07-06김형빈

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1 대한응급의학회지제 22 권제 3 호 Volume 22, Number 3, June, 2011 원 저 부산의일개대학병원에내원한익수손상환자의임상적특징및예후인자분석 부산대학교병원응급의학과, 양산부산대학교병원응급의학과 1 김형빈 한상균 이대섭 박성욱 정진우 염석란 박맹렬 1 민문기 1 김용인 1 류지호 1 Analysis of the Clinical Features and Prognostic Factors in Sea Water Drowning Patients Hyung Bin Kim, M.D., Sang Kyoon Han, M.D., Dae Sup Lee, M.D., Sung Wook Park, M.D., Jinwoo Jeong, M.D., Seok Ran Yeom, M.D., Maeng Real Park, M.D. 1, Moon Gi Min, M.D. 1, Yong In Kim, M.D. 1, Ji Ho Ryu, M.D. 1 Conclusion: Most drowning injuries occurred at night and in relatively young aged patients. CPR in the field did not result in good outcomes because of the longer immersion time. The death group had respiratory acidosis. Because the survival group did not show significant hypernatremia, isotonic saline as an initial fluid was thought to be appropriate. Drowning injuries occur differently based on geographic and social characteristics; therefore, local characteristics should be considered to establish preventive measures. Purpose: Drowning is a common preventable cause of accidental death. Although many studies about drowning injuries have been conducted, most are related to freshwater drowning. The aim of this study was to analyze the clinical features and prognostic factors in seawater drowning patients. Methods: This study was performed retrospectively with sea water drowning patients who visited the emergency department at Pusan National University Hospital between January 2005 and December Results: In total, 51 sea water drowning patients presented at the emergency department with a mean age of 48.65± years. The survival group included 42(82.4%) patients, and the death group was comprised of nine patients(17.6%). Fifteen patients arrested in the field, and cardiopulmonary resuscitation (CPR) was performed. Median immersion time in the death group was 15.0 minutes (range, 9.5~22.5 minutes). Among the death group, five patients had respiratory acidosis and nine showed pulmonary edema on a chest X-ray. Initial sodium level in the survival group was meq/l (range, ~ meq/l), but the level was normalized with isotonic saline. 