유기인계 농약 중독 환자에서 초기 적혈구 아세틸콜린에스테라제 활성도의 임상적 의의

김훈,한승백,김준식,이미진,박준석,권운용,어은경,오범진,이성우,서주현,노형근,Kim, Hoon,Han, Seung-Baik,Kim, Jun-Sig,Lee, Mi-Jin,Park, Joon-Seok,Kwon, Woon-Yong,Eo, Eun-Kyung,Oh, Bum-Jin,Lee, Sung-Woo,Suh, Joo-Hyun,Roh, Hyung-Keun 대한임상독성학회 2008 대한임상독성학회지 Vol.6 No.1

Purpose: Acute organophosphate (OP) poisoning may be monitored by measuring the acetylcholinesterase (AChE). It is important to assess severity and establish prognostic tests in the early stage of OP poisoning. The aim of this study was to look at the relationship between various clinical aspects of the OP poisoning, prognostic indicators of OP poisoning including Simplified Acute Physiology Score (SAPS) 3, and the associated changes in AChE levels. Methods: Clinical data and initial AChE levels from thirty-seven patients with OP poisoning were prospectively reviewed from 12 teaching hospitals in South Korea from August 2005 to July 2006. Clinical manifestations at the time of arrival such as miosis, respiratory abnormality, salivation, urinary incontinence, GCS score, AVPU scale, need for intubation, and mechanical ventilation requirements were recorded. SAPS 3 was calculated using clinical data and laboratory results. Results: The median level of AChE was 9.8 (1.3-53.6) U/gHb. There was no significant difference in AChE levels between the groups with and without cholinergic symptoms. The median level of AChE of the patients who required intubation and those who did not were 3.5 U/gHb and it 19.7 U/gHb respectively (Mann-Whitney test; p<0.001). The AChE levels were also significantly different (p=0.007) in patients who needed mechanical ventilation compared to those who did not with AChE levels found to be 3.1 U/gHb and it was 14.8 U/gHb, respectively. Level of consciousness assessed using the AVPU scale was correlated with AChE levels (Kruskal-Wallis test; p=0.013). GCS score were correlated with AChE levels (p=0.007, Spearman's rho = 0.454). In addition, the lower the level of initial AChE, the longer the ICU stay (p=0.029, Spearman's rho=-0.380). SAPS 3 was inversely correlated with the initial AChE (p<0.001, Spearman's rho=-0.633). Conclusion: In the acute OP poisoning, low AChE levels appear to help indicate the severity of poisoning. The initial AChE level may be a useful prognostic parameter for acute OP poisoning.

Dicamba 급성 중독으로 인한 사망 1례

홍대영,엄욱현,이경미,김지혜,한승백,서주현,김준식,노형근,Hong Dae-Young,Um Wook-Hyun,Lee Kyoung-Mi,Kim Ji-Hye,Han Seung-Baik,Suh Joo-Hyun,Kim Jun-Sig,Roh Hyung-Keun 대한임상독성학회 2006 대한임상독성학회지 Vol.4 No.1

Dicamba is a benzoic acid and classified as a chemically related chlorophenoxy herbicide which is widely used for the control of broad-leaved weeds. While the chlorophenoxy herbicide poisoning is known to be uncommon, its ingestion can result in serious or sometimes fatal outcome. A 65-year-old man ingested about 300 ml of dicamba in a suicidal attempt and three hours later he was admitted hospital, complaining abdominal pain, nausea and vomiting. On admission his vital signs were normal and laboratory findings were not remarkable except metabolic acidosis in arterial blood gas analysis. Shortly after the admission endotracheal tube was inserted due to altered mental state and activated charcoal was given after performing gastric lavage. However, his vital signs became unstable 6hrs after the ingestion and mechanical ventilation was started with administration of inotropic agents. In spite of urine alkalization for rapid elimination of the absorbed dicamba, the metabolic acidosis was aggravated with concomitant rhabdomyolysis and acute renal failure, and he died 24 hrs after the ingestion.

