심폐소생술 중 하행 대동맥 내 압력 차이 발생의 혈역학적 의의

황성오,박해상,이서영,안희철,김현,이강현,유병수,이승환,윤정한,최경훈 대한응급의학회 2002 대한응급의학회지 Vol.13 No.3

Purpose: There have been no reports concerning the role of the aorta in explaining why blood flow is low below the diaphragm and a pressure gradient is present between central and peripheral arteries during standard cardiopul-money resuscitation (CPR). The aim of this study was to assess the morphologic changes of the descending thoracic aorta and its effect on aortic pressure during precordial chest compression in cardiac arrest victims. Methods: Twelve patients with non-traumatic cardiac arrest (8 males, mean age: 58 years) were enrolled. Transesophageal echocardiography was performed to verify the morphologic changes of the descending thoracic aorta during standard manual CPR. The pressure gradient across the maximally compressed site of the aorta was measured by pullback tracing using a pigtail catheter. Results: Focal compression and deformation of the descending thoracic aorta was uniformly observed in all patients during compression systole. The mean systolic blood pressure of the descending thoracic aorta proximal and distal to the maximally compressed site was 135±36 mmHg and 115±21 mmHg, respectively. The mean systolic pressure gradient across the maximally compressed site was 20.5±17.7 mmHg. During compression systole, the pressure gradient between the right atrium and the descending thoracic aorta proximal to the maximally compressed site during compression systole was 49±12 mmHg while pressure gradient between the right atrium and the descending thoracic aorta distal to the maximally compressed site was 29±8 mmHg. Conclusion: We found that the descending thoracic aorta was focally compressed and that a pressure gradient developed across the maximally compressed site during compression systole. This may contribute to limiting blood flow to the subdiaphragmatic region during standard manual CPR in humans.

이중혈류유발 심폐소생술이 심정지를 유발한 개의 단기 생존율에 미치는 영향

황성오,조준휘,강구현,김성환,문중범,이강현,이승환,윤정한,최경훈,홍은석 대한응급의학회 2000 대한응급의학회지 Vol.11 No.3

Background and Objectives: We previously reported that, compared with standard cardiopulmonary resuscitation(S-CPR), better hemodynamic effects could be achieved by simultaneous sterno-thoracic cardiopulmonary resuscitation(SST-CPR) in which we compressed the sternum and constricted the thorax circumferentially during the systolic period by using a device. This study was designed to assess whether SST-CPR, compared with S-CPR, improve the survival rate of dogs with cardiac arrest. Subjects and methods: Twenty-five mongrel dogs(19∼31㎏) were enrolled in this study. After four minutes of ventricular fibrillation induced by an AC current, animals were randomized to resuscitate with either S-CPR(n=13) or SST-CPR(n=12). Epinephrine(1 ㎎) was injected into the right atrium every three minutes after the beginning of CPR. Defibrillation was attempted after 6 minutes of CPR. Standard advanced cardiac life support was started if defibrillation was not successful. Results: SST-CPR resulted in significantly(p<0.001) higher systolic arterial pressure(91±47 vs 47±24 ㎜ Hg), diastolic pressure(43±24 vs 17±10 ㎜ Hg), coronary perfusion pressure(35±25 vs 13±9㎜ Hg), and end tidal CO2 tension(9±4 vs 3±2 ㎜ Hg). Two of 13 animals(15 %) resuscitated with S-CPR and six of 12 animals(50%) resuscitated with SST-CPR survived until 12 hours after cardiac arrest(p<0.05). Donclusion: SST-CPR, compared with S-CPR, improves the short-term survival rate in canine cardiac arrest.

