손목 관절과 발목 관절 손상 환자의 진단에 있어 응급 초음파의 유용성

이성실 ( Sung Sil Lee ),김동언 ( Dong Un Kim ),박득현 ( Deuk Hyun Park ),조현영 ( Hyun Young Cho ),안성준 ( Seung Jun Ahn ),고찬영 ( Chan Young Kho ),신태용 ( Tae Yong Shin ),김영식 ( Young Sik Kim ),하영록 ( Young Rock Ha ) 대한외상학회 2007 大韓外傷學會誌 Vol.20 No.2

Purpose: Ultrasound is of proven accuracy in abdominal and thoracic trauma and may be useful for diagnosing extremity injury in situations where radiography is not available, such as disasters and military and space applications. However, the diagnosis of fractures is suggested by history and physical examination and is typically confirmed with radiography. As a alternative to radiography, we prospectively evaluated the utility of extremity ultrasound performed by trained residents of emergency medicine (EM) one patient with wrist and ankle extremity injuries. Methods: Initially, residents of EM performed physical examinations for fractures. The emergency ultrasound (EM US) was performed by trained residents, who used a portable ultrasound device with a 10- to 5-MHz linear transducer, on suspected patients before radiography examination. The results of emergency ultrasound and radiography and the final diagnosis were recorded, and correlations among them were determined by using Kappa`s test. Results: Thirty-nine patients were enrolled in our study. The average age was 36.6±19.3 years. There were radius Fx. (n=21), radius-ulna Fx. (n=1), ulna Fx. (n=1), and contusion (n=2) injuries among the wrist injury and lat.-med. malleolar Fx. (n=13), lat. malleolar Fx. (n=6), and med. malleolar Fx. (n=3) injuries among the ankle injury. Comparing EM US with radiography, we found the sensitivity, specificity, positive predictive value, and negative predictive value of EM US for Fx. diagnosis to be 100%, 66.7%, 97.3%, 100% and those of radiography to be 97.2%, 100%, 100%, and 75%, respectively. Kappa`s test for a correlation between the Fx. diagnosis of EM US and the final diagnosis of Fx was performed, and Kappa`s value was 0.787 (P = 0.004). Conclusion: EM US for Fx. can be performed quickly and accurately by EM residents with excellent accuracy in remote locations such as disaster areas and in military and aerospace applications. EM US was as useful as radiography in our study and had a high correlation to the final diagnosis of Fx. Therefore, ultrasound should performed on patients with extremity injury to determine whether extremity evaluation should be added to the FAST (focused abdominal sonography trauma) examination. (J Korean Soc Traumatol 2007;20:130-137)

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)

외상 환자에서 초음파 유도 내경정맥 도관 삽입 시카테터 바늘과 피부 사이의 적정 각도

전현민 ( Hyun Min Jeon ),정성민 ( Sung Min Jung ),정루비 ( Ru Bi Jung ),전진 ( Jin Jeon ),홍종근 ( Chong Kun Hong ),신태용 ( Tae Yong Shin ),하영록 ( Young Rock Ha ),김영식 ( Young Sik Kim ) 대한외상학회 2013 大韓外傷學會誌 Vol.26 No.3

Purpose: The aim of this study was to identify the optimal insertion angle between the skin and the needle in ultrasound-guided internal jugular vein (IJV) catheterization with trauma patients. Methods: From March 2012 to December 2012, consecutive trauma patients who were planned to receive IJV catheterization were prospectively enrolled. We measured the distances from the skin to IJV`s anterior-posterior (AP) vessel wall on the longitudinal scan`s midline in supine-positioned patients. We calculated the AP diameter of IJV and the angle between skin and the imaginary line from the puncture site to the IJV`s internal center on screen`s midline (defined as optimal angle which is considered as the safest approach) on the longitudinal scan. We divided the patients into 3 groups based on the CVP (low CVP <5 cmH2O, 5≤ middle CVP ≤10 cmH2O, and high CVP>10 cmH2O) and compared their mean anterior posterior (AP) diameters and optimal angles. Results: A total of 56 patients were enrolled. Of these 21 were women(35.4%). The mean AP diameter of low CVP group was significantly lower than middle and high CVP groups(0.68±0.30, 1.06±0.31, and 1.23±0.49 cm respectively, p=0.003 vs. 0.002). There was no significant difference among 3 groups` mean optimal angles (28.1±6.1, 30.1±4.5, and 28.0±5.0 degree respectively). Conclusion: The optimal angle between the skin and the needle in ultrasound-guided IJV catheterization with trauma patients is not changed as about 30 degrees regardless of CVP even though IJV`s diameter is altered in proportion to the CVP.