응급센터를 내원한 대퇴골 골절 환자에서 골밀도와 생화학적 표지자들의 의의

이경미 ( Kyoung Mi Lee ),한승백 ( Seung Baik Han ),김준식 ( Jun Sig Kim ),백광제 ( Kwang Je Baek ),홍성빈 ( Seong Bin Hong ),문경호 ( Kyoung Ho Moon ),강준순 ( Joon Soon Kang ),윤승환 ( Seong Hwan Yoon ) 대한외상학회 2005 大韓外傷學會誌 Vol.18 No.2

Backgound: The most frequent fracture seen at the emergency department (ED) in the elderly is a femur fracture whereas they do not know the degree of osteoporosis. We analyzed the degree of osteoporosis in patients with femur fractures and compared patients with only femur fractures (FX) to patients with femur and vertebral fractures (VX) by examining the clinical features, the bone mineral density (BMD), and biochemical markers. Methods: From January 2004 to December 2004, we enrolled prospectively 30 femur fracture patients who visited the ED. The bone mineral densities of the lumbar spine and the femur were examined. Total calcium, phosphate, alkaline phosphatase, osteocalcin, and serum C-terminal telopeptide (s-CTx) were measured. The patients with femur fractures were divided into two subgroups according to the presence of vertebral fracture. Results: All BMDs of the FX group showed osteoporosis. The s-CTx levels were higher than normal. The patients in the FX with VX were older than those in the FX only group, and had lower BMDs. There were no significant differences in markers between the subgroups, but the incidence of trochanteric fractures was higher in FX with VX group than in the FX only group. Conclusion: Femur fractures in the elderly were associated with osteoporosis. In our study, despite a considerable difference in BMD between patients with femur fractures and those with femur fractures combined with vertebral fractures, there was no difference in biochemical markers on bone formation nor in the those of bone resorption. We will further investigate the biochemical markers and BMD in the population of osteoporotic fractures. So those indicators should be helpful for planning treatment and for prevention of FX in the elderly.

노인환자에서 전정신경염으로 오진된 후하소뇌동맥경색 1예

김준식(Jun-Sig Kim),한승백(Seung-Baik Han),신동운(Dong-Wun Shin),김훈(Hoon Kim),김강호(Kang-Ho Kim),백광제(Kwang-Je Baek) 대한임상노인의학회 2004 대한임상노인의학회지 Vol.5 No.2

노인 환자들이 가장 많이 호소하는 증상 중의 하나가 어지럼증, 이명, 청력손실 등이다. 저자들은 전정신경염으로 오진되었던 후하소뇌동맥경색 1예를 경험하여 보고하는 바이다. 67세 남자 환자가 어지럼증, 구토, 두통을 주소로 응급센터에 내원하여 신경학적인 검사로 뇌컴퓨터 단층촬영, 삼차원위상대조혈관 뇌전산화단층촬영(3D phase contrast angiography brain computed tomogram)을 시행하였으나 특이 사항은 발견되지 않았다. 그러나 환자는 증상이 심하여 전정신경염 진단하여 입원하였다. 입원 2일째에 환자는 기면상태로 의식변화가 발생하여 뇌자기공명영상 촬영을 시행하였는데 후하소뇌동맥경색이 발견되었다. 따라서 뇌압상승에 대한 치료를 하였으나 증가된 뇌압은 잘 조절이 되지 않았다. 입원 4일째 수두증이 발생하여 응급 뇌실외배액술(extraventriccular drainage)을 시행하였다. 적극적인 치료 후 환자의 의식은 명료해졌다. 저자들은 어지럼증을 호소하는 노인 환자에서 어지럼증의 원인이 확실하지 않을 경우에는 뇌컴퓨터 단층촬영이나 뇌자기공명영상 촬영을 하거나, 필요하면 두 가지 검사방법을 함께 시행하는 것이 중요할 것으로 생각된다. The elderly patients complaint most common frequently of dizziness, tinnitus, and hearing loss. We report a cerebellar infarction of posterior inferior cerebellar artery (PICA) that is misdiagnose as a vestibular neuritis. The 67 year-old patient complaints the vertigo, vomiting, and headache. The neuro-imaging study were performed. The non-contrast brain computed Tomogram (CT) and 3D phase contrast angiography brain computed tomogram (3D angio-CT) revealed that there was no specific findings. So He was admitted and the impression was vastibumar neuritis. The second hospital day, his menta status was changed, so Magnetic Resonance Image (MRI) was performed and the finding was cerebellar infarction of posterior inferior cerebellar arterty (PICA). After that, the increased intracranial pressure (ICP) was treated with mannitol. But increased ICP was not controled well. And the hydrocephalus was developed, so the extraventricular drainage was performed. After intensive treatment, his mental status become nearly alert. From this case, we think that the most important thing is the early correct differential diagnosis between psripheral and central origined vertigo. The final correct diagnosis was established with CT and/or MRI.

