중환자치료에서 스트레스 관련 위장관 출혈 및 병원성 폐렴

손대곤,이한식 한국의학사 1997 診斷과治療 Vol.17 No.5

경증 소아 두부 외상

손대곤,김경환 인제대학교 백병원 2002 仁濟醫學 Vol.23 No.5

Head trauma is one of the most common childhood injuries in the emergency department(ED). The majority of the patients have minor head trauma but minor head trauma can cause a not uncommon intracranial injuries(ICI). The goal of the ED clinician is identify those at risk for ICI while limiting unnecessary imaging procedures and sedation of the patients. We reviewed the current data and practice in assessing and treating minor head trauma in children. This review article can help the ED clinician for the diagnosis and treatment of the pediatric minor head trauma patients.

급성 acetaminophen 중독의 임상적 고찰

손대곤,최성욱,장석준 대한응급의학회 1996 대한응급의학회지 Vol.7 No.2

Acetaminophen-a common analgesics easily available without doctors prescription in our country-overdosed patient is one of most commonly encountered in the ED. But, acetaminophen is relatively safe drug and treatment of acetaminophen overdosage has been well established. But for the proper management of these patients, two following restrictions should be overcome. The first, serum acetaminophen level should be available immediately for proper disposition of the patients. The second one is the use of the antidote (NAC:N-acetyl cysteine, Mucomyst??) to the potentially toxic patients without delay and adequate dosage and route of administration of the NAC should be familiar to the emergency physician. Except a few hospital, serum acetaminophen level is not available in our country. This pitfall can make emergency physician delay the use of the NAC or misuse of the NAC. To overcome of this pitfall, we reviewed patients who admitted in our hospital due to acetaminophen overdosage from July 1. 1993 to June 30. 1995. Total 18 patients enrelled in our study, 4 male, mean age 25.5 years old, and mean ED presentation time after ingestion was 6.25 hours. Acetaminophen single ingestion was 14 cases and mixed ingestion was 4 cases. With the exception of the one case who ingested 3g of acetaminophen, all patients received 72 hour oral NAC as an antidote for poisoning of acetaminophen. Both NAC and MDAC(multiple dose activated charcoal) was used in 8 cases. 「Serum acetaminophen level was obtained in 12 cases」. "Three patients had showed hepatotoxicity-liver enzyme(SGOT/SGPT) level above 200 IU-recovered during hospitalization.` No fatal hepatotoxicity was noted in our study. Fourteen adjustment disorder, one personality disorder and three major depression was their final psychiatric diagnosis. Their mean hospital day was 7.2 days. In the conclusion, as the efficacy of NAC as an antidote decreases after 8 hours, treatment must be started immediately following all potentially toxic dose of acetaminophen. Administration can be stopped if the acetaminophen concentration is below the treatment line but it is important to avoid potentially fatal delay.

대한 응급의학회지 논문의 분석 및 고찰

손대곤,장석준,송근정,이한식 大韓應急醫學會 1997 대한응급의학회지 Vol.8 No.1

To raise the quality of research, medical articles which are feasible and objective must be continuously published and be continuously monitored. All articles published in the Journal of the Korean Society of Emergency from November, 1990 to November, 1995 were compared with a foreign emergency medical journal, the American Journal of Emergency Medicine(AJE). Classifying the articles in the Journal of the Korean Society of Emergency Medicine, there were 15 (8.4%) review articles, 145 (81.0%) original articles and 19 (10.6%) case reports. In the AJE, there were 103 (15.1%) review articles, 304 (44.4%) original articles and 277 (40.5%) case reports. Classifying the original articles in the Journal of the Korean Society of Emergency Medicine, There were 13 (9.0%) experimental articles, 88 (60.7%) descriptive articles and 44 (30.3%) analytic articles. In the AJE, there were 40 (13.2%) experimental articles, 59 (19.4%) descriptive articles and 205 (67.4%) analytic articles. The classification of original articles according to frequency in the Journal of the Korean Society of Emergency Medicine is trauma, resuscitation, toxicology and medical emergency, where as the AJE is medical emergency, trauma, toxicology and EMS. For statistical methods used in original articles, 90 (62.1%) case did not do any statistical analysis or where only descriptive statistics were used. In 6 (4.1%) cases the statistical level was described but statistical methods were nonmentioned. By simple calssificaton study, there were 44 (30.3%) cases of original articles in the Journal of the Korean Society of Emergency Medicine, and 6 (2.0%) cases in the AJE. Because the development of Emergency Medicine as a special department is based on logical articles, organization of articles have study design, make hypothesis, sample gathering, statistical analysis and feasibility of conclusion. For this, the emergency training course needs a course on research methodology.

