03-01 정광율

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인택 학
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1 Original Article 대한소아응급의학회지 2015 제 2 권제 2 호 Pediatric Emergency Medicine Journal Volume 2, Number 2, December, 2015 경미한두부손상을가진 2 세미만소아환자의뇌전산화단층촬영결정에있어서 PECARN Rule 의유효성 정광율 한승백 이재성 김재진 서영주 1 김지혜 인하대학교의과대학응급의학교실, 1 의생명과학과 Availability of the Pediatric Emergency Care Applied Research Network (PECARN) rule for computed tomography scanning decision in children younger than 2 years with minor head injury Kwang Yul Jung, M.D., Seung Baik Han, M.D., Jae Sung Lee, M.D., Jae Jin Kim, M.D., Young Ju Suh, M.D. 1, Ji Hye Kim, M.D. Departments of Emergency Medicine and 1 Biomedical Science, College of Medicine, Inha University, Incheon, Korea Purpose: Traumatic brain injury is the most common cause of pediatric injury. Although computed tomography (CT) scan is an effective modality for screening fatal craniocerebral trauma, there is growing concern about radiation exposure associated with the consequent cancer particularly in children. We assessed validity of previous large prospective study named Pediatric Emergency Care Applied Research Network (PECARN) retrospectively to determine the necessity of CT scans for children younger than 2 years with minor head injury. Methods: We reviewed medical records of children younger than 2 years discharged from our emergency department with S00-09 diagnosis code of ICD-10 from August 2008 to December Patients who had only soft tissue injury without blunt trauma, did not CT scan take brain CT, whose head trauma was not mild, and who was uncertain to meet the rule were excluded. All included patients were divided into the PECARN rule positive group and negative group. Each group was compared by sensitivity, specificity, positive predictive value and negative predictive value to predict four outcomes of clinically important traumatic brain injury (citbi), abnormal CT findings, intracranial hemorrhage, and isolated simple skull fracture. Results: A total of 1,491 patients were included, 656 PECARN rule positive and 835 negative patients. There is statistical difference between PECARN rule positive and negative the 2 group for citbi (P < 0.001), abnormal CT findings (P < 0.001), intracranial hemorrhage (P < 0.001), and isolated simple skull