유기인산 화합물 중독으로 의심했던 벤타존 중독 1례

정현민 ( Hyun Min Jung ),김지혜 ( Ji Hye Kim ),한승백 ( Seung Baik Han ),백진휘 ( Jin Hui Paik ),김지윤 ( Ji Yoon Kim ),김준식 ( Jun Sig Kim ) 대한임상독성학회 2010 대한임상독성학회지 Vol.8 No.2

Basagran® is a herbicide that is widely used in the field and it acts by interfering with photosynthesis in plants. It consists of bentazone, 2-methyl-4-chloro phenoxyacetic acid (MCPA) and surfactants. Bentazone is commonly used, but poisoning due to Bentazone has not been previously reported in Korea. The patients with toxic effects of bentazone show mild to severe symptoms and various complications. We report here on a case of a woman who intentionally ingested 500 ml of Basagran® and she was discharged without complication. As soon as the patient visited the emergency department, we started to treat her as if she had organophosphate intoxication because of the cholinergic symptoms. We could not detect the bentazone in her serum and urine, and we could confirm Basagran® ingestion only after getting information from her husband. Bentazone poisoning may induce harmful complications like muscle rigidity, rhabdomyolysis, respiratory failure and cardiac arrest. A detailed history taking, an accurate analysis method and early conservative management will be helpful for patients with acute bentazone poisoning.

65세 이상 노인 약물 중독 환자의 예후 인자

김지윤 ( Ji Yoon Kim ),정현민 ( Hyun Min Jung ),김지혜 ( Ji Hye Kim ),한승백 ( Seung Baik Han ),김준식 ( Jun Sig Kim ),백진휘 ( Jin Hui Paik ) 대한임상독성학회 2011 대한임상독성학회지 Vol.9 No.2

Purpose: Incidents of suicide attempt and acute poisoning in the elderly population is rising. This study investigated the clinical nature of acute poisoning and differences between the survival and mortality groups in the elderly. Methods: We retrospectively investigated 325 patients with acute poisoning who visited the emergency department. Patients were divided into two groups, one survival and one death group. Information regarding patient sex, age, root cause of poisoning, time of year of poisoning, type of intoxicant, duration of time between intoxicant ingestion and arrival at the emergency department, total length of hospital stay, and any previous suicide attempts and subsequent hospitalization were collected. An initial Glasgow Coma Scale (GCS) and an initial and final Poison Severity Score (PSS) for each patient was calculated. Results: The survival rate for men was higher than for women in this study. The most common reason of drug intoxication was suicide, with accidental ingestion and substance abuse occurring in descending frequency. Seasonal factors were reflected in the data with the highest number of incidents occurring in spring and the lowest number in winter. Compared with the mortality group, the survival group had a lower initial PSS with a higher GCS. Conclusion: We conclude that being female, having suicide as a root cause, agrochemicals as an intoxicant, low initial Glasgow Coma Scale and high initial Poisoning Severity Score, are all associated with poor prognosis.

Durogesic 부착포로 인한 fentanyl 중독 1례

윤성현 ( Sung Hyun Yun ),정현민 ( Hyun Min Jung ),김지혜 ( Ji Hye Kim ),한승백 ( Seung Baik Han ),김준식 ( Jun Sig Kim ),백진휘 ( Jin Hui Paik ) 대한임상독성학회 2013 대한임상독성학회지 Vol.11 No.1

Fentanyl, a synthetic, highly selective opioidμ-receptor agonist, is 50 to 100 times more potent than morphine. The low molecular weight, high potency, great transdermal permeation rate and lipid solubility of fentanyl make it very suitable for transdermal administration. Durogesic is a novel matrix transdermal system providing continuous systemic delivery of fentanyl. In recently, there are many reports that misused or overused fentanyl transdermal patches result in severe intoxication of fentanyl. We present a case of fentanyl toxicity with misused durogesic transdermal patch and discuss the safe and appropriate application of the patches. In conclusion, fentanyl patches should be used in opioid tolerant patients and prescribed at the lowest possible dose and titrated upward as needed. All patients and their caregivers should be educated safe application of fentanyl patches and advised to avoid exposing the patches application site to direct external heat sources, such as heating pads, or electric blankets, heat lamps, sauna, hot tubs, and others. In addition, concomittant medications that affect fentanyl’s metabolism should be avoided.

