독시라민 음독후 합병된 횡문근융해증 환자의 임상적 고찰

김세경,최세민,이원재,이미진,오동렬 대한응급의학회 2000 대한응급의학회지 Vol.11 No.1

Background. Doxylamine succinate(DS) is an antihistamine commonly used as an over-the-counter medication to relieve insomnia and frequently involved in overdoses. Its overdoses are dominated by anticholinergic effect. Recently it was revealed that DS had a direct effect on muscle, while its exact mechanism is not clear yet. We evaluated the patients with rhabdomyolysis induced by DS overdose for patients disposition bases upon clinical decision, especially by creatinine phosphokinase(CPK). Methods. We reviewed retrospectively the medical records of patients admitted by DS overdose from Jan. 1998 to Oct. 1999. Seventy and nine cases of DS overdose were evaluated with respect to age and sex distribution, amount ingested, clinical symptomatology, time from ingestion to visit, pattern of CPK, amount of bicarbonate used as therapy, complication and prognosis, especially in patients complicated rhabdomyolysis. Results. Rhabdomyolysis, diagnosed as more than 1,000I.U/L of CPK, has been noted in 25(31.6%) of 79 cases of DS overdose visited to our emergency department(ED). In patients diagnosed rhabdomyolysis, the number of man was 10 cases(40%) and the number aged between 20 and 40 years was 22 cases(88%). The average time from DS ingestion to ED visit was 459 minutes. The amount of DS ingested was 500-5,000mg(mean, 1,980mg). 13(52%) cases ingested less than 2,250mg of DS. The initial levels of CPK(range, 48-14900I.U/L; normal range, 26-200I.U/L) after admitting to our emergency department were normal in 15 cases(60%) of rhabdomyolysis patients. The range of peak CPK levels after ingestion was 607 to 412,500I.U/L(mean, 33,550I.U/L). Its peak time was 6 to 96 hours(mean, 28.96 hours). In 14 cases(67%) of 21 visiting within 24 hours after ingestion, peak time of CPK ranged 12 to 24 hours after ingestion. The amount of bicarbonate used as therapy of rhabdomyolysis ranged 100 to 2,740mEq(mean, 656mEq) and all patients was discharged after improvement without other complication including acute renal failure. Conclusions. Although patients ingested less than 2,250mg of DS, emergency physicians should observe them more than 24 hours after DS ingestion with CPK follow-up after gastric irrigation and charcoal administration.

폐부종과 심정지가 발생한 페노바비탈 중독환자

오동렬,이운정,박규남,김세경,김영민,이환,유은영,최경호,정시경 大韓應急醫學會 1999 대한응급의학회지 Vol.10 No.2

Phenobarbital is a long-acting barbiturate causing generalized depression of neuronal activity in the brain. Its effect is primarily achieved through enhanced GABA-mediated synaptic inhibition. Its use as an antiepileptic agent was first described in 1912. Before the introduction of phenytoin, phenobarbital is used as sedative-hypnotics. It is used for the treatment of epilepsy and status epilepticus. All barbiturates, including phenobarbital, have a high potential for abuse. They were frequently used for suicide attempts in the past, but they have in large part been replaced by benzodiazepines. The onset of symptoms depends on the drug and the route of administration. Mild to moderate barbiturate intoxication resembles ethanol inebriation with slurred speech, ataxia, and lethargy. Severe acute barbiturate intoxication is life threatening. Early deaths are generally cardiovascular-related. Hypotension, shock, pulmonary edema, and cardiac arrest that occurs with large doses are caused by depression of central sympathetic tone and as well as by direct depression of cardiac contractility. The potentially fatal oral dose of phenobarbital is 6-10g. We describe an 23-year-old woman with pulmonary edema, and cardiac arrest ingestion of 18grams of phenobarbital. She was completely recovered by successful cardiopulmonary resuscitation and homoperfusion. We report a case with literature review.