fracture (P < 0.001) with high sensitivity (100.0%, 89.5%, 91.7%, 85.7%) and negative predictive value (100.0%, 99.3%, 99.6%, 99.6%). Conclusion: We confirmed that PECARN rule is a useful tool to determine the necessity of CT scan and reduce unnecessary CT scan for children younger than 2 years with minor head injury. Key Words: Craniocerebral Trauma; Head; Pediatrics; Tomography; Radiation Corresponding Author Ji Hye Kim Department of Emergency Medicine, College of Medicine, Inha University, 27 Inhang-ro, Jung-gu, Incheon 22332, Korea Tel: Fax: ziihye@inha.ac.kr 서론 외상성뇌손상은전세계적으로소아사망과장애의중요한원인중의하나이다 1). 신속한치료가필요한임상적 67

2 대한소아응급의학회지제 2 권제 2 호 2015 으로중요한외상성뇌손상 (clinically important traumatic brain injury) 을빨리진단하는것은사망률발생을낮추는데중요하다 1). 전산화단층촬영 (computed tomography, CT) 은외상성뇌손상을진단하는데가장좋은방법으로알려져있다 2). 그러나 CT 촬영에의한방사선노출이암발생의위험을높일수있고특히소아의경우성인에비해상대적으로더큰위험에노출될수있어서 CT 촬영결정에있어서신중함이요구된다 3,4). 그러나아주어린소아는증상을제대로표현할수는없고, 신경학적검사는제한적이다. 아주어린소아가중증뇌손상을확연히의심할수있는징후를보이는경우가아니면서, 경미한두부손상으로응급실에내원한경우, CT 를촬영할것인지결정하는것은쉬운일이아니다. 따라서경미한두부손상을가진소아의뇌 CT 촬영의결정기준을만들기위한여러가지연구들이이루어져왔으나아직확실히정립된결정기준이없는상태이다 2,5,6). 그중에서도 2세미만의소아만을위해별도의 CT 촬영기준을제시한것은 Pediatric Emergency Care Applied Research Network (PECARN) rule이유일하다. PECARN rule은 42,412명의경미한두부손상을가진소아들을 2세이상과 2세미만의연령으로구분하여각각에서임상적으로중요한외상성뇌손상을의심할수있는증상과징후를도출하여자체적인유효성을검증한대규모다기관연구를통해제시되었다 (Table 1) 1). 저자들은이연구에서 5년 4개월간일개대학병원응급의료센터에경미한두부손상으로내원한 2세미만의소아를대상으로임상적으로중요한외상성뇌손상및그외의외상성뇌손상을진단하는데에있어 PECARN rule의 유효성을후향적으로평가함으로써경미한두부손상을가진 2세미만소아들의 CT 촬영결정에도움이되고자하였다. 대상과방법 2009년 8월부터 2014년 12월까지일개대학병원응급의료센터에내원한소아중, 수상후내원까지의시간에관계없이퇴원시진단명이 ICD-10 (International Statistical Classification of Diseases and Related Health Problems 10th Revision) 진단기준에서두부손상에해당하는 S00-S09이었던모든 2세미만소아중머리부위에둔상없이연부조직손상만있던소아는제외하고, 의무기록을토대로응급실내원당시의증상, 수상기전및 CT 검사여부와판독소견, 입원한경우는입원후경과등을후향적으로조사하였다. 후향적인연구로시행된만큼기록미비로인한문제를최소화하기위해전자의무기록이도입된이후를연구기간으로설정하였다. 의무기록은한명의평가자가여러번검토하였고, 기록된증상의해석에의문이있을경우주관적인평가는지양하고다른저자들과논의를거쳐결정하였다. CT 촬영을시행하지않고퇴원하여예후를정확히알수없는소아는연구대상에서제외하였다. 내원당시의증상을분석하여경미한두부손상의정의, 즉외상후의식소실이 15분미만이고, Glasgow Coma Scale (GCS) 점수가 14점미만이거나의무기록상수상기전이없거나불분명하면서다른만족기준이없는소아는연구대상에서제외하였다 7). Table 1. Predictor variables of pediatric emergency care applied research network rule (age < 2 years) Severe mechanism of injury Motor vehicle crash with patient ejection, death of another passenger, or rollover Pedestrian/bicyclist without helmet