응급수술을 시행한 응급의료센터 내원 외상 환자 분석; 응급의학과 진료는 외상환자에 대한 외과의 수술과 같은 전문적인 진료를 오히려 지연시키는가?

이경원 ( Kyung Won Lee ) 대한외상학회 2007 대한외상학회지 Vol.20 No.1

Purpose: Trauma surgery is not an official medical specialty in the Republic of Korea (South Korea). Thus, a trauma victim transported to an emergency room (ER) is resuscitated and surveyed by an intern, a resident, or an emergency physician (EP) at first. Currently an operative management is decreasing because of multiple factors. Nevertheless, trauma surgery is the key for some patients. Does the EP`s treatment in the ER delay the surgeon`s emergency operation? Methods: A retrospective study was performed for trauma victims who underwent trauma surgery from March 2004 to February 2005 in a local emergency center of Daegu-city. We reviewed the medical records and analyzed the trauma victim`s age, sex, cause of injury, method of transport, time from the trauma to the operation, EP`s treatment, surgical department, mortality, and injury severity score (ISS). Results: Of the 223 trauma victims included in this study, males were predominant (83.4%). The mean age was 37.98 years of age. The main Causes of trauma were trauma NOS (not otherwise specified) and motor vehicle accidents (MVA). The main methods of transport was privately owned automobile. The mean time from trauma to operation was 617.46 min. The mean ISS was 7.67. Trauma surgery with the EP`s treatment group included 40 trauma victims with higher ISS, and the time from trauma to operation was shorter than it was for the 183 trauma victims not in that group. Conclusion: The EP`s treatment of high-ISS multiple-injury trauma victims can shorten the time from trauma to trauma surgery and will help the surgical department treatment. In the trauma care system of the Republic of Korea, and increased role should be encouraged for emergency physician. (J Korean Soc Traumatol 2007;20:19-25)

2차와 3차 병원에서 외상 치료의 적정성 비교

홍석현 ( Suk Hyun Hong ),한갑수 ( Gap Su Han ),정상헌 ( Sang Hun Jung ),전정민 ( Chung Min Chun ),최성혁 ( Sung Hyuk Choi ),이성우 ( Sung Woo Lee ),홍윤식 ( Yun Sik Hong ) 대한외상학회 2005 대한외상학회지 Vol.18 No.1

본 연구에서는 응급처치 및 중환자 처치 능력의 확충이 중증 외상환자 치료에 미치는 영향을 알아보고자 두 기간 동안 대도시의 3차 병원과 중소도시의 2차 병원에서 외상치료의 적정성을 비교하였다. 응급 및 중환자 처치 능력의 확충 이후, 2차 병원은 타 병원으로의 전원 없이도 중증 외상 환자를 치료할 수 있게 되었으며, 생리학적 외상 치료 능력이 향상되어 보다 정확한 외상 치료가 가능해 졌다. 비록 특별하게 고안된 외상 센터가 아니라 하더라도, 잘 구축된 응급 의료 체계하에서 지역별로 응급 및 중 환자 처치 능력을 강화하면 외상 환자 치료 성적을 향상 시킬 수 있을 것이다. Background: This study compared the performance of trauma care in an urban and a suburban hospital before and after the enhancement of emergency and intensive care. Method: The medical records of patients who were admitted to the intensive care unit following trauma from 1994 to 1995 and from 2002 to 2003 were examined. The standardized W (Ws), the 95% confidence interval (CI) of the Ws, and the predicted survival rate (Ps) were calculated. During each period, each hospital`s actual survival rate was compared with the 95% CI of the Ps according to the revised trauma score (RTS) and injury severity score (ISS). Spell out RTS and ISS. Result: From 1994 to 1995, 225 and 121 records from the urban and the suburban hospitals were reviewed, respectively. The 95% CI`s of the Ws were -2.30 to 2.73 and -11.40 to -5.90, respectively. The actual survival rate of the suburban hospital was significantly lower than the predicted survival rate at all RTS. From 2002 to 2003, 315 and 268 records from the urban and the suburban hospitals were reviewed, respectively. The 95% CI`s of the Ws was -3.56 to 0.24 and -3.73 to 0.26, respectively. There was no difference between the actual survival rate and the predicted survival rate. Conclusion: An enlargement of the capacities of emergency and intensive care may improve the performance of trauma care at a small suburban hospital.