백서의 심실세동성 심정지 모델에서 해마신경세포 손상에 대한 단백질 합성저해제의 효과

오동렬,채장성,박승현,김세경,최세민,박제영 대한응급의학회 2000 대한응급의학회지 Vol.11 No.4

Background: The goal of successful resuscitation is not only to stop the process of ischemia as soon as possible but also to overcome the secondary injury process after resuscitation, which involves a complex interplay of mechanisms. Brain damage accompanying cardiac arrest and resuscitation is frequent and devastating. Cells die by one of two mechanisms: necrosis or delayed neuronal death. Delayed neuronal death may require protein synthesis. Neurons in the CA1 subfield of the hippocampus are selectively vulnerable to death after injury by ischemia and reperfusion. Death of these neurons occurs after an interval of 1 or 2 days. We assessed the effects of a protein synthesis inhibitor, cycloheximide(CHX), on hippocampal neuronal death of rats by using the ventricular fibrillation cardiac arrest(VFCA) model. Methods: The effect of CHX(3 mg/kg, s.c.) on hippocampal neuronal death was studied in two groups of 18 rats each, one group being subjected to a 2-min VFCA and the other to a 3-min VFCA. Each group was divided into three subgroups: control(groupⅠ,Ⅱ) without subcutaneous injection of CHX, "esp-12" of group Ⅰ/Ⅱ treated with CHX 12 hours after return of spontaneous circulation (ROSC), and "exe-24" of group Ⅰ/Ⅱ treated with CHX 24 hours after ROSC. The coronal sections of the hippocampus levels were stained with hematoxylin-eosin after 72 hours of survival. The histologic damage score(HDS) was used to assign a score to the total number of damaged neurons counted in each of the hippocampal CA1 subfields. Results: 1. There were not significant differences in heart rates, blood pressures, blood sugar, and blood gas in group I & Ⅱ during the pre-arrest steady state or at 5 min and 30 min after ROSC. 2. In group I & Ⅱ, the HDS, were significantly reduced in rats(I exp-12, 1.1 ±0.6;Ⅰexp-24, 1.3 ±0.5;Ⅱ exp-12, 1.4±0.7; and Ⅱ exp-24, 1.8±0.8) treated with CHX 12 hours or 24 hours after ROSC than control rats(1,2.5 ±0.9;Ⅱ,2.9±0.8)(p<0.05). Conclusion: These results suggest that delayed hippocampal neuronal death from ischemic insult after ventricular fibrillation cardiac arrest followed by resuscitation can be prevented by a protein synthesis inhibitor, CHX. Further experimental studies of the action mechanism of protein synthesis inhibitors to delayed neuronal death and clinical applications are required.

반복적인 경련을 동반한 아이소니아지드(Isoniazid) 중독환자의 치험 1례

이환,오동렬,정시경,김영민,이운정,김세경,이원재,최경호 大韓應急醫學會 1999 대한응급의학회지 Vol.10 No.2

Isoniazid(Isonicotinic acid hydrazide) is an antimicrobial drug used since 1952 as a first line agent for the prophylaxis and treatment of tuberculosis. Isoniazid is well known for problems in population having a high prevalence of isoniazid use for prophylaxis or treatment of tuberculosis. But intentional or accidental isoniazid overdose is uncommon. The ingestion of toxic amounts of isoniazid causes recurrent seizures, profound metabolic acidosis, coma and even death. In adults, toxicity can occur with the acute ingestion of as little as 1.5g of isoniazid. Doses larger than 30mg per kg often produce seizures. When ingested in amounts of 80-150mg per kg or more, isoniazid can be rapid fatal. 40-year-old woman having previous pulmonary tuberculosis ingested 7gram of isoniazid(140mg/kg) to attempt suicide approximately 30 minutes prior to visit to our emergency medical center. She had recurrent generalized tonicclonic seizures and metabolic acidosis. We report one patient treated with pyridoxine, which was equivalent to the amount of isoniazid ingested and administered as a intravenous dose and oral dose