책임저자 : 한상균부산광역시서구구덕로 305 부산대학교병원응급의학과 Tel: 051) , Fax: 051) hansoft@hanmail.net 접수일 : 2010년 12월 11일, 1차교정일 : 2010년 12월 26일게재승인일 : 2011년 1월 10일 242 Key Words: Drowning, Seawater, Prognosis Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea, Department of Emergency Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea 1 서 익수로인한사망은세계적으로줄어드는추세이지만여전히예방가능한사망률의가장큰원인을차지한다 1,2). 세계적으로익수로인한손상은연간약 2백만명이발생하며이중약15만명정도가사망한다 3). 우리나라통계청자료에의하면익수는 20대미만의연령층에서운수사고와자살에이어 3번째큰사망원인을차지하고있다 4). 통계청의사망통계자료및보험청구자료를기반으로국내에서발표된논문에따르면국내익수손상환자는주로여름에약 53% 가발생한다고한다 5). 수상레저스포츠의보급과더불어비교적젊은연령층에서익수로인한손상환자는증가하는추세이며따라서사망률을낮추기위한다양한예방대책뿐만아니라적극적인심폐소생술및병원내의치료에대한중요성이강조되고있다. 또한익수손상환자의예후를예측하기위한다양한연구도국내에서발표되고있으나대부분의논문들은민물에서발생한익수손상에대한연구이거나혹은피서철에집중된익수환자에대한연구이었다 6,7). 부산은연간약 210명의익수환자가발생하며또한중증도에따른분류에서도중증의환자비율이다른지역에비해비교적높다 5). 익수와관련된손상을분석 론

2 김형빈외 : 부산의일개대학병원에내원한익수손상환자의임상적특징및예후인자분석 / 243 하고이에따른예방대책을세우기위해선한지역의익수손상과관련된특징뿐만아니라다른지역의지리적, 역학적특징을고려해야한다고생각한다. 따라서본연구에서는부산대학교병원에내원한익수환자중해수에서발생한익수손상환자의특징및예후와관련된인자를분석하여익수와관련된손상을처치하는기초자료를제공하고자한다. 대상과방법본연구는 2005년 1월부터 2009년 12월까지부산대학교병원의응급의료센터에익수로내원한환자중해수에서발생한익수손상환자를의무기록을통해후향적으로분석하였다. 환자의나이, 성별, 발생시간, 발생장소, 추정침수시간, 수온, 익수와관련된원인을조사하였다. 수온은국립해양조사원의연안정지관측자료를참조하였다 8). 추정침수시간은현장에있던목격자의진술을통해조사하였다. 익수손상과관련된예후인자를알기위해현장에서의심정지여부, 심폐소생술시행여부및심폐소생술의주체, 심폐소생술을시행한시간을조사하였다. 또한응급실내원시심정지여부, 응급실에서심폐소생술시행여부를조사하였다. 응급실내원시초기체온, 혈중알코올농도, 동맥혈가스분석소견, 혈중포도당농도, 혈중백혈구수, 혈중전해질농도를조사하였다. 혈중알코올농도는 Roche/Hitachi Modular P analyzer (Roche, Indianapolis, USA) 을이용하였고, 환자의혈액검체에완충액과 NAD 를첨가하여전환된 NADH의흡광도를통한효소측정방법을이용하여측정하였다. 내원초기의흉부단순방사선촬영에서폐부종이나흡인성폐렴이있는경우는양성군으로정의하였으며폐부종이나흡인성폐렴이없고정상적인소견을보인경우는음성군으로정의하였다. 퇴원시생존한익수손상환자들을생존군, 사망한익수손상환자들을사망군으로정의하였다. 통계분석은 chi square test와 Mann-whitney test를이용하여분석하였고연속변수는중앙값과사분위수를이용하여표시하였다. 통계프로그램은 SPSS 16.0 for windows (SPSS Inc., Chicago, IL, USA) 을이용하였으며 p value가 0.05미만인경우를통계학적으로유의하다고정의하였다. 결과 1. 익수손상환자의일반적특징연구기간중부산대학교병원의응급의료센터에내원한 전체익수손상환자는모두 68명으로이중해수에서발생한익수손상환자는모두 51명 (75.0%) 이었다. 평균나이는 48.6세이었으며남자가 46명 (90.2%), 여자가 5명 (9.8%) 이었다. 발생장소는부둣가에서발생한경우가 49 명 (96.1%), 해수욕장에서발생한경우가 2명 (3.9%) 이었다. 발생원인은실수가 18명 (35.3%), 자살이 5명 (9.8%), 원인을모르는경우가 28명 (54.9%) 이었다. 월별발생건수는 8월에 9명 (19.6%), 6월에 7명 (13.7%) 으로주로여름에익수손상환자가발생하였으나 6월부터 8월까지총발생건수는모두 19명 (31.4%) 이었고 6월부터 8월까지의발생건수를제외한나머지발생건수는총 32명 (68.6%) 이었다 (Table 1). 2. 생존군과사망군사이의임상적특징에관한비교 총 51명의환자중에생존군은 42명 (82.4%), 사망군은 9명 (17.6%) 이었다. 생존군의나이는 49(37~60) 세, 사망군에서는 46(42~59) 세이었으나통계학적인유의성은없었다 (p=0.571). 생존군에서남자는 37명, 여자는 5 명이었고 9명의사망군은모두남자이었다. 