응급의학과 의사가 시행한 상복부 초음파의 정확성

하영록,김훈,유승,정성필,김승환,유인술 대한응급의학회 2002 대한응급의학회지 Vol.13 No.4

Purpose: The purpose of this study is to determine for upper abdominal pain, the accuracy of emergency abdominal ultrasonography (EAU) performed by emergency physicians with limited training. Methods: Two PGY-3 emergency physicians, who had received 2 hours of hands-on training, including the normal anatomy of a biliary system, liver, kindney, spleen, and pancreas, and who had studied the pathologic findings for another month were the subjects of this study. They used a Sonosite 180? to perform EAU on patients with upper abdominal pain within 2 months after training. We determined the agreement between the radiologist’s abdominal ultrasonography(RAU) and EAU by using Kappa statistics. Results: A total of 59 patients were enrolled. The agreement between the EAU and the RAU findings was 0.97, 0.88, 0.79, 0.73, 0.62, and 0.57 for gall bladder (GB) distension, cholelithiasis, GB wall thickening, duct dilatation, choledocholithiasis, and pericholecystic fluid, respectively (p<0.05). Conclusion: The results of EAU, performed by emergency physician with limited training on patients suffering from upper abdominal pain had a significant agreement with the RAU. However, more educations and cautions are warranted for diagnosing pericholecystic fluid and choledocholithiasis.

노인 외상 환자의 중증도 분류 시 Triage-revised Trauma Score의 의의

양영모,하영록,정성필,김승환,유인술 대한응급의학회 2001 대한응급의학회지 Vol.12 No.3

Backgrouds: The mortality of geriatric trauma patients is higher than that of other age groups. However, little research has been done the methods or criteria of triage for geriatric trauma patients. This study evaluated a clinical significance of the triage-revised trauma score(t-RTS) for triage of geriatric trauma patients. Methods: We retrospectively analyzed clinical data on 528 trauma patients over 65 years of age who were treated from Jan 1999 to Dec 2000. The t-RTS was calculated utilizing the RR(respiratory rate), SBP(systolic BP), and GCS scores and the ISS was abstracted from the final diagnosis. The obtained t-RTS and ISS were evaluated using the measures of sensitivity, specificity, accuracy, and AUC curve. Results: The overall mortality rate was 9%, and there was no significant differences between the survival group and the mortality group according to age and sex. The mean scores of SBP, RR and GCS of the survival group were significantly higher than those of mortality group(p=0.001). The mean of t-RTS and RTS of the survival group were also significantly higher(p=0.001), but the ISS was significantly higher in the mortality group(p=0.001). The t-RTS, RTS, and ISS showed good prediction rates on the ROC curve(p=0.001), and the AUC value was higher in the ISS than in the t-RTS and the RTS. The sensitivity and the accuracy were high in the t-RTS and the RTS, and the specificity was high in the ISS. The t-RTS is less than 10 for a survival probability of 50% or less Conclusions: Implementation of the t-RTS in the triage of geriatric trauma patients in the field and in emergency room would be very useful. The probability of death in geriatric trauma patients is high when the t-RTS is less than 10.

