학회 2018 Clinical and Experimental Emergency Medicine Vol.5 No.1

Objective Many studies have proposed reducing unnecessary use of computed tomography (CT), and ongoing studies in pediatric populations are aiming to decrease radiation dosages whenever possible. We aimed to evaluate the long-term changes in the utilization patterns of CT and ultrasound (US) in pediatric emergency departments (PEDs). Methods This retrospective study reviewed the electronic medical data of patients who underwent CT and/or US in the PED of a tertiary referral hospital from 2000 to 2014. We compared the changes in utilization patterns of brain and abdominal CT scans in pediatric patients and analyzed changes in abdominal US utilization in the PED. Results During the study period, 196,371 patients visited the PED. A total of 12,996 brain and abdominal CT scans and 12,424 abdominal US were performed in the PED. Comparison of CT use in pediatric patients before and after 2007 showed statistically decreasing trends after 2007, expressed as the coefficient values of the differences in groups. The numbers of brain and abdominal CT scans showed a significant decreasing trend in children, except for abdominal CT in adolescents. The abdominal US/CT ratio in the PED showed a statistically significant increase (2.68; 95% confidence interval, 1.87 to 3.49) except for the adolescent group (5.82; 95% confidence interval, -2.06 to 13.69). Conclusion Overall, CT use in pediatric patients has decreased since 2007. Pediatric US use has also shown a decreasing trend; however, the abdominal US/CT ratio in pediatric patients showed an increasing trend, except for adolescents.

요골두아탈구 환자에서 방사선 검사 시행과 연관된 인자 분석

장익완 ( Ik Wan Chang ),김도균 ( Do Kyun Kim ),박소영 ( So Young Park ),서동범 ( Dong Bum Suh ),정재윤 ( Jae Yun Jung ),곽영호 ( Young Ho Kwak ) 대한외상학회 2014 大韓外傷學會誌 Vol.27 No.2

Purpose: In general, X-ray examinations are not recommended for radial head subluxation (pulled elbow) patients. The purpose of this study was to determine the frequency of X-ray examinations and to investigate the factors associated with the decision to perform an X-ray examination on a patient with a pulled elbow. Methods: Patients who visited the pediatric emergency department (ED) of one tertiary hospital from January 1, 2011, to December 31, 2012, with a diagnosis of radial head subluxation at discharge were enrolled in this study. Through retrospective chart reviews, factors that could have influenced the decision to perform an X-ray examination and their statistical relevance were analyzed. Results: A total 308 patients were enrolled, and 101 patients (32.8%) underwent X-ray examinations. Among the 252 patients with a typical pulled elbow, 65 underwent X-ray examination. This result showed statistical significance compared to atypical pull-elbow group (25.8% vs. 64.3%, p<0.001). Factors associated with the decision to perform an X-ray examination were analyzed using the Chi-square test and the Fisher`s exact test. The mechanism of injury and consultation with an orthopedic surgeon (p=0.001) showed statistical significance. In the multivariable logistic regression, the odds ratio (OR) for the injury mechanism was 4.7 (95% CI: 1.8~8.8, p<0.001) and that for consultation with an orthopedic surgeon was 8.0 (95% CI: 1.6~40.7, p=0.004). Conclusion: One third of patients with a pulled elbow underwent X-ray examination, and patients with an atypical mechanism of injury underwent more frequent X-ray examinations than did patients with a typical mechanism of injury. The factors that could have influenced the decision to perform an X-ray examination weremechanism of injury and consultation with an orthopedic surgeon.

중증 외상 특성화 센터에서 사망률에 영향을 미치는 인자 분석

장익완 ( Ik Wan Chang ),김훈 ( Hoon Kim ),신희준 ( Hee Jun Shin ),전우찬 ( Woo Chan Joen ),박준민 ( Joon Min Park ),신동운 ( Dong Wun Shin ),박준석 ( Jun Seok Park ),김경환 ( Kyung Hwan Kim ),박제훈 ( Je Hoon Park ),최승운 ( Seun 대한외상학회 2012 大韓外傷學會誌 Vol.25 No.4