struck by motorized vehicle Falls > 0.9 m Head struck by high impact object Loss of consciousness 5 sec Not acting normally per parent Glasgow Coma Scale < 15 Other signs of altered mental status Agitation Somnolence Repetitive questioning Slow response to verbal communication Palpable or unclear skull fracture Occipital, parietal or temporal scalp hematoma 68 Pediatric Emergency Medicine Journal

3 경미한두부손상을가진 2 세미만소아환자의뇌전산화단층촬영결정에있어서 PECARN Rule 의유효성 수상기전은 PECARN rule에서쓰인기준에따라 0.9 m 이상높이로추정되는높이에서의추락이나차대보행자사고를중증기전으로분류했고, 그외의단순넘어짐이나서있는물체에부딪침, 0.9 m 미만높이로추정되는높이에서의추락등은경증및중등도기전으로분류했다 1). CT 검사는영상의학과전문의에의해판독되었다. 2세미만의소아에적용되는 PECARN rule에따라 GCS 15점미만이거나보호자가보기에아이가평소와달리처지거나졸림, 심하게보채는등의행동변화를보인경우, 전두부가아닌머리부위의혈종 (non-frontal scalp hematoma), 5초이상의의식소실, 두개골의함몰골절, 중증외상기전중하나이상을만족했던경우와아닌경우로분류하였다. PECARN rule에서는 GCS 14 점과보호자가보기에아이의행동변화를따로구분하였으나실제적으로소아 GCS 점수의기준과행동변화는많은부분겹쳐서두기준을완전히분리하기힘들기때문에저자들은이두가지기준을위와같이하나로통합하였다. 행동변화나만졌을때두개골함몰골절여부자체에대해의무기록에따로언급이없는경우에는음성으로분류하였고, 혈종의위치의경우, 확실히전두부가아닌위치에대한기록이있는경우에만양성으로평가하였다. PECARN rule을만족하는군과아닌군을 CT에서이상소견을보인모든경우, 두개내출혈을보인모든경우, 두개내출혈없이두개골골절만보인경우 ( 이하단순두개골골절 ) 와임상적으로중요한외상성뇌손상의 4가지결과에대해분석하고, 각각의경우민감도, 특이도, 양성예측도, 음성예측도를구하였다. 전체연구대상중 PECARN rule을적어도하나이상만족해서연구대상에포함되었으나만족개수는정확히알수없었던소아를제외한환자군을대상으로 PECARN rule 만족개수에따른예후관련성도따로분석하였다. 이중임상적으로중요한외상성뇌손상은 PECARN rule에서쓰인정의에따라사망하거나외상성뇌손상으로인해수술을받은경우, 하루이상의기도삽관이필요했던경우, CT에서외상성두개내손상을보이면서계속되는의식저하나반복되는구토나경련이있어서 2일이상의병원입원을했던경우중에하나라도해당될때로하였다 7). 이때단순두개골골절은 CT상의외상성두개내손상으로포함하지않으며두개골두께이상의함몰이있는함몰골절은외상성두개내손상에포함했다 1). 통계분석프로그램은 SPSS ver (SPSS Inc., Chicago, IL, USA) 을이용하였으며, 이분형자료간의관련성검정을위해카이제곱검정 (chi-square test) 이나피셔의정확한검정 (Fisher exact test) 을사용하여분석하고, 순위형과이분형자료의관련성검정을위해서는카이제곱경향성검정 (chi-squared for trend test) 을사용하였으며, P < 0.05인경우통계학적으로유의한차이가있다고판정하였다. 결과 1. 일반적특징 2008 년 8 월부터 2014 년 12 월까지퇴원시진단명이 Fig. 1. Patient flow diagram. CT: computed tomography, PECARN: Pediatric Emergency Care Applied Research Network. Pediatric Emergency Medicine Journal 69

4 대한소아응급의학회지제 2 권제 2 호 2015 ICD-10에서 S00-S09인 2세미만의환자중머리부위둔상없이연부조직손상만있던경우를제외한숫자는모두 2,962명이었으며이가운데에경미한두부손상이아니었던 54명과 CT 검사를시행하지않은 1,402명을일차로제외한숫자는 1,506명이었다. 이를다시분석했을때의무기록상수상기전이기록되지않았거나수상기전을모르던소아는 23명이었는데, 수상기전외에다른 PECARN rule은하나도만족하지않은 15명을제외하고, 미상인수상기전외에하나이상을만족한소아 8명을포함한최종연구대상군은 1,491명이었다 (Fig. 1). 