반복적인 비경구노출에 의한 유기인계 중독: 중간형증후군과 급성췌장염 1례

오세현,강희동,이부수,Oh, Se-Hyun,Kang, Hui-Dong,Lee, Boo-Soo 대한임상독성학회 2006 대한임상독성학회지 Vol.4 No.2

Organophosphate insecticides, commonly used in agriculture, are a gradually increasing cause of accidental and suicidal poisoning. Intoxication can occur by ingestion, inhalation or dermal contact. Exposure to organophosphorus agents causes a sequentially triphasic illness consisting of the cholinergic phase, the intermediate syndrome, and organophosphate-induced delayed polyneuropathy. Acute pancreatitis as a rare complication of organophosphate intoxication has also been infrequently observed. We report a case of intoxication with organophosphate (phos-phamidon) by parenteral exposure (inhalation and/or dermal contact). A 34-year-old male patient was transferred to our Emergency Medical Center and was intubated due to a progressive respiratory failure. He presented with meiotic pupils, cranial nerve palsies, weak respiration, and proximal limb motor weaknesses without sensory changes. He had been employed in filling syringes with phosphamidon during the previous month. Because the patient's history and symptoms suggested organophosphate intoxication with intermediate syndrome, he was mechanically ventilated for 18 days with continuous infusion of atropine and pralidoxime (total amounts of 159 mg and 216 g, respectively). During his admission, hyperamylasemia and hyperli-pasemia were detected, and his abdominal CT scan showed a finding compatible with acute pancreatitis. He was administered a conservative treatment with NPO and nasogastric drainage. The patient was discharged and showed neither gastrointestinal nor neurologic sequelae upon follow up at one week and three months.

바닷가에 인접한 응급센터에 내원한 익수환자의 예후인자

정용택 ( Yong Taeg Jeong ),오세현 ( Se Hyun Oh ),이부수 ( Boo Soo Lee ) 대한외상학회 2003 大韓外傷學會誌 Vol.16 No.2

Background: Drowning is the fourth most common cause of accidental deaths in Korea. The number of drownings in Korea has decreased, but the number of victims visiting our hospital has increased. If a prognosis is to be given and a poor outcome prevented, it is necessary to know the prognostic factors related to the submerged patients. Methods: The medical records of 126 submerged patients who visited our emergency department between January 1997 and December 2002 were reviewed retrospectively. These patients` final outcomes were categorized into two groups: good (no neurological impairment) and poor (vegetative or dead). Demographic, clinical, laboratory, and treatment variables were compared between the two groups. The patients were classified in six subgroups using the following clinical parameters in the emergency department: presence of breathing, arterial pulse, pulmonary auscultation, and arterial blood pressure. Results: Among the 126 patients, 101 cases had a good outcome and 25 cases had poor outcome. There was a statistically significant difference between the two groups in respiratory rate, pH, PaCO2, bicarbonate, oxygenation index, serum glucose, and sodium (p<0.05). The six subgroups based on 4 clinical parameters showed significant differences in poor outcome rate. Among the 41 patients who were in cardiopulmonary arrest at scene, 30 patients were given prehospital CPR, and 16 given of them showed a good outcome. The remaining patients, 11 cases who were not given prehospital CPR had a poor outcome. Conclusion: Our results showed that immediate resuscitation prior to arrival at the emergency department was associated with a better clinical outcome in submerged patients. For the purpose of immediate and appropriate prehospital CPR, CPR education for paramedics, lifeguards, and the general populations is needed. To clarify the prehospital prognostic factors and to improve the prognosis for submersion victims, a systematized protocol should be developed which can assess and feed-back actions of prehospital persons.

급성 심근경색증 환자에서 조기에 적절한 재관류 요법을 시행받지못한 요인

유병수(Byung Su Yoo),윤정한(Jung Han Yoon),박금수(Keum Soo Park),여경구(Kyung Koo Yoh),조윤경(Yun Kyung Cho),안승찬(Seung Chan Ahn),이용규(Yong Kyu Lee),송광선(Kwang Seon Song),최경훈(Kyung Hoon Choe),이부수(Boo Soo Lee),황성오(Sung 대한내과학회 1995 대한내과학회지 Vol.48 No.6