Purpose: An increase in the demand for specialized Trauma Centers led to a government-driven campaign, that began in 2009. Our hospital was selected as one of the Trauma Centers, and we reviewed data on trauma patients in order to correlate the mortality at a regional Trauma Center with its contributing factors, such as the severity of the injury, the means of arrival, and the time duration before arrival at our center. Methods: Data on the patients who visited our Trauma Center from January 2010 to November 2011 were retrospectively reviewed using electronic medical records. The patients who had revised trauma scores (RTSs) less than 7 or injury severity scores (ISSs) greater than 15 were included. The patients were categorized as survivors and non-survivors, and the means of arrival as transferred or visited directly. Time durations before arrival of less than one hour were also taken intoconsideration. Results: Two hundred(200) patients were enrolled, and the mortality rate was 36.5%. The most common cause of the accident was an automobile accident, and the most common cause of death was brain injury. The RTSs and the ISSs were significantly different in the non-survivor and the survivor groups. The mortality rate of the patients who were transferred was not statistically different from that of patients who visited directly. However, a time duration before arrival of less than one hour was statistically meaningful. Conclusion: The prognosis of the trauma patients were correlated with the severity of the trauma as can be expected, but the time between the incidence of accident and the arrival at hospital and whether the presence of transfer to trauma center were not statistically significant to the prognosis. (J Trauma Inj 2012;25:188-195)

Factors Associated with Triage Modifications Using Vital Signs in Pediatric Triage: a Nationwide Cross-Sectional Study in Korea

이봉진,장익완,김도균,박준동 대한의학회 2020 Journal of Korean medical science Vol.35 No.16

Background: Previous studies on inter-rater reliability of pediatric triage systems have compared triage levels classified by two or more triage providers using the same information about individual patients. This overlooks the fact that the evaluator can decide whether or not to use the information provided. The authors therefore aimed to analyze the differences in the use of vital signs for triage modification in pediatric triage. Methods: This was an observational cross-sectional study of national registry data collected in real time from all emergency medical services beyond the local emergency medical centers (EMCs) throughout Korea. Data from patients under the age of 15 who visited EMC nationwide from January 2016 to December 2016 were analyzed. Depending on whether triage modifications were made using respiratory rate or heart rate beyond the normal range by age during the pediatric triage process, they were divided into down-triage and non-down-triage groups. The proportions in the down-triage group were analyzed according to the triage provider's profession, mental status, arrival mode, presence of trauma, and the EMC class. Results: During the study period, 1,385,579 patients' data were analyzed. Of these, 981,281 patients were eligible for triage modification. The differences in down-triage proportions according to the profession of the triage provider (resident, 50.5%; paramedics, 47.7%; specialist, 44.9%; nurses, 44.2%) was statistically significant (P < 0.001). The triage provider's professional down-triage proportion according to the medical condition of the patients showed statistically significant differences except for the unresponsive mental state (P = 0.502) and the case of air transport (P = 0.468). Conclusion: Down-triage proportion due to abnormal heart rates and respiratory rates was significantly different according to the triage provider's condition. The existing concept of inter-rater reliability of the pediatric triage system needs to be reconsidered.

중증환자 이송 서비스가 환자의 생존에 미치는 영향

박용주,이경원,정주,장익완,안기옥,노영선,신상도 대한응급의학회 2017 대한응급의학회지 Vol.28 No.1

Purpose: Critical care transport (CCT) has been known to be beneficial for inter-hospital transport of critically ill patients. Seoul Mobile Intensive Care Unit (SMICU) has been established and provided CCT in Seoul Metropolitan City since 2015. We tested the association between SMICU transport and hospital outcome for critically ill patients. Methods: This is a before and after intervention study. SMICU group with cardiac arrest, acute myocardial infarction, acute stroke, major trauma, respiratory failure, and shock who were transported by SMICU from January to July 2016 were collected as an intervention group. Non-SMICU group with the same above diagnosis criteria who were transported by private ambulance services during same period in 2015. By National Emergency Department Information System (NEDIS), demographics were compared for original data and sampling data. Multivariable logistic regression analysis was done to calculate the adjusted odds ratios (AORs) with 95% confidence intervals (95% CIs) adjusting for potential confounders. Results: Total 1,837 patients (128 SMICU and 1,709 non-SMICU group) for original dataset and 180 patients (60 SMICU and 120 non-SMICU group) for sampling dataset were finally analyzed. Hospital mortality rates are 22.7% in SMICU and 11.8% in non-SMICU in original dataset (p<0.001), 26.7% in SMICU and 31.7% in non-SMICU in sampling dataset (p=0.490), respectively. AOR (95% CIs) for hospital mortality by SMICU in original and sampling dataset were 0.80 (0.48- 1.35) and 0.71 (0.33-1.51), respectively. Conclusion: The CCT for critically ill patients did not show significantly better hospital mortality in the pilot study.