골반골절 환자에서 출혈의 정도를 반영하는 분류

황태식,손대곤,김인병,장석준 大韓應急醫學會 1996 대한응급의학회지 Vol.7 No.1

The causes of death of pelvic bone fracture are hemorrhage, associated internal organ injuries, sepsis, and multi-organ failure, among which hemorrhage still remains as the leading cause of death. While previous classification for pelvic bone fracture was focused on orthopedic treatment, Pennel & Sutherland suggested a new classification according to the pelvis AP film took in the emergency room. Since this classification supposedly evaluates hemorrhage from pelvic bone fracture, we are reporting on the efficiency of this classification. Out of all the 150 patients admitted to Yong Dong Severance Hospital Emergency Room from 1992, Jan. through 1994, Dec. due to pelvic bone fracture, 18 people with incomplete medical record and X-ray film excluded from the study. The study was done Cohort method and t-test was used. According to the new classification, the unstable fracture had a much more bleeding amount regardless of the type, and type I stable fracture bled more than all the other stable fracture. These were statistically meaningful. Also, there was no differences in the type of fracture when ISS(Injury Severity Scale), GCS(Glasgow Coma Scale), and associated injury were compared. In conclusion, previous classification was done according to orthopedic treatment and this classification could be done only after pelvis X-ray series and pelvic bone CT was performed. Therefore much more time is consumed, more stress is put upon the patient and no comparisons can be made in performing emergency care. On the other hand, modified Pennel &-Sutherl`s classification can be simply classified in the emergency room by taking pelvis AP film only and the bleeding amount can be measured according to the type. Therefore, this classification can be helpful in performing emergency care.

응급맥박산소측정기

조광현,손대곤,이한식 대한응급의학회 1994 대한응급의학회지 Vol.5 No.1

Study objective: To determine the accuracy of the pulse oximetry in the emergency department. Study design: Prospective, cross-sectional, paired measurement of SpO₂against SaO₂. Setting: University affiliated hospital. Interventions: A pulse oximeter with digital probe was used to measure SpO₂. Arterial blood gas was drawn at the same time to measure SaO₂. Results: There were no significant difference between SaO₂and SaO₂when SaO₂was above or less than 90%(mean≥90%=0.598±2.655 mean<90%=2.926±7.807;p≥90%=0.0796,p<90%0.0860), but all together there weresignificant difference(mean=1.22±4.70;p=0.017) Conclusion: The pulse oximetry is potentially useful in patients with clinical signs of acute hypoxemia and patients receiving interventions that may produce acute hypoxemia, and is a must device in emergency department.

허혈성 흉통환자에서 증상 경과시간에 따른 TROPT TnT Rapid Assay의 진단적 유용성

고재욱,손대곤,김승호,이철주 대한응급의학회 1998 대한응급의학회지 Vol.9 No.2

A prospective study was carried out to evaluate the validity of TROPT troponin T rapid assay in early diagnosis of acute myocardial infarction(AMI) in patients with ischemic chest pain, in comparison with conventional diagnostic tools such as serum troponin T(c-TnT) level, creatine kinase(CK), CK-MB level and initial EKG finding. The study was performed at the emergency department(ED) of YongDong Severance hospital from March 1st 1996 to February 28th 1997. One hundred eighty one patients visiting ED with chief complaint of atraumatic chest pain within 24 hours of visit were eligible for the study. Those who lacked enough data collection and those who had chest pain of noncardiac origin and EKG of PSVT were excluded from the study. The overall study population was a total of 131 patients. Initial EKG, TROPT rapid assay, CK, CK-MB and c-TnT level were obtained simultaneously. Diagnosis of AMI was made according to the international diagnostic criteria for AMI. Of the 131 patients 61 patients(46.6%) were diagnosed as AMI. Within 4 hours of their symptom onset, initial EKG showed the highest sensitivity(63.2%) whereas the sensitivities of TROPT rapid assay, c-TnT, CK and CK-MB were poor(0∼7.9%). From 4∼8 hours, the sensitivities of c-TnT, CK and CK-MB were higher than that of TROPT rapid assay(80% vs. 30%). The sensitivities of TROPT rapid assay, c-TnT, CK and CK-MB rose over time and reached 100% after 8 hours symptom onset. The specificities of the TROPT rapid assay, c-TnT, CK & CK-MB and EKG were all 100% within 8 hours after symptom onset. Discrepancy between TROPT rapid assay and c-TnT was noted in nine patients(6.9%). In this study TROPT rapid assay was valuable in the diagnosis of AMI after 8 hours of symptom onset.