교통사고 예방 및 대책에 대한 워크샵

대한외상학회 대한외상학회 1989 大韓外傷學會誌 Vol.2 No.1

노인 외상 환자에 대한 분석 및 외상성 혈기흉의 임상양상

김정태 ( Jung Tae Kim ) 대한외상학회 2009 대한외상학회지 Vol.22 No.2

Purpose: This study was conducted to analyze chest-trauma patients and the old-aged patients with a traumatic hemopneumothorax. Methods: We reviewed the medical records of 101 chest-trauma patients admitted to the department of cardiovascular and thoracic surgery from June 1999 to November 2008. We evaluated the general characteristics of the chest-trauma patient, especially those of old-aged patients with a traumatic hemopneumothorax. Results: Rib fracture was observed in 99 of the cases, the location distribution was right: left =261: 255, with right being dominant. Rib fractures commonly involved the 4th and the 7th rib. The average number of rib fractures was 5.1, and the average number of rib fractures in the old-aged patients was significantly higher than that in the non-old-aged patients (p=0.04). There were 17 cases of a hemopnuemothorax in old-aged patients, 52 cases in non-old-aged patients. The blood loss through the chest tube for old-aged patients was significantly more than that for the non-old-aged patients, and the initial hemoglobin level was lower in the old-aged patients. Conclusion: Elderly trauma patients are more likely to die after trauma than other age groups. Even with relatively stable vital signs, invasive hemodynamic monitoring and intensive treatment are recommended. (J Korean Soc Traumatol 2009;22:161-66)

다발성 중증 외상 환자들의 치료에 대한 응급 외상팀 운영의 효과

이성화 ( Seong Hwa Lee ),조석주 ( Suck Joo Cho ),염석란 ( Seok Ran Yeom ),류지호 ( Ji Ho Ryu ),정진우 ( Jin Woo Jung ),한상균 ( Sang Kyun Han ),김용인 ( Yong In Kim ),박맹렬 ( Maeng Real Park ),김영대 ( Young Dae Kim ) 대한외상학회 2009 대한외상학회지 Vol.22 No.2

Purpose: We performed this study to determine how the emergency trauma team affects the treatment of patients with multiple severe trauma and to discuss the effect and the direction of the emergency trauma team`s management. Methods: We performed a retrospective analysis of 518 patients who visited our emergency department with severe trauma from August 2006 to July 2008. We divided the severe trauma patients into 2 groups: patients before and after trauma team management (Group 1 and Group 2). Then, we compared demographic characteristics, mechanisms of injury, and treatment outcomes (lengths of stay in the ED, admission ratio, and in-hospital mortality) between the 2 groups. In the same way, patients with multiple severe trauma were divided into 2 groups, that are patients before and after trauma team management (Group 3 and Group 4) and analyzed. Results: There was no significant difference, except mean age, between groups 1 and 2. In group 4 patients, compared to group 3 patients, the lengths of stay in the ED were lower (p value<0.001), and the admission ratio were higher (p value=0.017), but there was no significant difference in the in-hospital mortality between the groups 3 and 4. Conclusion: When patients with multiple severe trauma visit the ED, the emergency trauma team`s management can decrease the lengths of stay in the ED and increase the admission ratio, but does not produce a decrease in the in-hospital mortality rate. Further investigations of emergency trauma team management are needed to improve treatment outcomes for patients with multiple severe trauma. (J Korean Soc Traumatol 2009;22:172-78)

외상성 대량 간 손상 환자에서 수술 후 간 동맥 색전술의 유용성

차수현 ( Soo Hyun Cha ),정용식 ( Yong Sik Jung ),원제환 ( Jae Hwan Won ),김욱환 ( Wook Whan Kim ),왕희정 ( Hee Jung Wang ),김명욱 ( Myung Wook Kim ),이국종 ( Kug Jong Lee ) 대한외상학회 2006 대한외상학회지 Vol.19 No.1

Purpose: Acute liver failure after massive partial hepatectomy is critical condition with high mortality. To prevent postoperative liver failure from being induced by a massive partial hepatectomy, many doctors do a minimal resection on the single lobe of the liver that might cause postoperative bleeding from the remaining ruptured parenchyma. The objective of this study was to assess clinical experience with postoperative hepatic arterial embolization to control bleeding from the remaining ruptured liver during the postoperative period. Methods: This retrospective 4-year study was conducted from May 2002 to April 2006 and included consecutive patients who had sustained massive hepatic injuries and who had undergone a laparotomy, followed by postoperative hepatic arterial angiographic embolization to control bleeding. Data on the injury characteristics, the operative treatment and embolization, and the amount of transfused packed red cells (PRBC) were gathered and analyzed. In addition, data on the overall complications and survival rate were collected and analyzed. Results: Every case showed severe liver injury, higher liver injury scaling grade IV. Only ten cases involved a ruptured bilateral liver lobe. A lobectomy was done in 6 cases, a left lobectomy was done in 3 cases, and a primary suture closure of the liver was done in 2 cases. Suture closure was also done on the remaining ruptured liver parenchyma in cases of lobectomies. The postoperative hepatic arterial embolizations were done by using the super-selection technique. There were some cases of arterio-venous malformations and anomalous vessel branches. The average amount of transfused PRBC during 24 hours after embolization was 2.36±1.75, which statistically significantly lower than that before embolization. Among the 11 cases, 9 patients survived, and 2 died. There was no specific complications induced by the embolization. Conclusion: In cases of postoperative bleeding in severe hepatic injury, if there is still a large amount of bleeding, postoperative hepatic arterial embolization might be a good therapeutic option. (K Korean Soc Traumatol 2006;19:59-66)