N/A Objectives: Early application of reperfusion therapy such as thrombolytic agent or direct PTCA is utmost important to amximize the efficacy of reperfusion therapy in patients with aute myocardial infarction. However, early adequate reperfusion thearpy was given only in 15% to 36% pf patients with acute myocardial infarction and substantial patients were not benefited from reperfusion therapy, Therefore, we performed these study to evaluate the reasons for which patients with acute myocardial infarction cannot receive an adequate reperfusion therapy. Methods: We analyzed the initial electrocardiogram and various time delays from chest pain onset time, first hospital arrival time, transfer time, ER arrival time, and door to reperfusion time in 138 patients with acute myocardial infarction from Jan. 1991 to Oct. 1993 admitted to Wonju Christian Hospital. Patients were grouped as reperfusion group(n=55) who had reperfusion therapy such as thrombolytic trial or direct PTCA and conservative grou who had not received reperfusion therapy(n= 83). Results: 1) Eighty-three cases(60.1%) did not received an adequate reperfusion therapy. 2) Hospital arrival time of patients was 237±162min and 786±615min in reperfusion and conservative group(p<0.05) respectively. Patient time delay was 103±98min and 439±511min, first hospital time delay, 93±78min and 333±482min, and transfer time, 81±59min and 105±64min in reperfusion and conservative group respectively(p<0.05). Only 4.8% of patients was transferred from first hospital after reperfusion therapy. 3) Patient time delay was the most common reason of not receiving reperfusion therapy, and time delay and lack of adequate reperfusion therapy at the first hospital inspite of early arrival were the second place. Other reasons were contraindication to lytic therapy(4 cases), definite Q wave MI(11 cases), inconclusive EKG(4 cases), and delay in therapy(4 cases). Conclusion: The most common reason of not receiving reperfusion therapy was patient delay in seeking medical care(45.8%) and time delay at first hospital in 22 cases(26.5%). To maximize the effectiveness of reperfusion therapy, it is important to shorten hospital arrival time delay and widespread use of reperfusion therapy at first hospital is recommeded.

소방헬기를 이용하여 직접 내원한 외상환자의 분석: 3차 의료기관으로의 이송의 적절성 평가

송송원 ( Song Won Song ),윤재철 ( Jae Chol Yoon ),이부수 ( Boo Soo Lee ),김우주 ( Woo Joo Kim ),안지윤 ( Ji Yoon Ahn ),오범진 ( Bum Jin Oh ),임경수 ( Kyung Su Lim ) 대한외상학회 2006 大韓外傷學會誌 Vol.19 No.2

Purpose: The number of patients transported by the Helicopter Emergency Medical Service (HEMS) has increased recently. In our review of the Korean HEMS, there was no established helicopter utilization criteria or triage tool on the scene, so many patients with minor injuries were transported to tertiary care centers. The aim of this study is to evaluate the percentage of patients with minor injuries and to propose a more appropriate triage tool for predicting the need for transport to a tertiary care center. Methods: The subjects of this study were 59 trauma patients transported to Asan Medical Center (AMC) from the scene by Seoul HEMS from January 2004 to December 2005. The Triage score (TS), Injury Severity Score (ISS), and modified Canadian Triage and Acuity Scale (mCTAS) were calculated as severity scales. Patients with minor injuries were defined as those with TS=9, ISS≤15, and mCTAS≥3. We evaluated the association of TS, ISS, and mCTAS with the appropriateness of transport. Results: Many of the patients transported to tertiary medical centers were classified as having a minor injury: TS=9 group 35 cases (72.9%), ISS≤15 group 30 cases (62.5%) and mCTAS≥3 group 27 cases (56.2%). However, 56.2% (27/59) of the patients were appropriately transported according to need for admission or an operation. The more severely injured patients classified by TS, ISS, and mCTAS were more appropriately transported to a tertiary center (p<0.05). Conclusion: Many patients with minor injuries were transported to a tertiary center from the scene directly. The TS can be easily calculated by an emergency medical technician at the scene. Thus, we propose the TS as a useful triage tool for determining the necessity of transport to a tertiary center by helicopter. (J Korean Soc Traumatol 2006;19:159-163)