생존군의추정침수시간은 5.0(2.0~10.0) 분, 사망군에서는 15.0 (9.5~22.5) 분이었으며통계학적인유의성이있었다 Table 1. General characteristics of drowning-related injury patients Patient data No. (%) Age (years), mean±(sd) 48.65±15.40 Sex Male (%) 46 (90.2) Female (%) 05 (09.8) Location Quayside (%) 49 (96.1) Beach (%) 02 (03.9) Cause Suicide (%) 05 (09.8) Mistake (%) 18 (35.3) Unknown (%) 28 (54.9) Monthly distribution January (%) 04 (07.8) February (%) 04 (07.8) March (%) 03 (05.9) April (%) 03 (05.9) May (%) 02 (03.9) June (%) 07 (13.7) July (%) 03 (05.9) August (%) 9 (17.6) September (%) 05 (09.8) November (%) 02 (03.9) December (%) 04 (07.8) SD: standard deviation

3 244 / 대한응급의학회지 : 제 22 권제 3 호 2011 (p<0.001). 생존군의익수당시의수온은 19.0(12.3~22.8) C, 사망군은 17.4(12.7~21.5) C 이었으며통계학적인유의성은없었다 (p=0.653). 구조당시현장에서심정지가발생한경우는모두 15명이었다. 이중생존한사람은 6명으로전체생존군 42명의 14.3% 였고, 사망한사람은 9명으로전체사망군 9명의 100.0% 를차지하였다. 현장에서목격자에의한심폐소생술을시행한경우는사망군중 1명 (11.1%) 이었으나 119 구급대원에의한심폐소생술은모두사례에서시행되었다. 현장에서의심폐소생술시간은생존군에서 8.0(4.0~17.0) 분이었고사망군에서 18.0(11.0~30.5) 분이었으나통계학적인유의성은없었다 (p=0.167). 응급실내원당시심정지가지속된경우는모두 13명이었다. 모두응급실에서심폐소생술을시행하였고이중 4 명이생존하여전체생존군 42명의 9.5% 였고 9명은소생되지않아전체사망군 9명의 100.0% 를차지하였다 (Table 2). 3. 생존군과사망군사이의초기검사실검사소견, 초기단순흉부방사선소견에관한비교 초기동맥혈가스검사에서 ph는생존군에서 7.29 (7.19~7.48), 사망군에서 7.04(6.89~7.18) 로통계학적으로유의성이있었으며 (p=0.010), PaO 2 는생존군에서 65.55(46.88~98.93)mmHg, 사망군에서 (11.58~62.85)mmHg로통계학적인유의성이있었다 (p=0.019). PaCO 2 는생존군에서 41.60(37.00~54.30) mmhg, 사망군에서 74.70(60.13~90.00)mmHg로통계학적인유의성이있었다 (p<0.001). 혈중전해질농도에서나트륨은생존군에서 (142.38~152.60)mEq/L, 사망군에서 (146.80~165.50)mEq/L로통계학적인유의성이있었으며 (p=0.026), 칼륨은생존군에서 3.80(3.38~4.30)mEq/L, 사망군에서 4.56(3.97~5.82) meq/l로통계학적인유의성이있었다 (p<0.001). 내원 Table 2. Comparison of clinical data between survival group and non-survival group, No (%) Survival group Non-survival group p-value Total 42 (82.4) 9 (017.6) Age (years), median (range) 49 (37~60)0. 46 (42~59)0. <0.990 Sex (male/female) 37/5 9/0 <0.571 Immersion time (min), median (range) 5.0 (2.0~10.0) 15.0 (9.5~22.5)0 <0.001 Water temperature ( C), median (range) 19.0 (12.3~22.8) 17.4 (12.7~21.5) <0.653 Cardiac arrest in the field (%) 06 (14.3) 9 (100.0) <0.001 CPR* performed in the field (%) 06 (14.3) 9 (100.0) <0.001 CPR duration in the field (min), median (range) 8.0 (4.0~17.0) 18.0 (11.0~30.5) <0.167 Cardiac arrest in the emergency department (%) 04 (09.5) 9 (100.0) <0.001 CPR performed in the emergency department (%) 04 (09.5) 9 (100.0) <0.001 * CPR: cardiopulmonary resuscitation Table 3. Comparison