외상으로 인한 상처의 치료에 있어서 선택적 항균제의 효과 및 적응증에 관한 연구

김재은 ( Jae Eun Kim ),서주현 ( Joo Hyun Suh ),최윤희 ( Yoon Hee Choi ),배현아 ( Hyun A Bae ),정진희 ( Jin Hee Jung ),어은경 ( Eun Kyung Eo ),전영진 ( Young Jin Cheon ),정구영 ( Koo Young Jung ) 대한외상학회 2007 대한외상학회지 Vol.20 No.1

Purpose: The primary goal of wound management is to avoid infection. Wounds in all patients presenting to the Emergency Department are contaminated with bacteria. Despite this, there is a low incidence of infection. Unfortunately, physicians continue to use antimicrobial agents indiscriminately. The authors intended to determine the effect of selective antimicrobial agents and the indications for appropriate antimicrobial agent use in traumatic simple wounds. Methods: This prospective study was performed from Jul. 2005 to Aug. 2005. A pilot study had been performed from Nov. 2003 to Jul. 2004 at the Ewha Woman`s University Mokdong Hospital. Structured data sheets were completed at the times of the patient`s visits to the Emergency Department and to the Outpatient Department for follow-up. Infection was determined at the time of follow-up. The indications of antimicrobial agent use are immunocompromised patients, wounds contaminated for 3 hours or longer, devitalized tissue, and extremity wounds except hand wounds caused by sharp objects. Results: The study enrolled 216 injured patients. The general characteristics of patients and wounds between the two groups were not significantly different. The antimicrobial agent use and infection rate of the pilot study were 227 cases (90.4%) and 10 cases (4.0%), and those of this study were 100 cases (46.3%) and 9 cases (4.1%). In this study, antibiotic use was reduced to almost half compared with the previous study, but the infection rate was similar (p<0.001). Conclusion: Rational use of antimicrobial agents in simple wounds reduced the use of antimicrobial agents in the Emergency Department without increasing the infection rate. (J Korean Soc Traumatol 2007;20:40-46)

추락과 동반된 강관파이프에 의한 흉-복강 관통상 1례

양봉준 ( Bong Jun Yang ),유재명 ( Jae Myung Yu ),김진승 ( Chin Seung Kim ),이광찬 ( Kwang Chan Lee ),고진철 ( Jin Chul Ko ) 대한외상학회 2006 대한외상학회지 Vol.19 No.2

An increase has been see in fall injuries at construction sites and in penetrating injuries by iron bars or pipes associated with the fall. In particular, a thoraco-abdominal penetrating injury had the worse prognosis, and multiple organ injury occurred because of blunt trauma associated with fall. Iron bars were the most common penetrating materials, and pipe penetrating injuries were uncommon. However, because the diameter of the pipes were large than those of the bars, penetrating injuries associated with pipes were more often fatal. A secondary thoraco-abdominal injury worsened the prognosis. We reported a case of a 33-year-old man with a thoraco-abdominal trauma secondary to a penetrating injury with a scaffolding pipe following a fall. (J Korean Soc Traumatol 2006;19:183-187)

다발성 외상 환자에서 발생되는 급성 호흡 곤란 증후군의 예측 인자로서 혈청 페리틴의 의의

지예섭 ( Yae Sub Ji ),김낙희 ( Nak Hee Kim ),정호근 ( Ho Geun Jung ),하동엽 ( Dong Yeup Ha ),정기훈 ( Ki Hoon Jung ) 대한외상학회 2007 대한외상학회지 Vol.20 No.2