심정지환자에서 심폐소생술 중 좌심실 조영 심초음파로 관찰된 승모판 역류의 의의 : Its Implications for the Mechanism of Forward Blood Flow

황성오,이서영,김현,이강현,장용수,최한주,유병수,이승환,윤정한,최경훈,조준휘 대한응급의학회 2003 대한응급의학회지 Vol.14 No.2

Purpose: In the mechanism of forward blood flow during cardopulmonary resuscitation (CPR) in humans, the role of the left ventricle remains to be investigated. The aim of this study was to assess the role of the left ventricle in generating forward blood flow in humans during CPR by performing contrast echocardiography. Methods: Ten patients with non-traumatic cardiac arrest were enrolled. During CPR, a pigtail catheter was introduced to the left ventricle and a central venous catheter was introduced to the right atrium under transesophageal echocardiographic guidance. Ten (10) ml of agitated saline was injected into the left ventricle to perform contrast echocardiography during CPR. The direction of contrast flow and the presence of mitral regurgitation were assessed with a 135˚ longitudinal view. Pressures were traced in the left ventricle, the aorta, and the right atrium. Results: Forward flow toward the aorta and mitral regurgitation (MR) were visualized during compression systole on left ventricular contrast echocardiography in all patients: grade I in 1, grade 11 in 3, grade III in 4, and grade IV in 2 patients. There was no differences in the clearing times (29±24 vs 22±12 sec) or he numbers of chest compressions (53±32 vs 48±28) of the contrast from the left ventricle, the systolic left ventricular pressures (96±13 mmHg vs 126±48mmHg), the systolic aortic pressures (90±11 mmHg vs 116±58 mmHg), the diastolic aortic pressures (33±13 mmHg vs 32±9 mmHg), the coronary perfusion pressures (23±12 mmHg vs 26±8 mmHg), and the end tidal carbon dioxide tensions (13±12 mmHg vs 9±3 mmHg) between the mild MR group (MR grades I and 11) and the severe MR group (MR grades III and IV). The left ventricular ejection fraction was higher in the severe MR group than in the mild MR group. Conclusion: Mitral regurgitation on left ventricular contrast echocardiography during compression systole suggests that cardiac pumping is the dominant mechanism in generating forward blood flow during standard CPR in humans.

폐좌상시 혈역학적 변화가 폐단락과 동맥혈 산소압에 미치는 영향

황성오,김영식 연세대학교 원주의과대학 1993 원주의대논문집 Vol.6 No.1

심폐소생술중 심정지의 원인 규명을 위한 경식도 심초음파의 유용성

황성오,김현,이상현,임종천,오범진,조준휘,강구현,김성환,이승환,윤정한,최경훈 대한순환기학회 1998 Korean Circulation Journal Vol.28 No.2

응급환자의 중증도 분류를 위한 지표의 개발 : Triage Score와 Modified Triage Score NEW METHODS TO TRIAGE ALL EMERGENCY PATIENTS

임경수,홍은석,김선만,황성오 대한응급의학회 1996 대한응급의학회지 Vol.7 No.2

Up to now, triage system for all emergent patients, which can be used fast and conviently according to their severity has not been developed yet. For the triage of trauma patient, emergency medical technicians and emergency medical doctors are commonly using R.T.S. (Revised Trauma Score). The R.T.S. consists of GCS(Glasgow coma scale), systolic blood, pressure and respiration rate per minute. But it is difficult for emergency medical technicians to calculate GCS in the prehospital because of its complexity and need for more time. Therefore we develop the Triage Score by remodelling the R.T.S. by replacing GCS with AVPU scale and systolic blood pressure that is under 49 mmHg after adding 1-49 mmHg with 0 mmHg and respiration rate per minute that is under 5/min after adding 1-5/min with 0/min. We stuied the significance and the possible triage application of Triage Score in traumatic emergency patients. For nontraumatic emergency patients, we develop the Modified Triage Score to triage the cardiovascular emergencies by adding the item of chest pain to Triage Score. A prospective study was carried out on 530 patients from March 1 to 31 1996. There were 210 trauma patients and 320 nontraumatic emergency patients and the result shows as follows. For trauma patients, there was linear correlation between R.T.S. and Triage Score(R²=0.965). Comparison analysis between high risk group (admission+death patients) and low risk group(discharge patients) of nontraumatic emergency patients by using Modified Triage Score is statistically significant(P<0,001) The cardiovascular emergencies could not categorized as urgency by Triage Score, but that was possible by application of Modified Triage Score. In conclusion, we can triage the injured patients effectively by Triage Score and the nontraumatic emergency patients including emergency cardiovascular disease can be categorized as urgency by applying the Modified Triage Score.