심폐소생술중 심실기능 및 판막운동의 평가

이부수,김영식,이강현,황성오,임경수,박금수,윤정한,안무업,최경훈 대한응급의학회 1994 대한응급의학회지 Vol.5 No.2

Background : Mechanism of blood flow during cardiopulmonary resuscitation(CPR) in humans remains controversial and poorly understood, although cardiac or thoracic pump theory was proposed. We investigated cardiac movement, ventricular function and atrioventricular valve motion with aid of transesophageal echocardiography during precordial compression during CPR in humans. Methods and results : During CPR transesophageal echocardiography was performed in 14 patients with non-traumatic cardiac arrest. Manual precordial compression during CPR was performed according to American Heart Association guidelines. Mitral valve closed in 9 and did not close in 5 patients during "compression systole". Tricuspid valve closed during compression systole. Compression vector directed to right ventricle, basal portion of interventricular septum and left atrium. The heart rotated clockwise and the apex was more displaced than the base("swing motion"). Fractional shortening(FS) and ejection fraction(EF) of right ventricle exceeded those of left ventricle(FS : 55±9% vs 18±8%, p<0.05), EF : 79±9% vs 37±16%, p<0.05). FS and EF of left ventricle was higher in patients with systolic mitral valve closure than patients with persistent systolic opening of mitral valve(FS : 21±7 vs 13±7%, EF : 45±12 vs 22±12%, p<0.05), but FS and EF of right ventricle was not different. Conclusion : During precordial compression, the heart rotated clockwise and displaced. Systolic function of right ventricle exceeded left ventricle. Marked compression of right ventricle and systolic closure of tricuspid valve suggested that right ventricle functioned as a pump generating blood flow during precordial compression. Closure of mitral valve was dependant on systolic function of the left ventricle.

혼수상태의 외상환자에서 초음파를 이용한 흉부 및 복부손상의 진단

임경수,이강현,이진웅,이부수,황성오,유수영,강성준 대한응급의학회 1995 대한응급의학회지 Vol.6 No.1

The need for rapid diagnosis and treatment of life-threatening thoracic and intra-abdominal injury result in controversy over the appropriate triage of unconscious blunt trauma patients. To aid in early decisions for these patients, a prospective analysis of 98 patients with glasgow coma scale(GCS) scores≤8 was undertaken. Although intra-thoracic and intra-abdominal injuries were frequently identified based on systolic blood ressure, the use of clinical signs alone resulted in more missed injuries than did using the emergency ultrasonography. In normotensive patients(n=34), intra-thoracic injuries was identified in one patient(2.9%), and intra-abdominal injuries were in 7 patients(20.6%). In shock(systolic blood pressure<90mmHg) Pa-tients(n=64), thoracic injuries and intra-abdominal injuries were diagnosed in 8(12.5%) and 27 patients(42.3%), thoracic and abdominal combined injuries were identified in 11 patients(17.2%). The sensitivity, specificity, and accuracy of emergency ultrasonography were 96.3%, 91.7%, 94.9%. This study suggests that all unconscious trauma patients undergo immediate emergency ultrasonography to prevent missing life-threatening injuries.

심정지환자에서 epinephrine투여시 혈중 catecholamine의 변화

임경수,황성오,이부수,이강현,이진웅,임종천,김영식,김선만,김 현 대한응급의학회 1995 대한응급의학회지 Vol.6 No.1

Background : Cardiac arrest is a potent stimulus for the release of endogenous catecholamine and high plasma catecholamine concentration has been reported during cardiopulmonary resuscitation(CPR). Few data were present about the clinical effect of high plasma catecholamine and endogenous catecholamine response to exogenous epinephrine administration during CPR. Purpose : This study was designed to evaluate endogenous catecholamine response to cardiac arrest and exogenously administered epinephrine during CPR. Method : In 21 cardiac arrest victims, blood sample for epinephrine and norepinephrine was drawn before and 1 minute after each epinephrine administration during CPR. 1mg of epinephrine was administered immediately after intravenous access and 3 minute interval during CPR. Plasma catecholamines were quantitated by high-performance liquid chromatography. Result : Baseline plasma epinephrine concentraqtion was higher in patients with cardiac arrest than normal controls (985±1627 vs 194±173 pg/ml, p<0.05). Baseline plasma norepinephrine concentration was also elevated in patients with cardiac arrest than normal controls, although statistically insignificnat(1965±4915 vs 360±250 pg/ml). Plasma epinephrine concentration in cardiac arrest patients was significantly elevated after exogenous administration of epinephrine, but its response was blunted after the third does of epinephrine. Plasma norepinephrine concentration in cardiac arrest patients was also elevated, but its response was observed only after the first epinephrine administration. Plasma epinephrine concentration was persistently higher in patients with return of spontaneous circulation (ROSC) than patients without ROSC. there was no significant difference of plasma norepinephrine concentration whether spontaneous circulation was restored or not. Endogenous epinephrine response to exogenous epinephrine was not observed in patients having prolonged arrest time over 20 minutes. Conclusion : Results of this study suggests that significant amount of catecholamine is released by exogenous epinephrine administration in spite of high plasma catecholamine concentration, and degree of endogenous catecholamine response influences resuscitation outcome.