두부외상 환자에서 뇌 전산화 단층촬영 여부결정을 위한 고효율적 임상지표고찰

최성욱,손대곤,이한식 대한응급의학회 1994 대한응급의학회지 Vol.5 No.2

A retrospective analysis by chart review of consecutive 136 patients with head trauma, during period of 2 months from Jan. 1st. 1994 to Feb. 28th. 1994. who visited YDSH ED. All patients underwent brain CT scan to rule out intracranial lesion at the time of initial ED visit. The purpose of this study is to determine which clinical parameters can be used effectively to select patients requiring brain CT scan after an event of head trauma. The results were as follows : 1. Consecutive 136 cases of head trauma patients who had taken brain CT scan. Mean age was 31.1 years old. There were higher incidence of intracranial lesion developed in over sixty year old. 2. Pedestrian accident was most common cause of injury(42.0%), followed by MVA(25.7%) and falling down injury(23.1%) 3. There were 12 symptomatic variables and 8 sign variables and among variable with more than 50% positive in brain CT scan was selected to be high-yield clinical variable. 9 high-yield clinical variables were selected and they are : ① abnormal Babinski sign(100%) ② anisocoria and/or fixed dilated pupil(90.5%) ③ basal skull Fx. sign(84.6%) ④ positive focal neurologic sign(80.0%) ⑤ GCS less than 15 point(78.6%) ⑥ antegrade amnesia(66.7%) ⑦ prolonged LOC(65.9%) ⑧ mental change(52.1%) ⑨ alcohol intoxication(50.0%) This study suggest that significant number of patients with head trauma for brain CT can be effectively reduce by using high-yield clinical criteria. Use of these criteria requires thorough and complete history taking and neurologic examination, possible intoxication by an alsohol and antegrade memory loss. There were no surgical lesion missed in this study, but this protocol cannot assure that such lesion would be missed. The further prospective evaluation using this clinical variable is required to confirm the results.

응급 전산화단층촬영에서 조영제 사용에 따른 신독성

조영순,정태녕,손대곤,김승호 대한응급의학회 2003 대한응급의학회지 Vol.14 No.2

Purpose: In the last 30 years, there has been a markedly increased use of iodinated contrast agents in diagnostic and interventional radiological procedures. Due to the possible side effect of nephrotoxicity of these radiocontrast agents, we investigated the incidence of nephrotoxicity and attempted to identify the patient groups at higher risk for contrast nephrotoxicity among the patients who underwent emergency computerized tomography. Methods: We reviewed the medical records of 1,572 patients who had undergone contrast computerized tomography at the Emergency Center, Yonsei Medical Center, from January to May 2002. We defined contrast nephrotoxicity as any increase in the creatinine value of more than 0.5mg/dL (44㎛ol/L) or 25% compared to the baseline value. Results: We found 21 patients (1.3%) who met the criterion for contrast nephrotoxicity: 13 patients with normal renal function, and 8 patients with a higher than normal creatinine value before contrast-enhanced computerized tomography. The incidence of contrast nephrotoxicity in the patient group with normal renal function was 0.8% (13/1551), compared to 38.1% (8/21) in the pre-existing renal insufficiency group. There were no statistical differences on the amounts of dye used and the frequencies of risk factors for contrast nephrotoxicity between the patients in pre-existing renal insufficiency group who developed nephrotoxicity and who did not. The renal function of all patients returned to the baseline value without dialysis or renal replacement therapy. Conclusion: Pre-existing renal insufficiency is the most important risk factor for contrast nephrotoxicity. We need to take precautions and to have a proper protocol for the prevention of contrast nephrotoxicity in emergency care.

오르필(Orfil) 과다복용에 의한 중독환자 1예

김인병,조광현,손대곤,이한식 대한응급의학회 1994 대한응급의학회지 Vol.5 No.2

Orfil intoxication is not often encountered. But using the new knowledge about its pharmacodynamics and pharmacokinetics we could improve on its fatalities which are usually associated its central nervous system depression mediated by γ-aminobutyric acid, idiopathic hepatotoxicity and hemorrhagic pancreatitis thought to be mediated by immune mechanism. We report a case of valproate intoxication patient with serum valproic acid level of 2020 ㎍/mL who died from complications of progressive liver and pancreas failure known to be associated with valpoic acid.