대상군의나이평균은 13.14±6.22개월이었으며이중 3개 Table 2. Demographic and clinical characteristics of patients Variable No. (%) Age (mo), mean±sd 13.14±6.22 < (4.5)0 3 1,424 (95.5) Sex (male:female) 863:628 (57.9:42.1) Mechanism of injury Severe (25.6) Non-severe 1,101 (73.8) Unknown (0.5)0 Symptom Glasgow Coma Scale (0.2)0 Vomit (6.9) (6.7) (0.3)0 Seizure (0.9)0 Location of scalp hematoma Frontal (4.1)0 Non-frontal (18.0) Abnormal activity Irritability (4.6)0 Decreased activity (5.3)0 Computed tomography findings Normal 1,434 (96.2) Intracranial hemorrhage (2.4)0 Isolated simple skull fracture (1.4)0 Outcome Discharge 1,450 Clinically important traumatic brain injury (0.8)0 Death 0 Neurosurgery (0.1)0 Intubation for 2 or more days 0 Admission of 2 nights or more for persistent neurologic symptoms (0.7)0 월이하는 67명이었다. 남아가 863명이었고여아가 628 명이었다. CT에서이상을보인경우는모두 57명으로전체의 3.8% 였고, 이중 36명 (63.2%) 이두개내출혈이있었으며 21명 (36.8%) 은두개내출혈없이단순두개골골절만있었다. 두개골골절없이 CT에서두개내출혈이있던환자는전체 36명중 6명 (16.7%), 두개골골절과출혈이같이동반된환자는 30명이었다. 전체의 0.8% 인 12명이임상적으로중요한외상성뇌손상이었는데이중세명은수술없이중환자실에서치료를받았으며, 응급수술이필요했던경우는한명이었고함몰골절과동반된외상성경막외출혈로인한것이었다. 사망한환자는없었다 (Table 2). 2. PECARN rule 만족여부와다양한결과와의비교 CT에서이상소견을보인경우는 PECARN rule을만족하는환자군이만족하지않는군에비해통계적으로의미있게많은것으로나타났다 (P < 0.001) (Table 3). 이를다시두개내출혈을보인경우와두개내출혈없이단순두개골골절만보인경우로나누어서분석하였고, 두경우모두 PECARN rule 만족군에서통계적으로유의하게많았다 (P < 0.001, P < 0.001) (Table 3). 임상적으로중요한외상성뇌손상의경우도 PECARN rule을만족하는군에서통계적으로의미있게더많은것으로나타났다 (P < 0.001) (Table 3). PECARN rule을만족하지않는소아들중임상적으로중요한외상성뇌손상이었던소아는한명도없었다. 3. PECARN rule 기준만족개수에따른예후비교 전체 PECARN rule 만족대상군 656명중의무기록에수상기전에대한기술이없거나수상기전을몰라서 PECARN rule 만족개수를정확히알수없었던소아 8 명을제외한숫자는 648명이었다. 이중 CT에서이상소견을보인모든경우, 두개내출혈을보인경우, 단순두개골골절만보인경우와임상적으로중요한외상성뇌손상을보인경우모두 PECARN rule을만족하는개수가많아질수록통계적으로의미있게많이나타났다 (P < 0.001, P < 0.001, P < 0.001, P < 0.001) (Table 4). 4. PECARN rule 의민감도, 특이도, 양성예측도, 음성예측도 PECARN rule 은임상적으로중요한외상성뇌손상에 70 Pediatric Emergency Medicine Journal

5 경미한두부손상을가진 2 세미만소아환자의뇌전산화단층촬영결정에있어서 PECARN Rule 의유효성 대하여 100% 의민감도와음성예측도를나타내었다. 두개내출혈에대해서도 90% 이상의비교적높은민감도를보 였으며모든그밖의모든예후에대해서 99% 이상의음성예측도를보였다 (Table 5). Table 3. Comparison of patients with PECARN rule positive and negative group for various outcomes Outcome PECARN (+) PECARN ( ) P value* Computed tomography finding < Normal Abnormal Intracranial hemorrhage < Positive Negative Isolated skull fracture < Positive Negative Clinically important traumatic brain injury < Positive Negative *P value of less than 0.05 is significant. This