응급환자 의료정보의 공유 현황과 개선방안

오세현,이부수,김병철,김원,임경수 대한응급의학회 2001 대한응급의학회지 Vol.12 No.4

Background: To manage the EMS(emergency medical services) system effectively, departments, such as fire stations, emergency information centers, hospitals, and The Ministry of Health and Welfare, should exchange information that they own and/or gather during patient care and/or transportation. Medical records and information are very important for continuing the patient's care and for deciding on a treatment plan, but medical information is not exchanged fully in spite of its importance. Method: We analyzed the transfer medical reports that were written by medical doctors who transferred emergency patients to our hospital. The contents and the accuracy of the transfer medical records were analyzed and graded into 4 groups. Group A was fully described and was equipped with diagnosis, laboratory data, X-ray fi1ms; group B had a diagnosis and full laboratory data; group C had a diagnosis, but only partial laboratory data; and group D had only a diagnosis. Results: Among 38,214 patients who visited our hospital from Jan. 2001 to Jun. 2001, 7,031 cases were transferred from other hospitals with transfer medical records. According to the accuracy and important contents of the transfer records, Group A occupied 1.9%, group B 5.2%, group C 32.5%, and group D, with only a diagnosis,60.4%. In the case of our hospital, we delivered all emergency medical information by written paper(transfer note), E-mail, and web-based information system(caber-AMC) to the doctors concerned with managing the patient. However, 93% of the medical records of patients transferred from other hospital contained insufficient information to adequately care for the emergency patients. In addition, most of the transferred patients had been transorted without prior information about transportation. Conclusion: Within the near future, a medical information center equipped with a computerized system should be operated to exchange medical data. As most general hospitals are operating the OCS(order communication system), EMR(electronic medical record), telemedicine, and PACS(picture-archiving communication system), medical information can be exchanged freely in real time if a code standard and HL7(Health Level 7) can be established.

다발성 외상환자에서 필수적 단순 방사선검사의 의의

임경수,황성오,임종천,이부수,이강현,이진웅 대한응급의학회 1995 대한응급의학회지 Vol.6 No.2

In the guidelines of Advanced Trauma Life Support(ATLS), essential plane roentgenograms (chest AP vIew, cervical spine lateral view and pelvis AP view) are recommanded when primary survey and resuscitation phase are finished in care of multiple injured patients. A prospective study was carried on 376 multiple trauma patients who admitted to Wonju Christian Hospital from July, 1995 to October. We analyzed clinical significance of essential X-ray in multiple trauma patients, and classified the patients by their status of mentality. The one is alert group when their Glasgow Coma Scale(GCS) is over 13 point, the other is disoriented mentality group when their GCS are below 12 point. The alert group was redivided by presence of clnical symptoms and/or signs, and clinical significances of essential X-ray were analyzed. Among the 376 patients, 330 patients are alert group that their GCS score is over 13 point and 46 patients are disoriented group who's GCS were below 12 point. The detection rate of abnormality in essential X-ray is higher in disoriented group than alert group(cervical-spine lateral view : 13.5% vs 3.0% cheat AP view : 0.4%, pelvis AP view : 0%). This study suggests that their are no needs of taking essential X-ray in patients who is alert in mental state and have no clinical symptoms and/or signs.

Dispatcher(전화 상담원)의 보조에 의한 심폐소생술

안무업,김영식,이부수,황성오,임경수 大韓應急醫學會 1992 대한응급의학회지 Vol.3 No.1

Background: Dispatcher-assisted telephone instruction in cardiopulmonary resuscitation(CPR) has been proposed to increase rates of bystander CPR in cases of out-of-hospital cardiac arrest. In Korea, bystanders do not know how they resuscitate the victims and EMS(Emergency Medical System) is incomplete. Study Objectives: This study was undertaken to tested the efficacy of dispatcher assisted telephone CPR using a recording mannikin(Anne Resusci) in a highstress, simulated cardiac arrest scenario. Study Subjects: We assesed in a group of volunteers, without prior CPR lectured and training(GroupⅠ, n=20), without prior CPR training but received lecture previously(Group Ⅱ, n=20) who received telephone instruction were compared with that of previously recevied lecture and tranined(Group Ⅲ, n=20) who received same massage. Performances of above groups were also compared with a group(Group Ⅳ, n=20) composed of previously received lecture and trained volunteers who did not receive the massage. Results: Members of groups Ⅰ,Ⅱ, and Ⅲ delivered similar average ventilation volumes, approximately 1L/cycle. In contrast, group Ⅳ delivered somewhat less, about 700ml/cycle(p<0.05). Group Ⅰ performed ventilation better than group Ⅳ but there was no significant intergroup differences in the performing effective chest compressions. The global performance of group Ⅲ, the group with prior CPR lecture, trained and telephone instruction, was superior to that achieved by other groups(p<0.05). We conclude that dispatcher-assisted telephone CPR can offer a safe and cost-effective means to increase the rate of bystander CPR and also improves the quality of CPR performed by persons with prior CPR training.