심폐소생술후 혼수상태의 환자에서 체성감각유발전위의 예후 예측인자로서의 유용도

최세민,오동렬,최승필,박규남,김세경 대한응급의학회 2000 대한응급의학회지 Vol.11 No.4

Background: The improved technique for cardiopulmonary resuscitation(CPR) has resulted in the survival of many patients who experienced cardiac arrest. However, mortality in resuscitated patients is high, and the survival rate without brain damage is very low. Various neurological examination models, neuro-imaging techniques, electrophysiological procedures, and biochemical tests have been studied with respect to the detection of cerebral damage and outcome, but an early, reliable prediction of individual outcomes is still uncertain. Methods: We studied twenty patients who had been in a coma for more than 24 hours after CPR, Somatosensory evoked potentials(SEP) were measured within the first three days after CPR. Results: Of the twenty patients, seven patients(35%) had a good outcome, and thirteen patients(65%) had a bad outcome. Of the eleven patients with loss of the cortical evoked potential's N2O peak, all had a bad outcome. Conclusion: SEPs are of great benefit in prognostic evaluation after CPR.

허혈성 장질환의 조기진단을 위한 혈청 락테이트(lactate)의 유용성

이미진,오동렬,박규남,김세경,양진홍,박상현 대한응급의학회 2000 대한응급의학회지 Vol.11 No.4

Background: Intestinal ischemia remains a devastating event despite improvements in clinical recognition and in diagnostic and therapeutic modalities. The ischemic bowel diseases encompass a wide clinical spectrum from mild, reversible disease to severe, irreversible injury. The clinical picture is characterized initially by poorly localized visceral pain. Thus, it is difficult to diagnose this ischemia at an early stage. This study investigated whether an increased serum lactate level is a recognized danger signal marker for intestinal ischemia in patients who present at the emergency department because of abdominal complaints. Methods: Patients who came to our emergency department with abdominal pain and the risk factors of intestinal ischemia between Apr. 1999 and Nov. 1999 were included in this study. The data analysis included age, sex, final diagnosis, pathogenesis of bowel ischemia, and serum lactate level. Results: The serum lactate level in the intestinal ischemia group was 28.54±22.51 mg/dl; in non-ischemia group, it was 15.49±22.52 mg/dl. This difference between the two groups was significant(p<0.05). An increased serum lactate level had a sensitivity of 88.2% and specificity of 59.2%, a positive likelihood ratio of 4.92, and a negative likelihood ratio of 0.47 as a marker of bowel ischemia. These results do not represent a very meaningful revision of bowel ischemlc provability, but may make a small contribution to management of the disease, depending upon their magnitude and the clinical context in which they are applied. Conclusion: In patients with abdominal complaints, an increased serum lactate level is usually a useful aid as a diagnostic marker of bowel ischemia.

급성신부전을 동반한 알콜성 횡문근융해증 2례

김영민,오동렬,이원재,김형국,황두영,이환,최경호,정시경,김세경,김영옥 大韓應急醫學會 1998 대한응급의학회지 Vol.9 No.4

Rhabdomyolysis is a biochemical and clinical syndrome caused by lysis of skeletal muscle cell and release of muscle cell contents into the circulation. In addition to traumatic cause, various nontraumatic causes have been reported. Rhabdomyolysis has frequently been associated with seamy aspects of life and society: alcoholic abuse, drug addiction, sadistic drill exercise, war events and attempted suicide. The abuse of alcohol causes many hazards in many organs. One of these is acute alcoholic myopathy that may present as a fulminent syndrome of muscle pain and tenderness associated with rhabdomyolysis and acute renal failure. Because the prognosis of adequately treated rhabdomyolysis is excellent, early recognition and prompt management are essential in emergency situation. We experienced two typical cases of alcohol-induced rhabdomyolysis with acute renal failure and report these cases with literature review.