하부 늑골골절과 masked 복부손상과의 상관관계

이강현,임경수,홍은석,황성오 대한응급의학회 1996 대한응급의학회지 Vol.7 No.2

Some emergency physicians neglect abdominal injuries if a patient does not complaint of abdominal pain or abdominal tenderness was absent on physical examination. But intra-abdominal injuries are correlated closely with lower rib fractures and pelvic bone fractures. In cases of lower rib fractures, intra-abdominal organs are injured as a diaphragm is elevated as high as 5th intercostal space in expiration period. When intra-abdominal solid organ is ruptured, a patient complaints of abdominal pain, but there`s no abdominal pain if small hematoma occurs in solid organs. Although the most of solid organ hematoma are resolved spontaneously without complications, sometimes delayed rupture of hematoma occurs especialy in patients with the coagulopathy. So emergency physician must evaluate the abdomen closely when the possibility of intra-abdominal injury is high. To evaluate the intra-abdominal injuries, we investigated 57 patients with lower rib fractures by ultrasonography. The patients were divided in 2 groups according to presence of abdominal symptomes; patients with abdominal symptoms(n=10). Among 57 patients, intra-abdominal injuries were found in 35 patients. In group with lower rib fractures and presence of abdominal symptoms, intra-abdominal injuries were diagnosised in 32 patients(68.9%) with 48 cases(hepatic injury; 20, spleen injury; 19, renal injury 7, hemoperitoneum without solid organ injury; 2). In group with lower rib fractures and abscence of abdominal symptoms, intra-abdominal injuries were diagnosised in 3 patients(30.0%) with 3 cases(spleen injury; 1. hemoperitoneum without solid organ injury;2). In conclusion, emergency physician must do ultrasonography to evaluate intra-abdominal injuries in patients with lower rib fractures although a patient does not complaint of abdominal pain.

두가지 혈류 유발방법에 의한 새로운 심폐소생술(이중 혈류 유발 심폐소생술)장치의 개발

황성오,김현,조준휘,오범진,임종천,최경훈,윤정한,이승환,김영식,이강현,이윤선 大韓應急醫學會 1999 대한응급의학회지 Vol.10 No.2

Background: There have been many efforts to augment blood flow during cardiopulmonary resuscitation. These efforts have focused on maximizing the effect of cardiac pump or thoracic pump alone. However, considering that the heart is the biggest blood reservoir and increase of intrathoracic pressure can generate blood flow, simultaneous exploitation of both mechanisms may have synergistic effect. We hypothesized that simultaneous chest constriction in addition to sternal compression by standard CPR may have additive hemodynamic effects by preventing deformation of the chest and increase of intrathoracic pressure. Methods and results: we built a new mechanical device to perform compression and thoracic constriction simultaneously. The device consists of two main elements. Piston in the center is to depress the sternum. Strap is to constrict the thorax circumferentially. Strap is attached to both sides of the piston. When the piston is pushed down, it depresses the sternum and pulls on the thoracic strap. To determine strap width to produce optimal hemodynamic effect, we measured hemodynamic parameters with variable widths of strap in two dogs after induction of ventricular fibrillation. Result of the experiment showed that 10cm wide strap was determined to be most effective. We also determined optimal depth of compression to produce maximal hemodynamic effect with animal experiments using two dogs. Animal experiments showed that the highest aortic pressure could be generated when the stemum was depressed to 5 cm. Cardiopulmonary resusciation using a new device could generate higher systolic aortic pressure, coronary perfusion pressure and end-tidal carbon dioxide tension in comparison with standard cardiopulmonary resuscitation in a pilot animal study using two dogs. Conclusion: New cardiopulmonary resuscitation method using a mechanical device designed by us could perform sternal compression and simultaneous thoracic constriction, and generate better hemodynamic effects than standard cardiopulmonary resuscitation in pilot animal experiments.