of laboratory data, simple chest X-ray between survival group and non-survival group, median (range) Survival group Non-survival group p-value ph 7.29 (7.19~7.48) 7.04 (6.89~7.18) <0.010 PaO 2 (mmhg) (46.88~98.98) (11.58~62.85) <0.019 PaCO 2 (mmhg) (37.00~54.30) (60.13~90.00) <0.001 Base excess (-10.60~-3.60) (-21.50~ -4.80) <0.223 HCO 3- (mm) (18.95~23.90) (12.38~26.55) <0.694 White blood cell (10 9 /L) (8.50~14.84) 7.57 (5.99~8.93) <0.061 Glucose (mg/dl) (142.38~152.60) (120.25~335.25) <0.257 Sodium (meq/l) (142.38~152.60) (146.80~165.50) <0.026 Potassium (meq/l) 3.80 (3.38~4.30) 4.56 (3.97~5.82) <0.001 Chloride (meq/l) (107.23~115.48) (111.60~128.30) <0.057 Alcohol (mg/dl) (205.73~313.53) (249.60~301.90) <0.725 Simple chest X-ray, n (%) <0.016 Positive group 25 (59.5) 9 (100.0) Negative group 14 (33.3) 0 (0.0) Not performed 03 (07.1) 0 (0.0)

4 김형빈외 : 부산의일개대학병원에내원한익수손상환자의임상적특징및예후인자분석 / 245 시초기단순흉부방사선촬영에서생존군에서양성군은 25명 (59.5%), 사망군은 9명 (100.0%) 로통계학적인유의성이있었다 (p=0.016)(table 3). 고찰국내익수손상의역학적특성에대해연구한한논문에의하면국내에서익수손상의발생률은인구 100만명당 55.73건으로전체손상발생건수의약 0.02% 를차지하며, 주로 10세이하의어린이와노년층에서높다고알려져있다. 초과사망비보정중증도계수를이용하여익수손상의중증도를연구한논문에서는 25점이상의중증익수손상발생율이 10세미만의소아에서높게나타났다 5). 또한익수손상은소아와청소년에서사망의주요한원인을차지한다 9). 특히소아에서익수손상이많이발생하는이유는소아에대한관리및감독의부재, 소아의수영능력부족, 수영장내의울타리설치부족등으로알려져있다 3). 따라서현재의익수손상에관한연구는주로소아의익수손상과관련된예후인자와예방대책에관한것이대부분이었다. 지역의지리학적, 사회경제적특징에따라익수와관련된위험인자는다양하게나타난다 10). 부산대학교병원은자갈치시장, 부산여객터미널, 부산항등이인접해있으며본연구에서 96.1% 가부둣가인근의바닷물에빠져내원하였다. 또한해수에서발생한익수손상환자의평균나이는 48.6세로 10세미만의소아에서는 1명도발생하지않았다. 한강변응급센터에내원한익수환자에대해연구한논문에서도 20대가가장많은비율을차지하였다 11). 익수손상의원인은연령대별로다양하게나타날수있는데소아에서는주로사고에의해발생하며, 청소년에서는주로술혹은의식을저하시킬수있는다른물질을섭취후에발생하고, 성인에서는자살이가장큰원인을차지한다 12). 본연구에서는자살이 9.8%, 부주의에의한실수로발생한경우가 35.3%, 원인을모르는경우가 54.9% 를차지하였다. 한강변응급센터에내원한익수환자에대한논문에서는자살이 62.6% 를차지하였다 11). 성인익수손상에대해연구한논문에서는수영미숙이가장많은원인을차지하였고, 음주복용이두번째원인을차지하였다 13). 익수로인한사망환자를연구한한논문에서는사고로인해익수가가장많이발생하였으며약물에대한분석에서에탄올이가장많이검출되었다 14). 본연구에서도실수로발생한 18건중음주한사람은 8명이었다. 비록생존군과사망군사이의혈중알코올농도에서는통계학적인유의성은없었으나지리적으로부산의부둣가주위의음식점주변에펜스가설치되어있지않는곳이많기때문에본연구에서는자살보다음주후실수로익수손상이더많았던것으로판단된다. 월별발생건수에서본연구에서는주로여름에많이발 생하였다. 이는국내의다른논문들과비슷한결과를보이고있다 5,11). 국내에서는여름철에물놀이나레포츠등수상레저활동의증가로인해익수손상이많이발생한다고알려져있다 15). 하지만본연구에서는여름철에해수욕장에서발생한경우는 1건 (5.3%) 이었고나머지 18건 (94.7%) 은부둣가에서발생하였다. 또한여름철에발생한 19건중 9건 (47.3%) 은오후 5시에서밤 12시사이에발생하였다. 요약하면국내의익수손상에관한논문과는다르게본연구에서는비교적경제적인생산능력이있는연령층에서주로밤에부둣가에서익수손상이발생하였다. 비록본연구가모든익수손상에대한대표성을보일수는없지만지역의지리학적, 사회적, 경제적특징에따라역학적특징이다르게나타날수있으므로다양한예방대책이필요할것으로사료되며특히부둣가주위의펜스설치와같은안전관리시설의강화가필요할것으로생각된다. 익수에의한손상의기전에있어가장중요한것은저산소증이다 16). 성대문연축과표면활성제의손실로인한폐고혈압, 단락등이저산소증의원인이되며이는이차적으로순환정지를일으켜사망에이르게한다 3). 따라서현장에서는심폐소생술을즉시시행해야하며이는환자의예후와밀접하게관련된다 2). 성인익수손상의임상적특성을연구한논문에서는현장에서심폐소생술을시행한 8명의환자에서 87.5% 가생존하였으며이중 80.6% 가신경학적손상없이회복되었다 13). 또한헬기를통해이송된익수환아에대한논문에서는심폐소생술을시행한 10명의환아에서모두생존하였으며주요한신경학적합병증이발생하지않았다 17). 우리나라에서는일반인심폐소생술시행율에대한정확한통계는알수없으나서울시민에서일반인의심폐소생술경험은 3.7% 에불과하다고알려져있다 18). 심정지를일으킨익수손상에관한연구에서는사망군에서목격자심폐소생술의비율이 17% 이었고이에대한원인으로써자살의비율이높았다고말하고있다 19). 본연구에서도사망한 9명중목격자심폐소생술을시행한경우는 1명 (11.1%) 이었다. 본연구에서는기존의연구와는다르게현장에서목격자에의한심폐소생술의비율이낮았으며이는환자의예후에있어좋지못한결과를보여주었다. Ballesteros 등 20) 에의하면물의온도와같은혼란변수를고려해야하지만 10분이상의침수시간은생존할가능성이없다고말하고있다. 본연구에서도사망군의침수시간은 15.0(9.5~22.5) 분이었다. 또한현장및응급실에서시행된심폐소생술로생존한 6명중주요한신경학적합병증이발생한 3명의침수시간은모두 10분이상이었다. 따라서본연구에서는익수손상의예후에있어현장에서의심폐소생술은매우중요하나침수시간이길수록환자의예후는좋지못한것으로나타났다. 일반적으로저온의수온에서발생한익수손상에서는저체온증이발생하고이로인하여뇌에서의산소요구량을

5 246 / 대한응급의학회지 : 제 22 권제 3 호 2011 감소시켜저산소성뇌손상의발생율을감소시킨다고알려져있다. 하지만심각한저체온증은오히려심근의전도를지연시키고부정맥을일으킬뿐만아니라잠수반사의효율성을떨어뜨릴수있다 3). Suominen 등 21) 의연구에서는익수손상에서저온의수온이실제로체온을냉각시키는속도를산출하기가어려우며수온보다는침수시간이익수환자의예후에더중요하다고말하고있다. 또한건강한성인남자를대상으로 10도의수온에서 90분간몸을담근후에직장체온을측정하였을경우 35 C 미만으로체온이내려가지않은연구결과도있었다 22). 본연구에서는생존군과사망군간의수온의차이는없었다. 비록중심체온을측정하지못하였으나생존군의수온이저체온증을유발시키기는어려우며사망군에서도수온보다는추정침수시간이예후를반영하는인자라고볼수있다. 초기에익수손상의예후를결정하는객관적인인자로써저체온, 심한산증, 동공확장, 지속적인심폐소생술여부등이알려져있다 1). 하지만익수손상의예후인자에대한연구는대부분소아와관련된것이었으며성인과관련된연구는부족한실정이다. 익수손상은호흡성산증과대사성산증을모두일으킬수있다. 28명의익수환아의예후에대한연구에서는호전군에서는 ph가 7.31이었으나사망군에서는 7.02로사망군에서유의하게낮았다 19). 바닷가에인접한응급의료센터에내원한익수환자에대한연구에서는악화군에서 ph가낮았고, PaCO 2 는높았으며 HCO 3- 는낮은결과를보였다 7). 본연구에서도사망군에서 ph가낮았고, PaCO 2 는높았으며, PaO 2 는낮았다. 하지만 HCO 3- 는생존군과사망군사이에유의한차이는없었으나사망군에서 24.30(12.38~26.55)mM로높게측정되었다. 58명의중증익수환자를대상으로초기사망원인에대한연구에서는호흡부전이나흡인성폐렴같은급성폐병변보다는심혈관계순환부전이초기생존기간과관계가있었다 6). 하지만기존의익수손상에대한연구결과와다르게본연구에서는사망군에서대사성산증보다호흡성산증소견을보이고있었다. 담수에의한익수손상에서는주로표면활성제의손실로인해폐포가파괴되면서폐부종을일으킨다. 하지만해수에의한익수손상에서는폐포에있는고장성의액체와모세혈관막사이의높은삼투압차로인하여폐부종을일으킨다. 높은삼투압은폐포로체액을증가시킴으로써폐포내단락을더욱더악화시킨다. 또한담수에의한익수손상보다해수에의한익수손상에서는폐포내출혈을증가시킨다 3). 본연구에서사망한 9명모두초기의단순흉부방사선촬영에서폐부종소견을보이고있으며이중 5명이호흡성산증을보였다. 따라서해수에의한익수손상에서는담수에의한익수손상보다초기에호흡부전에의한심정지가더많이발생한것으로볼수있으며이러한이유로다른연구와다르게본연구에서는심혈관계의순환부전에의한사망보다호흡부전에의 한사망이많았던것으로생각된다. 익수환자의예후를반영하는인자로써초기혈당치의증가는신경학적예후에유해한영향을미친다고알려져있다 20). 정등 23) 의연구에서는사망한 7명의초기혈당치가 ± mg/dl이었으며바닷가에인접한응급센터에내원한익수환자의예후인자에관한연구에서도 27 명의악화군에서초기혈당치가 270.6±84.0 mg/dl이었다 7). Ashwal 등 24) 은초기증가된혈당치가신경학적으로예후가좋지않다고하였으며 Muranyi 등 25) 의연구에서는고혈당이과산화물음이온을증가시켜뇌경색을더욱더악화시킨다고말하고있다. 