데페록사민 전처치가 토끼 심근경색 크기의 감소에 미치는 효과

양관모,오동렬,박승현,박규남,이원재,김형국,황두영,최승필,채장성 대한응급의학회 1998 대한응급의학회지 Vol.9 No.4

Background: Reperfusion of ischemic myocardium has been postulated to result in a specific oxygen radical mediated tissue injury. Iron may liberate during ischemia and we hypothesized that administration of the iron chelator, deferoxamine during ischemia would result in improved recovery after postischemic reperfusion. Purpose: To test whether iron-catalyzed processes contribute to myocardial necrosis during ischemia and reperfusion, deferoxamine was administered to block iron catalyzed hydroxyl radical formation in rabbits. Methods: Eleven rabbits were divided into two groups : control group (n=5) and deferoxamine pretreatment group (n=6). The left circumflex coronay artery was ligated for 30 minutes and reperfused for 180 minutes. Area at risk (AR) was measured by non-stained area with methylene blue injection into left atrium after left circumflex coronary artery ligation. Infarct size was measured by weighing after triphenyltetrazolium chloride staining. Heart rate was measured using electrocardiographic recording and systemic blood pressure was monitored by pressure transducer connected to the catheter in the left ventricle. Results: 1. There was no significant difference of heart rate and blood pressure in deferoxamine pretreatment group compared with control group. 2. There was significant decrease of serum iron concentration after continuous infusion of deferoxamine compared with serum iron concentration before ligation of coronary artery(P<0.05). 3. There was no significant difference of area at risk between control and deferoxamine pretreatment group. 4. Area at necrosis to area at risk was significantly reduced in deferoxamine pretreatment group compared with control group(P<0.05). The results suggest that deferoxamine infusion prior to coronary artery occlusion has a significant benefit in reducing infarct size in this model.

저혈량성 쇼크를 동반한 자발성 복직근초 혈종

박상현,오동렬,김형국,김세경,박승현 대한응급의학회 2000 대한응급의학회지 Vol.11 No.4

Background: Intermediate myasthenia syndrome(IMS) is thought to have clinical importance because it may cause sudden respiratory failure during the recovery phase of a cholinergic crisis of organophosphate poisoning. We designed this study to identify the prevalence, the inducing agent, clinical predictor, and the proposed treatment of IMS. Methods: Patients who had admitted with the diagnosis of acute organophosphate poisoning from 1992 to 1998 at two teaching hospitals were enrolled in this study. We selected the cases of IMS based on a review of medical records using modified He' s criteria. Results: Twelve(12) out of 110 patients with acute organophosphate poisoning were diagnosed for a prevalence at 10.9%. The drug inducing IMS were identified as dichlorvos, fenthion, EPN, methidathion, and phosphamidon. The occurrence of IMS was not related to either the initial treatment with atropine and pralidoxime, or the level of serum cholinesterase. Complications were pneumonia, sepsis, pancreatitis, and pseudomembranous colitis, etc. Eleven(11) patients were discharged without sequelae, and one patient was discharged as a hopeless case. Conclusion: This study suggests that IMS is not rare, so close observation is required to detect IMS in organophosphate-poisoning patients. Also, more studies are required to find predictors and treatments.

응급의료센터에서 신경색의 조기진단

최경호,오동렬,이원재,박규남,박승현,황두영,김형국,정시경,김영민,김세경 大韓應急醫學會 1998 대한응급의학회지 Vol.9 No.4

To evaluate appropriate diagnostic studies for renal infartion in emergency medical center, we analysed 33 patients of renal infarction treated in this hospital for last 8 years. Eleven patients, 4 trauma associated and 7 aortic disease associated patients were excluded. They are 11 males and 11 females with a mean age of 51 years. Fourteen came to the emergency medical center and seven came to the outpatient department, in the other one patient renal infarction was developed during hospitalization with other disease. On their past history they had hypertension in 9, valvular heart disease in 5, and diabetic mellitus in 4 patients. Abdominal or flank pain was noted in 17 of 22(77%). The other symptoms were vomiting, nausea, fever and so on. On microscopic examination of initial urine in hospital, 5 patients showed more than 10 red blood cells by high power field examination. The mean lactic dehydrogenase level was 1,239 I.U/L(normal range 218-472 I.U/L), while the mean aspartate aminotransferase and mean alanine aminotransferase were 51 I.U/L(normal range 13-36 I.U/L) and 44 I.U/L(normal range 5-33 I.U/L). Abdominal ultrasonography showed positive findings in 5 of 16(31%), of which 3 were confirmed by Doppler ultrasonography. In 18, computed tomography was done and all those showed positive findings of renal infarction(100%). In conclusion, it is important that identify the elevated lactic dehdrogenase level in case of any suspicion about renal infarction and confirm by computed tomography.