group dose not including intracranial hemorrhage. PECARN: Pediatric Emergency Care Applied Research Network. Table 4. Relation with the satisfied number of PECARN rule and various outcomes Positive no. of PECARN rule Positive Negative Total P value* Abnormal CT finding < Total Intracranial hemorrhage < Total Isolated simple skull fracture < Total citbi < Total *P value of less than 0.05 is significant. This number is not including intracranial hemorrhage. PECARN: Pediatric Emergency Care Applied Research Network, CT: computed tomography, citbi: clinically important traumatic brain injury. Pediatric Emergency Medicine Journal 71

6 대한소아응급의학회지제 2 권제 2 호 2015 Table 5. Statistical analysis for PECARN rule positive and negative group with various outcomes Variable Abnormal CT Intracranial Isolated simple Clinically important finding hemorrhage skull fracture traumatic brain injury Sensitivity 89.5 ( ) 91.7 ( ) 85.7 ( ) ( ) Specificity 57.8 ( ) 57.2 ( ) 57.8 ( ) 56.5 ( ) PPV 7.8 ( ) 5.0 ( )0 2.9 ( )0 1.8 ( )0 NPV 99.3 ( ) 99.6 ( ) 99.6 ( ) ( ) Values are presented as percentage (95% confidence interval). PECARN: Pediatric Emergency Care Applied Research Network, CT: computed tomography, PPV: positive predictive value, NPV: negative predictive value. 고찰 지난수십년간감염과영양불량에의한소아사망률은위생과영양의개선으로인해줄었지만외상에의한장애와사망률은지속적으로증가하고있으며우리나라에서역시두부손상은소아외상의가장흔한형태이다 8). 이중특히증상을말로표현할수없는 2세미만의영유아들은검사없이는이상유무를확인하기힘들고, 이상여부를놓치게되는경우치명적인합병증을일으킬수있다. 또한, 현재의의료사회적현실은단순골절이라도놓치는것은의료외적인문제의소지가될수있는상황이다. 이러한상황에서간편하고빠른진단도구로서의 CT 촬영은관찰을위한입원율을줄이고합병증을막는데큰역할을하고있다 6). 그러나최근연구에서방사선노출에의한암유발위험성이부각되고있고, 상대적으로몸의크기가작고장기를싸고있는연부조직이부족한영유아들의경우방사능에의한피해가성인보다크다 3,4,9,10). 게다가소아의 CT 촬영은종종진정제사용의위험과도연관이있어신중한 CT 촬영을위한기준이필요하다 11,12). 이때문에경미한두부손상을가진소아에서 CT 촬영결정을위한진단적기준을만들기위한여러가지연구가진행되었으나, 아직확실히정립된기준이없는가운데 PECARN에의해개발된 PECARN rule은다중기관에서대규모소아환자들을대상으로방법론적으로높은기준하에잘진행된연구로평가받고있다. 또한유일하게 2세미만의소아와 2세이상의소아를분리하여각각의기준을제시하였고예후와의비교에서도다른 CT decision rule보다우수하였다는후속연구들이있다 2,5,6,13). 기존의 PECARN rule에대한외부기관의유효성검증 (external validation) 연구가전향적으로시행되어 CT를찍지않고임상적인결과로만예후를판단한환자군이대부분포함된데에반하여, 본연구는후향적으로시행하여서결과를확실히알수있는 CT를찍은환자군만 포함시킨점이차별점이라고할수있겠다. 또한 PECARN rule의자체적인유효성검증은 2세미만의소아의경우 CT를찍지않은소아를포함하여 2,216명을대상으로이루어졌는데, 본연구는 CT를찍은 2세미만소아만 1,491 명을대상으로하는등규모면에서도다기관연구로이루어진 PECARN rule의유효성을외부에서검증하는데충분한대상수를갖추었다고할수있겠다. 