에틸렌 글리콜 중독 2례

김재진 ( Jae Jin Kim ),윤성현 ( Sung Hyun Yun ),정현민 ( Hyun Min Jung ),김지혜 ( Ji Hye Kim ),한승백 ( Seung Baik Han ),김준식 ( Jun Sig Kim ),백진휘 ( Jin Hui Paik ) 대한임상독성학회 2013 대한임상독성학회지 Vol.11 No.1

Ethylene glycol poisoning is treated mainly by alcohol dehydrogenase inhibition therapy and hemodialysis. Early recognition and initiation of treatment is important because toxic metabolites increase over time by hepatic metabolism; however, there is no confirmative diagnostic tool in our clinical setting. Therefore, diagnosis is dependent on history, high anion gap acidosis, high osmolal gap, etc.. Diagnosis and treatment are delayed in cases where history taking is not possible, such as a mental changed patient. Authors report on two cases of ethylene glycol poisoning by contrasting clinical outcomes, demonstrating the importance of early diagnosis and treatment for achievement of a good outcome.

호흡기 증상 없이 발생한 뇌 지방색전증 1례

김형근 ( Hyung Geun Kim ),이경미 ( Kyung Mi Lee ),김지혜 ( Ji Hye Kim ),김준식 ( Jun Sig Kim ),한승백 ( Seung Baik Han ) 대한외상학회 2005 大韓外傷學會誌 Vol.18 No.2

Fat embolism syndrome is a collection of respiratory, neurological and cutaneous symptoms and signs associated with trauma and other disparate surgical and medical conditions. The incidence of clinical syndrome is low while the embolization of marrow fat appears to be an almost inevitable consequence of long bone fractures. The pathogenesis is a subject of conjecture and controversy. There are two theories which have gained acceptance(mechanical theory, biochemical theory). Onset of symptom is usually within 12 to 72 hours, but may manifest as early as 6 hours to as late as 10 days. The classic triad of fat embolism syndrome involves pulmonary changes, cerebral dysfunction and petechial rash. The cornerstone of treatment is preventing the stress response, hypovolemia and hypoxia and operative stabilization of fractures. Corticosteroid are the only drugs which have repeatedly shown a positive effect on the prevention and treatment of fat embolism syndrome. We report a case of post-traumatic fat embolism syndrome with severe cerebral involvement without respiratory distress. A 55 years old female had a traffic accident. She sustained pelvic bone fracture and both humerus fracture. Approximately 4 hours after the accident, mental status change developed without a focal neurologic deficits. She had no respiratory symptom and sign. Her brain MRI showed multiple cerebral fat embolism lesion. The patients received supportive treatment with corticosteroid, albumin. Her neurologic status stabilized over several days. After orthopedic surgery, she was discharged 62 days after admission.

덱스트로메토판과 클로르페니라민 과용으로 인한 세로토닌 증후군 2례

정광율 ( Kwang Yul Jung ),윤성현 ( Sung Hyun Yun ),정현민 ( Hyun Min Jung ),김지혜 ( Ji Hye Kim ),한승백 ( Seung Baik Han ),김준식 ( Jun Sig Kim ),백진휘 ( Jin Hui Paik ) 대한임상독성학회 2013 대한임상독성학회지 Vol.11 No.1

Dextromethorphan and chlorpeniramine are common ingredients of over-the-counter (OTC) cough pills. They are known to be safe when used alone, however, combination with other serotonergic drugs or use of an overdose can cause serotonergic toxicity. We report on a 43-year-old male and a 57-year-old female who ingested an overdose of antitussive drugs containing dextromethorphan and chlorpeniramine. They commonly presented with altered mentality and hyperreflexia on both upper and lower extremities. After conservative therapies, they were discharged with alert mentality. These cases are meaningful in that there are few cases of serotonin syndrome with an overdose of a combination of dextromethorphan and chlorpeniramine. Careful use with medication counseling for OTC cough pills is needed in order to prevent overdose of these ingredients.