응급의학과 전공의 대상의 소아응급초음파 교육의 재평가: 교육 직후와 6개월 후

김도연,이진희,정재윤,권혁술,장익완,김도균,정진희,곽영호 대한응급의학회 2017 大韓應急醫學會誌 Vol.28 No.6

Purpose: As emergency ultrasound (EUS) can improve the management of emergency department patients, education in EUS has become an essential part of emergency medicine resident training. This study examined the efficacy of pediatric EUS education for resident physicians 6 months after training. Methods: A survey was conducted on emergency medicine resident physicians who participated in the Pediatric Emergency Ultrasound Course in November 2014, which is a training program of pediatric EUS generated by Korean Society of Pediatric Emergency Medicine and Society of Emergency and Critical Care Imaging. The instructor checked the list to evaluate attendee after the course. After the course, resident physicians have been encouraged to use EUS at the patient’s bedside, and the same list was checked 6 months after the course. At the same time, a survey of the number of experience of EUS during the 6 months was performed. Results: Ten emergency resident physicians of Seoul National University of Hospital participated in the course and all attendees were re-evaluated 6 months after the course. The mean initial score immediately after the course and that at the 6 months follow-up was 28.6±3.13 and 20.8±3.79, respectively (p<0.05). No significant relationship was observed between the difference score and the EUS experience number, including the observations of the other physician’s EUS (p=0.603) and hands-on by themselves (p=0.771). Conclusion: Although a EUS education program could improve the resident physician’s ability, the effect decreased with time. Hence, the resident physician’s EUS ability cannot be maintained via simple emergency department duty. Therefore, the education program should be repeated regularly.

소아 응급실에서 급성 충수염의 영상검사 변화 추이와 음성개복술 비율의 변화

정지혜,곽영호,이진희,김도균,장익완,정진희,정재윤,권혁술 대한응급의학회 2015 대한응급의학회지 Vol.26 No.5

Purpose: We evaluated the relationship between changes in the trend of the utilization of diagnostic imaging studies and the rates of negative appendectomy, complications in pediatric patients with appendicitis. Methods: This retrospective observational study was conducted at a pediatric emergency department (PED) of a tertiary university hospital. Patients who underwent imaging studies under the clinical impression of acute appendicitis and underwent appendectomy at the hospital from 2010 to 2013 were enrolled. We compared the percentages of imaging studies performed and negative appendectomy rate (NAR), complications between first two years (FTY) and second two years (STY). Results: The total number of patients was 197 with a mean age of 9.68 (±3.17) years, and 66% were boys. The percentages of performed computed tomography (CT) of FTY and STY were 46.2% and 25.5% (p<0.05). Patients who were evaluated by ultrasound alone were 53.8% and 74.5%, respectively (p<0.05). The NARs of the two groups were 13.2% (FTY) and 8.0% (STY) (p=0.19). There was no significant difference in the number of hospital days, drainage insertion rates, duration of draining, and the rates of perforations between groups. The duration of antibiotics use was significantly longer only in the STY group than in the FTY group (6.20±3.95 vs. 6.94±3.41 days, p=0.04). Conclusion: Although the number of patients who underwent ultrasound without a CT scan for the diagnosis of acute appendicitis was increased, the NAR and clinically important complications were comparable from the preceding two years at a tertiary PED.

계획되지 않은 소아응급실 재방문: 환자의 임상적 특성과 응급실 과밀화와의 관련성

장동현,김도균,곽영호,정재윤,서동범,장익완,정재현,서혜향,김주원,추지혜 대한응급의학회 2014 대한응급의학회지 Vol.25 No.5

Purpose: Revisit to the pediatric emergency department(ED) in the short-term period may be due to inadequateevaluation during the previous visit, which may indicate aproblem with quality in emergency care. The aims of thisstudy are to analyze the characteristics of patients whorevisited the pediatric ED within 48 hours after dischargeand to evaluate the relation between overcrowding andrevisit rates. Methods: Retrospectively, we reviewed the charts ofpatients who returned within 48 hours after visiting a PEDduring a one-year period between June 1st, 2011 andDecember 31st, 2011. We determined the rate of return visitsand review the characteristics of patients, emergency severityindex (ESI) level at visits, cause of revisit, diagnosis, andcrowding degree of the pediatric ED at the patient’s first visit. Results: A total of 16,688 patients visited the pediatric EDand 13,716 patients were discharged from the PED duringthe period. Of these discharged patients, 534 patients revisitedinevitably within 48 hours. The most common cause ofrevisit was relapse or worsened symptoms (70.0%). Therewas no significant difference in sex, severity of patient, andcrowding degree of the pediatric ED at the first visit, however,patients who revisited were younger than those who didnot (p=0.005). The ESI level at the return visit was significantlyhigher irrespective of admission after revisit(p<0.001). In diagnosis grouping, patients with gastrointestinaldiseases, respiratory diseases, and neoplastic diseasesshowed a higher rate of revisit. Conclusion: Approximately 4% of our pediatric ED visitswere for children returning within 48 hours. Patients whorevisited were younger and patients with gastrointestinal diseases,neoplastic diseases, and respiratory diseases weremore likely to revisit. Careful explanation of the possibility ofworsened symptoms is necessary for these patients.