외상환자에서 전신성 염증 반응 증후군 (Systemic Inflammatory Response Syndrome)의 발생과 혈청 TNF-α와의 관계

김현,이강현,임종천,조준휘,오범진,황성오 大韓應急醫學會 1998 대한응급의학회지 Vol.9 No.4

Background and purpose: The systemic inflammatory response syndrome(SIRS), as defined recently by critical-care specialists, may result from various etiologies including infection, burn, or trauma. The purpose of this study was to determine whether TNF-αis associated with the development of systemic inflammatory response syndrome caused by multiple trauma. Methods: The study population consisted of 21 patients with multiple trauma presented emergency department within 2 hours after insult were enrolled in this study. Multiple blood samples were serially drawn to measure serum TNF-αlevel on admission, 12 hours, 24 hours, and every day until 5 days after injury. Serum TNF-αwas measured by ELISA ("Sandwich type"). Blood samples of fifteen volunteers were used as a reference value for serum TNF-α. Results: Serum TNF-αlevels of SIRS group were persistently elevated above reference value until 3 days after on admission. Peak serum TNF-αlevel at 12 hours after admission was higher in SIRS group than non-SIRS group(p<0.05). There was no significant correlation between injury severity score and TNF-αlevels on regression analysis, all patients with ISS higher than 16 had SIRS. No one had SIRS among patients with ISS less than 16. Conclusion: The result of this study suggests that persistent elevation of TNF-αand degree of injury severity are associated with the development of systemic inflammatory response syndrome in multiple trauma.

구급차의 종류 및 주행속도에 따른 흉부압박법의 성공률에 대한 연구

임경수,인요한,황성오 대한응급의학회 1995 대한응급의학회지 Vol.6 No.2

Chest compressions performed in a controlled environment can generate adequate coronary perfusion pressure, but compression is frequently inadequate even when CPR is performed under optimal circumstances, In Korea the average highway of road is narrow and curved more than in other countries, and the back-space in ambulance of Korea is limited to perform CPR. As a result, the CPR in a moving ambulance is no effective in Korea. We studied the effectiveness of chest compression in a moving ambulance by the use of a CPR manikin(Skillmeter Resusci Annie, Laerdal company). The ambulance was driven without a warming siren with obeying all the traffic signals and rules. Eight emergency physicians performed a total of 8 sessions of 2 minutes of continuous chest compression on the manikin in the ambulance(Van-type). They did the same thing in truck-type ambulance. We compared the results between small ambulance(Van type) and large ambulance(Truck type). To compare the effectiveness of manual and mechanical cardiac massage, the mechanical cardiac resuscitator(Thumper: Michigan company) was used. The success rate of manual CPR in a constant speed was not different between the Van-type ambulance and Truck-type ambulance(p>0.05), but mean percentage of correct compression by mechanical chest compressor showed 100%(p=0.004). The success rate of manual CPR in driving at downtown was 67.4± 15.7 in Van-type ambulance, but that was 93.4 ± 5.2 in Truck-type ambulance(p=0.007). These results demonstrate that the performance of manual chest compression in a moving ambulance(Van type) is suboptimal. As the patient care area in the Van-type ambulance is much more spacious than that of the Truck-type ambulance, the diminution of compression efficacy in the smaller ambulance is consistent with the assumption that space is the most important factor in the ability to perform adequate CPR in a moving ambulance. Although the results were good in a truck-type ambulance, chest compression was performed for only 2 minutes. It is difficult for one person to deliver manual chest compression in a moving ambulance for a long period. Mechanical chest compression may be employed where manual compression is technically difficult to perform.