응급실에서의 확산강조 자기공명 영상

정성필,이석우,양영모,하영록,김승환,유인술 대한응급의학회 2001 대한응급의학회지 Vol.12 No.3

Background: This study was designed to review the cases of patients who had undergone diffusion-weighted magnetic resonance imaging(DWI) in the emergency department(ED), and to investigate its clinical usefulness and current indications. Methods: We analyzed the cases of 152 consecutive patients who underwent DWI in the ED from Jan to Mar 2001. DWI was obtained with the use of a multislice, single-shot, spin-echo plana imaging technique(GE SignaR). Imaging time was less than one minute. The medical records, the DWI films and the computed topography results were reviewed. We investigated the chief complaint, initial findings of physical examination, final diagnosis, decision-making department, interval from admission to imaging, and DWI findings. Results: DWI showed positive findings of high signal intensity in 84 patients(55.3%). Among the 68 patients who yielded a negative result, false negative occurred with 12 patients(17.6%): 10 lacunar infarctions, a pons infarction, and a brainstem infarction. Eleven patients were determined as having a cerebral hemorrhage, all of whom showed the abnormal finding of a mixed signal in DWI. The sensitivity and the specificity of DWI to rule out stroke were 85.5% and 98%, respectively. Current indications for DWI in our ED are age older than 60, alert mental status, and one of the symptoms or signs among lateralyzing sign, language disturbance, and dizziness/vertigo. Conclusion: DWI was highly specific to rule out stroke, so emergency care professionals should be familiar with this new technology. Further prospective study is required to determine the proper indications and clinical usefulness of DWI in the ED.

세가지 의식상태분류법의 객관성 비교

박인철,정성필,하영록,구홍두,김옥준,최옥경,장석준,김승호 대한응급의학회 1994 대한응급의학회지 Vol.5 No.1

Rapid and accurate assessment of impaired consciousness is very important especially for emergent patients. For early diagnosis and treatment of patients with altered mental state, it is essential for emergency physician to provide a guide to ultimate outcome and to communicate the patient's information between medical personnels. We have evaluated and compared three methods that are mostly used in clinic for assessing the impaired consciousness in order to find out the most objective method which may not be influenced by individual medical knowledge and training. Three months(Oct, 1993 and Jan to Feb, 1994) of assessments by 3 observant groups(a 1st-year resident of dept. of emergency medicine, an intern, and a senior student of medical college) were made to 78 patients with altered mental state(ages above 15), who have been admitted to the department of emergency medicine, Severance Hospital Yonsei University College of Medicine. The methods under comparison were 5-scale method. AVPU method, and Glasgow coma scale(GCS). The results are as follows; The patient population ranged from 19 to 89 with an average of 55.8 yrs. 54% of the pa-tients were older than 60 years of age. The causes of emergency visit were disease(69%), trau-ma(23%), and intoxication(8%). The causes of the disease include intracranial hemorrhage (40%), cerebral infarction(9%), and medical illness(20%). McNemar test showed no statisti-cal significance between any of these comparisons. Kappa-value, the reliability was highest at the resident-intern group assessed by the AVPU method(0.782) and lowest at the resident-student group measured by the 5-scale method(0.582). These values were, however, above the "fair to good agreement" level indicating that all the methods can be used for assessment of im-paired consciousness with objectiveness. The ranks of comparison groups in each methods were in the following order of magnitude. (1) 5-scale method: resident-intern, intern-student, resident-student, (2) AVPU method: resident-intern, resident-student, intern-student, (3) GCS: intern-student, resident-intern, resident-student. The ranks of compared methods in each groups were, (1) resident-intern: AVPU method, 5-scale method, GCS (2) resident-student: AVPU method, 5-scale method, (3) intern-student: GCS, 5-scale method, AVPU method. These results suggests that, the most objective method not influenced by medical knowledge and training is AVPU method, showing highest reliability especially inthe resident-student group with greatest difference in the level of medical knowledge and training.

의료계 파업기간중 전문의의 응급실 근무가 진료에 미치는 영향

이석우,양영모,하영록,정성필,유인술,김승환 대한응급의학회 2002 대한응급의학회지 Vol.13 No.2

Purpose: To evaluate the quality of the emergency medical care during doctors' strike at a hospital in Korea. Methods: During a period of 7 consecutive days, from 20th to 26th June 2000, the training physicians in Korea were on strike against medical reform and the emergency medical care was provided by medical staffs without training physicians. We drew out convenient samples by systematic allocation method and reviewed the medical records. We evaluated the patients' severities, the number of diagnostic tests and therapeutic procedures, the admission rates, and the lengths of stay at emergency department(ED) in the strike period (SP) compared to control period(NSP) from 20th to 26th June, 1999. Results: The two groups(SP: 191 vs NSP: 202 patients) showed significant differences in the proportion of emergent patients(17.3 vs 32.7%), ED length of stay(1.98 vs 4.47 hours), the number of diagnostic tests (1.47 vs 3.92), the injection rates(17.3 vs 35.1%), and the adverse event rates(4.5 vs 6.5%). Conclusion: This study suggested that the ED administration by medical staffs without training physicians improves medical quality of emergency care.