Purpose: Clinically, acute respiratory distress syndrome (ARDS) occurs within 72 hours after acute exposure of risk factors. Because of its high fatality rate once ARDS progresses, early detection and management are essential to reduce the mortality rate. Accordingly, studies on early changes of ARDS were started, and serum ferritin, as well the as injury severity score (ISS), which has been addressed in previous studies, thought to be an early predictive indicator for ARDS Methods: From March 2003 to March 2005, we investigated 50 trauma patients who were admitted to the intensive care unit in Dongguk University Medical Center, Gyeongju. The patients were characterized according to age, sex, ISS, onset of ARDS, time onset of ARDS, serum ferritin level (posttraumatic 1st & 2nd day), amount of transfused blood, and death. Abdominal computed topography was performed as an early diagnostic tool to evaluate the onset of ARDS according to its diagnostic criteria. The serum ferritin was measured by using a VIDAS(R) Ferritin (bioMeriux, Marcy-1` Etoile, France) kit with an enzyme-linked fluorescent assay method. For statistical analysis, Windows SPSS 13.0 and MedCalc were used to confirm the probability of obtaining a predictive measure from the receiver operating characteristics (ROC) curve. Results: The ISS varied from 14 to 66 (mean: 33.8) whereas the onset of ARDS could be predicted with the score above 30 (sensitivity: 90.0%, specificity: 60.0%, p<0.05). On the posttraumatic 1st day, the serum ferritin levels were measured to be from 31 mg/dL to 1,200 mg/dL (mean: 456 mg/dL), and the onset of ARDS could be predicted when the value was over 340 mg/dL (sensitivity: 80.0%, specificity: 65.0%, p<0.05). On the posttraumatic 2nd day, the serum ferritin levels were measured to be from 73 mg/dL to 1,200 mg/dL (mean: 404 mg/dL), and the onset of ARDS could be predicted when the value was over 627 mg/dL (sensitivity: 60.0%, specificity: 92.5%, p<0.05). The serum ferritin levels and the ISS were significantly higher on the posttraumatic 1st and 2nd day in the ARDS group, suggesting that they are suitable indices predicting the onset of ARDS, however relationship between the serum ferritin levels and the ISS was not statistically significant. Conclusion: In this study, we discovered increasing serum ferritin levels in multiple- trauma patients on the posttraumatic 1st & 2nd day and concluded that both the serum ferritin level and the ISS were good predictors of ARDS. Although they do not show statistically significant relationship to each other, they can be used as independent predictive measures for ARDS. Since ARDS causes high mortality, further studies, including the types of surgery and the methods of anesthesia on a large number of patients are essential to predict the chance of ARDS earlier and to reduce the incidence of death. (J Korean Soc Traumatol 2007;20:57-64)

패혈증에서 Heat Shock Protein 70의 과도발현이 Inducible Nitric Oxide Synthase의 발현에 미치는 효과

이용근 ( Yong Keun Lee ),신효근 ( Hyo Keun Shin ),권운용 ( Woon Yong Kwon ),서길준 ( Gil Joon Suh ),윤여규 ( Yeo Kyu Youn ) 대한외상학회 2008 대한외상학회지 Vol.21 No.1

Purpose: The aim of this study was to evaluate the effect of overexpression of heat shock protein 70 (HSP70) on the expression of inducible nitric oxide synthase and on the concentration of nitric oxide and to determine the mechanism for the relationship between HSP70 and inducible nitric oxide synthase (iNOS) in sepsis. Methods: Experiments were performed on male Sprague-Dawley rats, and sepsis was induced by using cecal ligation and puncture (CLP). Glutamine (GLN) or saline was administered 1 h after initiation of sepsis. We acquired serum and lung tissues from the rats 12 h or 24 h after initiation of sepsis. We analyzed the concentration of nitric oxide, the expression of HSP70 in the lung, and the gene expression of iNOS in the lung. Results: In CLP+GLN, glutamine given after initiation of sepsis enhanced the expression of HSP70 in the lung at 12 h (CLP+GLN vs. CLP:: 47.19 ± 10.04 vs. 33.22 ± 8.28, p = 0.025) and 24 h (CLP+GLN vs. CLP: 47.06 ± 10.60 vs. 31.90 ± 4.83, p = 0.004). In CLP+GLN, glutamine attenuated the expression of iNOS mRNA in the lung at 12 h (CLP+GLN vs. CLP: 4167.17 ± 951.59 vs. 5513.73 ± 1051.60, p = 0.025) and 24 h (CLP+GLN vs. CLP: 9,437.65 ± 2,521.07 vs. 18,740.27 ± 8,241.20, p = 0.016) and reduced the concentration of nitric oxide in serum at 12 h (CLP+GLN vs. CLP: 0.86 ± 0.48 vs. 3.82 ± 2.53 umol/L, p = 0.016) and 24 h (CLP+GLN vs. CLP: 0.39 ± 0.25 vs. 1.85 ± 1.70 umol/L, p = 0.025). Conclusion: The overexpression of HSP70 induced by the administration of glutamine in sepsis attenuated the gene expression of iNOS and reduced the concentration of nitric oxide.