임상적으로중요한외상성뇌손상이외에도여러가지결과와관련지어 PECARN rule의유효성을분석하였고, PECARN rule 만족개수에따른결과와의관련성도추가로분석한점도의미가있다고하겠다. PECARN rule이도출된연구에서는대상군을수상후 24시간이내에온경우만포함한것에비해본연구대상군 1,491명중에는 24시간경과후내원한 32명의환아도포함되었다. 이 32명의경우, PECARN rule의다른조건은문제가되지않으나내원당시의의식상태에대한경과시간의영향에대해우려가있을수있다. 그러나시간에따른영향의방향성은호전이나악화양쪽방향으로다나타날수있기때문에연구대상으로포함하였다. 실제로우리연구에서 32명의환아중 6명은수상후 24시간내에는별문제가없었으나도리어그후에처지거나졸려하는등의증상을보여외상과의관련성이걱정이되어온경우였다. 연구결과 PECARN rule을만족하는경우 CT에서이상을보이는경우가많은것으로나타났는데이를다시분석한결과두개내출혈과단순두개골골절모두관련성이높은것을알수있었다. 임상적으로중요한외상성뇌손상에대하여 PECARN rule은관련이있을뿐아니라 100% 의민감도 (95% confidence interval [CI], ) 와음성예측도 (95% CI, ), 특이도 56.5% (95% CI, ), 양성예측도 1.8% (95% CI, ) 로 PECARN rule의자체유효성검증연구결과 ( 각각순서대로 100.0%, 100.0%, 53.7%, 2.4%) 와거의유사하게나타났다. CT에서의이상소견과두개내 72 Pediatric Emergency Medicine Journal

7 경미한두부손상을가진 2 세미만소아환자의뇌전산화단층촬영결정에있어서 PECARN Rule 의유효성 출혈, 단순두개골골절모두 99% 이상의높은음성예측도를보인데반하여민감도는두개내출혈에서만 90% 이상이었다. 이는 CT를찍은환자중이상소견의유병률이 3.8% 로낮아서이에대한영향을감안하더라도이연구의주제가 CT 촬영결정에대한선별도구로서 PECARN rule의유효성을보는것이기때문에충분히의미있는결과라고생각할수있다. PECARN rule을적용했을경우 3명의두개내출혈환자를놓쳤겠으나, 그 3명중지속되는증상이나중환자실입원, 수술이필요한환자는없었다. PECARN rule을하나도만족하지않은 835명 (56.0%) 의 CT 촬영을감소시킬수있었을것이란점을생각할때기대효과에비해위험이크다고할수는없을것이다. PECARN rule을만족하는개수가늘어날경우 CT에서이상소견을보이는경향이나타났다. 그러므로 PECARN rule의여러기준을만족하는소아를볼때에는주의를기울일필요가있을것이다. 단순두개골골절만있는경우에대한 PECARN rule 의유효성은애초의연구에서전혀고려의대상으로하지않기도했지만, CT 촬영을하지않은소아도연구대상에포함된연구에서는확인자체가불가능하기도하다. 따라서실제관련성여부를확인해본연구가없기에저자들은확인해보았고, 중증두개내손상정도만큼의민감성은없는것으로보이나 PECARN rule 만족여부와관련성이있다는결과를볼수있었다. 이미단순방사선촬영에서골절을발견한경우에 CT 촬영을결정할수있는기준은달라질수있는지여부도앞으로고민해볼가치가있을것으로생각된다. 본연구의경우연구기간동안전체 2세미만의두부손상환자중 CT 촬영은 53.6% (1,560/2,908) 에서이루어졌음을확인할수있었다. 이는 PECARN rule이도출된연구에서 2세미만소아의 CT 검사율이 31.3%, 우리나라소아를대상으로이루어진소아두부손상에관한한역학연구에서 4세미만소아의 CT 검사율이 38.1% 로보고된 점에비하면월등히높았다 1,8). 3개월미만의소아의경우특히 CT 검사율이높다는연구가있는만큼, 3개월미만의소아비율이영향을미쳤을수있으나, 타연구에서는 3개월미만소아의비율을따로제시하지않아이에대한비교는할수없었다 14). 또한후향적인연구인만큼처음진단명을기준으로일차연구대상군을선별할때, 영상검사를하지않고귀가한소아가두부손상에대한진단명에서누락이된경우도있을수있다. 그러나이러한점들을감안하더라도이제까지특별한기준없이임상의사의판단에의존해서행해졌던우리의 CT 검사율이그동안지나치게높았던것은아닌지도저자들은반성하고고민할것이다. 본연구의제한점으로는후향적으로진행되어 CT 촬영을하지않았던소아환자의예후판정이어려워서 CT를찍지않은소아 1,402명이제외되고, 진단명이누락된소아가있을수있다는것이다. 제외된환자들의임상적인특징이연구대상군과달랐을가능성을완전히배제할수없고, 그결과이연구결과에영향을미쳤을수있기때문이다. 또한모두다른의사의소견으로작성된의무기록을바탕으로기록된증상에대해서다시 PECARN rule에따라정리하는과정에서의도치않게기록자와평가자간의증상해석에차이가있을수있다는점도완전히배제할수는없다. 그러나저자들은최대한이러한오류를줄이기위하여의무기록을면밀히검토하고, 객관적인시각을갖기위하여최선의노력을하였다. 요약하면, 2세미만의경미한소아두부손상환자에서 PECARN rule은임상적으로중요한외상성뇌손상과외상성두개내출혈을예측하는데에유용하므로, 2세미만의경미한두부손상환자의 CT 촬영기준으로고려되어야할것이며이로인하여불필요한 CT 검사를줄이는효과를기대할수있다. 