비록초기의고혈당이익수환자의신경학적인예후에있어미치는기전은확실하게알려져있지는않으나혈당치를 100~ 140 mg/dl로엄격하게조절할것을권고하고있다 3). 비록본연구에서는통계학적으로의의는없었으나사망군에서생존군보다초기혈당치가증가해있었다. 익수손상에서는흡인된양과물의종류에따라전해질의변화가일어날수있으나실제로전해질의변화는드물게일어난다고알려져있다. 해수에의한익수손상에서는주로저혈량증에의해고나트륨혈증과고칼륨혈증등이발생할수있으나상당한양의해수를흡인하기전까지는생존자에게있어드물게발생한다. 따라서초기수액을선택함에있어전해질검사가나오기전까지저장액은피하라고권고하고있다 3). 본연구에서는사망군의혈중나트륨이 meq/l으로증가되어있었으며이는상당한양의해수를흡인한것으로생각된다. 또한생존군의혈중나트륨은 meq/l로증가되어있었으나초기수액으로써저장액을선택한경우는없었고추후에모두혈중나트륨이감소한추세를보이고있었다. 물론더많은연구가필요할것으로생각되지만해수에의한익수손상에서는사망환자를제외한생존환자에있어생명을위협할정도의혈중나트륨이증가된경우는드물기때문에초기수액으로써저장액보다는등장액이적절할것으로생각된다. 본연구의제한점으로는첫째후향적연구로중심체온을측정하지않았기때문에본연구의예후인자로써중심체온을반영하지못하였으며, 의무기록의미비로인해익수손상의원인을알수없는경우가 54.9% 이었다. 둘째단일기관에서이루어진연구이기때문에대상환자수가적으며해수에의한익수손상의전체적인특징을반영하지못하였다. 따라서향후전향적으로다기관연구가필요할것으로생각된다. 결론본연구에서는비교적젊은연령층에서주로밤에부둣가에서익수손상이발생하였다. 또한목격자에의한심폐

6 김형빈외 : 부산의일개대학병원에내원한익수손상환자의임상적특징및예후인자분석 / 247 소생술의비율이낮았고사망군의추정침수시간이길었기때문에좋지못한결과를보여주었다. 사망군은대사성산증보다호흡성산증에의한호흡부전에의해주로사망하였다. 또한생존군과사망군모두고나트륨혈증을보이지만생존군에서는생명을위협할만한고나트륨혈증은없었기때문에초기수액으로등장성용액이적절하다고생각된다. 익수손상은지역의지리학적, 사회적특징에따라다르게나타날수있으므로이에대한예방대책또한지역적특징이고려되어야한다고생각한다. 참고문헌 01. Marx JA, Hockberger RS, Walls RM. Rosen Emergency Medicine. Concepts and clinical practice. 7th ed. Philadelphia: Mosby; p American Heart Association American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 10.3: Drowning. Circulation 2005;112:IV Layon AJ, Modell JH. Drowning: Update Anesthesiology 2009;110: Available at: index.action?bmode=read&cd=s004001/. Accessed September 20, Kim K, Kim JY, Shin SD, Koh SB, Lee KJ, Im JS, et al. The Epidemiologic characteristics of drowning in Korea. J Korean Soc Emerg Med 2008;19: Wee JH, Lee MJ, Choi SP, Park KN. Clinical analysis of early death in severe drowning patients. J Korean Soc Emerg Med 2007;18: Jeong YT, Oh SH, Lee BS. Prognostic factors related to submerged patients treated at an emergency medical center near a beach. J Korean Soc Traumatology 2003;16: Available at: Accessed March 4, Peden M, McGee K, Sharma G. The injury chart book: a graphical overview of the global burden of injuries. Geneva, World Health Organization; p Fang Y, Dai L, Jaung Ms, Chen X, Yu S, Xiang H. Child drowning deaths in Xiamen city and suburbs, People s Republic of China, Injury Prevention 2007;13: Yang JH, Park KN, Choi SP, Kim YM, Kim SK. Clinical Analysis of Submerged Patients Treated at an Emergency Medical Center near the Han River. J Korean Soc Emerg Med 2001;12: Available at: mmwrhtml/mm5321a1.htm/. Accessed September 20, Jung CY, Cha SI, Jang SS, Lee SY, Lee JH, Son JW, et al. Clinical feature of submersion injury in adults. Tuberc Respir Dis 2003;55: Gornia JM, Jenkins AJ, Felo JA, Balraj E. Drug prevalence in drowning deaths in Cuyahoga county, Ohio: a tenyear retrospective study. Am J Forensic Med Pathol 2005; 26: Available at: Accessed September 20, Lavelle JM, Shaw KN. Near drowning is emergency department cardiopulmonary resuscitation or intensive care unit cerebral resuscitaion indicated? Crit Care Med 1993;21: Barbieri S, Feltracco P, Delantone M, Spagna A, Michieletto E, Bortolato A, et al. Helicopter rescue and prehospital care for drowning children: two summer season case studies. Minerva Anestesiol 2008;74: Seoul Metropolitan Government, Korean Association of Cardiopulmonary Resuscitation. A research for the education of cardiopulmonary resuscitation and publicity activities in Seoul. 1st ed.seoul: Korean Association of Cardiopulmonary Resuscitation; p Stefek G, Matej S, Dejan P. Comparison of the characteristics and outcome among patients suffering from out-ofhospital primary cardiac arrest and drowning victims in cardiac arrest. Int J Emerg Med 2009;2: Ballesteros MA, Gutiérrez-CM, Muñz P, Miñambres E. Prognostic factors and outcome after drowning in an adult population. Acta Anaesthesiol Scand 2009;53: Suominen P, Baillie C, Korpela R, Rautanen S, Ranta S, Olkkola KT. Impact of age, submersion time and water temperature on outcome in near-drowning. Resuscitation 2002;52: Tipton M, Eglin C, Gennser M, Golden F. Immersion deaths and deterioration in swimming performance in cold water. Lancet 1999;354: Jung DB, Kim CH, Kim YB, Cho SH, Cho NS, Yang ES, et al. Analysis of predictive factors in the assessment of the near drowning in children. J Korean Soc Emerg Med 1998;9: Ashwal S, Schneider S, Tomasi L, Thompson J. Prognostic implications of hyperglycemia and reduced cerebral blood flow in childhood near-drowning. Neurology 1990;40: Muranyi M, Li PA. Hyperglycemia increases superoxide production in the CA1 pyramidal neurons after global cerebral ischemia. Neuroscience Letters 2006;393:

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