감사의글 이논문은인하대학교지원에의하여연구되었습니다. REFERENCES 01. Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009;374: Pickering A, Harnan S, Fitzgerald P, Pandor A, Goodacre S. Clinical decision rules for children with minor head injury: a systematic review. Arch Dis Child 2011;96: Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 2012;380: Brenner DJ, Hall EJ. Computed tomography: an increasing source of radiation exposure. N Engl J Med 2007;357: Easter JS, Bakes K, Dhaliwal J, Miller M, Caruso E, Pediatric Emergency Medicine Journal 73

8 대한소아응급의학회지제 2 권제 2 호 2015 Haukoos JS. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Ann Emerg Med 2014;64: e Lyttle MD, Crowe L, Oakley E, Dunning J, Babl FE. Comparing CATCH, CHALICE and PECARN clinical decision rules for paediatric head injuries. Emerg Med J 2012;29: Schachar JL, Zampolin RL, Miller TS, Farinhas JM, Freeman K, Taragin BH. External validation of the New Orleans Criteria (NOC), the Canadian CT Head Rule (CCHR) and the National Emergency X-Radiography Utilization Study II (NEXUS II) for CT scanning in pediatric patients with minor head injury in a non-trauma center. Pediatr Radiol 2011;41: Kim HB, Kim DK, Kwak YH, Shin SD, Song KJ, Lee SC, et al. Epidemiology of traumatic head injury in Korean children. J Korean Med Sci 2012;27: Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 2001;176: Brenner DJ. Should we be concerned about the rapid increase in CT usage? Rev Environ Health 2010;25: Malviya S, Voepel-Lewis T, Eldevik OP, Rockwell DT, Wong JH, Tait AR. Sedation and general anaesthesia in children undergoing MRI and CT: adverse events and outcomes. Br J Anaesth 2000;84: Cote CJ, Alderfer RJ, Notterman DA, Fanta KB. Sedation disasters: adverse drug reports in pediatrics-fda,usp, and others. Anesthesiology 1995;83:A Bressan S, Romanato S, Mion T, Zanconato S, Da Dalt L. Implementation of adapted PECARN decision rule for children with minor head injury in the pediatric emergency department. Acad Emerg Med 2012;19: Bressan S, Steiner IP, Mion T, Berlese P, Romanato S, Da Dalt L. The Pediatric Emergency Care Applied Research Network intermediate-risk predictors were not associated with scanning decisions for minor head injuries. Acta Paediatr 2015;104: Pediatric Emergency Medicine Journal

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar