02-04 박상민

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1 elssn plssn Journal of Trauma and Injury Vol. 27, No. 3, September, 2014 Original Article 25 인승버스전복사고의탑승자손상분석 건국대학교충주병원응급의학과, 1 연세대학교원주의과대학응급의학교실, 2 교통안전공단자동차안전연구원, 3 순천향대학교부천병원응급의학과, 4 건국대학교충주병원흉부외과 박상민, 김상철, 이강현 1, 이재완 2, 전혁진, 김호중 3, 김진용, 곽영수, 이우성 4 - Abstract - Injury Analysis of a 25-passenger Bus Left-quarter Turn Rollover Accident Sang Min Park, M.D., Sang Chul Kim, M.D., Kang Hyun Lee, M.D. 1, Jae Wan Lee, Ph.D. 2, Hyuk Jin Jeon, EMT., Ho Jung Kim, M.D. 3, Jin Yong Kim, M.D., Young Soo Kwak, M.D., Woo Sung Lee, M.D. 4 Department of Emergency Medicine, School of Medicine, Konkuk University Chungju Hospital, Chungju, Korea 1 Department of Emergency Medicine, Wonju College of Medicine, Yonsei University, Wonju, Korea, 2 Passive Safety Research Office, Korea Automobile Testing & Research Institute, Korea Transportation Safety Authority, Hwaseong, Korea, 3 Department of Emergency Medicine, College of Medicine, Bucheon Hospital of Soonchunhyang University, Korea, 4 Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University Chungju Hospital, Chungju, Korea Purpose: Rollover motor vehicle crashes have a higher injury severity and fatality than other motor vehicle crash types. From a left-quarter turn rollover accident of 25-passenger bus, we intend to assess the injury of the occupant and the injury severities according to the occupants position. Methods: We carried out the 3 steps investigation of occupants interview, visiting the repair shop and using the police report. We analyzed injuries sustained by occupants, and compared injury severities considering column, row in occupant s position and passenger interaction Results: The rollover involved 14 passengers in the bus who were all old women except a man driver. The most common injury was in the upper extremity, with six occurrences being a left clavicle fracture. Major injuries including hemothorax and pneumothorax were diagnosed at left side of the occupant. In the comparison of injury severity among driver s column (left side), mid column and passengercolumn, ISS of passenger column was the highest (9.9±7.4, 8.8 ±5.5, and 10.3±4.0, respectively, p>0.05). The injury severity of multiple occupants by row was higher than that of single occupant (10.8 vs. 3, p<0.05). Conclusion: An occupant must fasten their seat belt to prevent an injury by passenger interaction in the left-quarter turn rollover accident of a bus. [ J Trauma Inj 2014;27:50-56 ] Key Words: Traffic accident, Automobiles, Injury severity score, Seat belts Address for Correspondence : Sang Chul Kim, M.D. Department of Emergency Medicine, School of Medicine, Konkuk University Chungju Hospital, 82 kukwondaero, Chungju-si, Chungchoengbuk-do , korea Tel : , Fax : , ooiarahan@nate.com Submitted : March 11, 2014 Revised : June 10, 2014 Accepted : July 8,

2 Sang Min Park, et al.: Injury Analysis of a 25-passenger Bus Left-quarter Turn Rollover Accident I. 서론국내도로교통공단의차량교통사고통계분석에의하면 2012년도에발생한차량전도 / 전복사고는교통사고총 223,656건에서 1,477건 (0.7%) 으로보고된다.(1) 미국의경우 2005년차량교통사고에서전복에의한사고가 4.1% 분율을차지했지만, 탑승자사망사고에서전복사고에의한것이 34.4% 이었다.(2) 국내에서는차량주행시단독사고에의해우측및좌측으로 90도뒤집힌경우를전도사고, 180도뒤집힌경우를전복사고로정의하는데, 외국에서는차량단독사고에의한것뿐아니라타차량혹은물체와충돌한후차체의횡축및종축을기준으로 1/4 이상회전한것을전복사고로정의한다.(3) 도로교통공단에서는사고유형별로차대사람, 차대차, 차량단독, 건널목사고로분류하고전도 / 전복은차량단독사고의한유형으로구분하고있는데, 차대차사고에서충돌후전복을모두포함한다면전복사고는훨씬더많을것으로추정된다. 차량전복사고의경우다른유형의사고에비해탑승자의손상중증도가더크고, 탑승자손상은척추손상이흔하고, 전복시지붕의찌그러진정도가탑승자의경추손상이나사망과관련이있다고알려져있다.(4-7) 탑승자의승차위치와손상과관련된연구에서는, 탑승자가안전벨트를착용한상황에서전복될때회전력이큰쪽승객, 즉운전석으로전복된다면조수석탑승자의사망위험이 1.6배더높고, Injury Severity Score (ISS) 10점이상의중증손상을입을위험이 5.4배더높다고한다.(8) 특히탑승자의안전벨트미착용상태에서는전복시탑승자가차량밖으로튕겨나가게된다면더큰손상을입게된다. 차량전복실험에서는차량이뒤집히는횟수가승객의손상중증도의예측요소로도알려져있다.(9) 미국의자동차사고국가분석통계및차량실험연구에비해국내의차량사고탑승자손상및현장환자중증도분류에대한연구가미진하고, 특히전복사고에서탑승자손상에관한연구는거의없어국내자료를토대로한전복사고의현장중증도분류타당성에대한근거를전혀마련할수없는실정이다. 따라서저자들은소형버스전복사고 1례에서발생한탑승자손상유형분석과문헌고찰을통해국내차량전복사고와관련된연구의기초를마련하고자한다. II. 대상및방법이연구는 25인승버스전복사고로 14명의환자를대상으로한것으로건국대충주병원임상윤리위원회의심의를통과하였다. 사고파악을위한조사는 3단계에걸쳐실시하였다. 사고조사의 1단계는환자가연구병원응급센터에내원하였을때응급센터소속교통사고조사원이운전자를대상으로인터뷰를실시하여나이, 키, 몸무게, 탑승위치, 안전벨트 착용여부를포함한사고정보를입수하였다. 2단계로사고차량정보는사고차량이보관되어있는공업사를방문하여차량사진촬영및내부조사를통해파악하였다. 사고차량사진은정면, 후면, 좌측면, 우측면을기본으로 8부위의외부사진을촬영하였다. 내부파손부위, 안전벨트착용여부의증거, 에어백전개유무를포함한내부사진도수집하였다. 3단계로경찰서에서제공한교통사고사실확인원을통해사고개요및사고기전에관한추가정보를입수하였다. 환자의손상분석은환자의진료가종료되는퇴원시점에의무기록을통해이루어졌다. 탑승자의손상중증도는 Glasgow coma scale (GCS), Revised trauma score (RTS), and ISS로나타내었고, 탑승자손상중증도의비교는탑승자좌석에따라, 차량이전복된운전석열좌석과가운데열좌석, 조수석열좌석으로나누어비교하였고, 탑승자상호간의충돌을고려하여동일행에서단독탑승자와복수탑승자의손상을비교하였다. 자료는 PASW 18 (IBM, Chicago, USA) 을이용하여탑승자나이, Body Mass Index (BMI), Maximal Abbreviated Injury Scale (MAIS), ISS의연속변수는평균및표준편차를이용하여나타내었고, 탑승좌석에따른손상중증도비교는두그룹간에는 Mann-Whitney U test, 세그룹간에는 Kruskal-Wallis test를이용하여나타내었고 p값이 0.05 미만을통계적유의성이있는것으로해석하였다. III. 결과 1. 사고개요초여름오전 6시35분께여주시가남면금당리중부내륙고속도로마산기점상행선 Km 지점노상에서양평방면 1차로로진행하던아반떼승용차가우측 2차로로진로를변경하는과정에서차량조작을제대로하지못해중심을잃고주행차로를이탈하며갓길철제보호난간을우측앞펜더 (fender) 부분으로부딪혔다. 이후좌측으로진행하다마침 1차로직진중이던소형버스우측뒷바퀴부분을좌측전면부분으로충격하여소형버스가중심을잃고 180도가량회전후 2차로상에운전석방향으로 90도전복되어발생한사고이다 (Fig. 1). 2. 사고차량조사사고차량은 4열 7행의좌석으로배치되어있고, 3열은간이석으로되어있는 25인승버스 (County Super, Hyundai, Korea) 로운전석측면쪽으로전복되면서고속도로에서주행하던차량속도에의해심하게미끄러져쓸린흔적이보였다. 전복당시충격에의해차량앞과뒷부분의지붕이일부 51

3 - Journal of Trauma and Injury Vol. 27, No. 3 - Fig. 1. Accident schematic diagram. Fig. 2. Exterior and interior photo of a 25-passenger bus. ((A) left side of vehicle, the scratches and broken windows shows the evidence of one quarter turn rollover accident. (B) the site of roof collapse lies at the rear of the bus cage) B 합입 (collapse) 되어있었고, 정면과후면운전석측면창문은모두파손된상태였다 (Fig. 2). 3. 환자의일반적특성과진단명및손상중증도비교버스탑승자는 14명으로운전자를제외하고는모두여자 이었고, 평균나이는 68.1세, 평균 BMI는 22.4이었다. 손상중증도에서평균 MAIS는 2.4점이었고, 평균 ISS는 9.6점이었다. 전복된방향인운전석쪽열의탑승자는 7명이었고, 둘째열은 3명, 셋째열은 1명, 조수석열은 3명이었다. 첫째행운전자와다섯째행운전석쪽탑승자는단독으로승차하였고그외행은여려명이승차하였는데, 제 3열의간이석 52

4 Sang Min Park, et al.: Injury Analysis of a 25-passenger Bus Left-quarter Turn Rollover Accident Table 1. Summary of injured occupants in the mini-bus at the time of the crash. Case Sex Age BMI* Position Seat Belt Air Bag Deployment GCS crts MAIS ISS 01 Male Driver s side Yes No Female Row 2 driver s side No No Female Row 2 passenger s side No No Female Row 3 driver s side No No Female Row 3 mid side No No Female Row 4 driver s side No No Female Row 4 mid side No No Female Row 4 passenger s side No No Female Row 5 driver s side No No Female Row 6 driver s side No No Female Row 6 passenger s side No No Female Row 7 driver s side No No Female Row 7 mid side No No Female Row 7 mid side No No Mean±SD 68.1± ± ± ± ± ±5.9 * BMI: body mass index GCS: Glasgow coma scale crts: coded revised trauma score MAIS: maximal abbreviated injury scale ISS: injury severity score SD: standard deviation Table 2. Injury sustained and diagnosis according to occupant position in the bus. Position Injury sustained Diagnosis Total Number Total Number Driver s side Mid side Passenger s side of diagnosis of subject (N=7) (N=4) (N=3) Head Cerebral concussion Scalp laceration 1 (L*) 1 6 Face Contusion Neck Cervical sprain Contusion, Lt. 2 (L) 2 Thorax Rib fracture 3 (L) 2 (L) 5 Pneumothorax 1 (L) 1 7 Hemothorax 1 (L) 1 (L) 2 Thoracic spine Compression fracture Abdomen Contusion 1 (L) 1 1 Lumbar spine Lumbar strain Compression fracture Shoulder sprain 3 (L, R, B ) 3 Shoulder contusion 2 (L) 1 (L) 3 Upper extremity Shoulder abrasion Hand tendon injury 1 (L) 1 11 Rotator cuff muscle rupture 1 (R) 1 Clavicle fracture 4 (L) 1 (L) 1 (L) 6 Calf contusion 1 (R) 1 Thigh contusion 1 (L) 1 (L) 2 Lower extremity Hip contusion 1 (B) 1 4 Hip abrasion 1 (B) 1 Pelvic fracture 1 (R) 1 * L: left R: right B: both 53

5 BMI < ± Journal of Trauma and Injury Vol. 27, No. 3 - Table 3. The comparison of injury severity score by body mass index, seat location and number of passenger in the same row. Variable Number of passengers ISS* p value > ±6.9 Seat-1 Driver s side ± The others side ±4.6 Seat-2 Driver s side ± Mid side ±5.5 Passenger s side ±4.0 Number of passenger in the same row Single ± Multiple ±5.6 * ISS: injury severity score BMI: body mass index p value by Mann-Whitney test and Kruskal-Wallis test 자리는탑승자가없었고제 3, 4, 7행은첫째와둘째열에나란히승차하였다. 운전자외에는사고당시안전벨트를착용하지않았다 (Table 1). 탑승자의손상부위는상지부위가 11 명으로가장많았고, 그외경부 9명, 흉부 7명, 두부및요추 6명순이었다. 특히좌측쇄골골절이 6명에서발생하였고, 늑골골절을동반한기흉및혈흉도모두좌측에서발생하였다 (Table 2). BMI에따른 ISS 비교에서 22이상군에서 ISS 가높았으나통계적으로유의한차이는없었다. 좌석배치에따른손상의비교에서전복이유발된운전석열탑승자의 ISS 평균은 9.9점, 중간석열은 8.8점, 조수석열은 10.3점으로조수석열의 ISS 평균이가장높았으나통계적으로유의한차이는없었고, 운전석열탑승자와그외좌석탑승자의비교도마찬가지로통계적유의한차이가없었다 ( 각각 9.9±7.4 vs 9.4±4.6, p=0.646). 좌석행기준으로단독탑승자와복수탑승자의손상중증도비교에서는 ISS 3점과 10.8±5.6점으로복수탑승자가중증도가높았다 (p<0.05, Table 3). IV. 고찰 3단계의조사과정을통한사고의분석에서평균 68세의고령, 안전벨트미착용탑승객 13명을포함한 14명이승차했던 25인승버스는타차량과충돌후운전석방향으로 90도전복 (one quarter turn) 되면서전복사고당시운전석열쪽으로의충격에의해탑승자는주로좌측부위손상이흔했고, 손상부위는상지가가장많았으며, 버스좌석의동일행에서복수로탑승한승객의손상중증도가높은것을알수있었다. 2012년소방방재청에서제작된 119 현장응급처치표준지침의중증외상환자현장분류제 3단계의손상기전에따른기준에서차량전복사고를고위험교통사고로분류하여전복사고로인한탑승자를중증외상환자로분류하여지역응급외상센터이상의의료기관으로이송하도록지침을마련하고있다.(10) 그러나일찍이미국 Centers for Disease Control and Prevention (CDC) 2006년 field triage의개정과정에서차량전복사고가제 3단계손상기전의위험요인에서제외되었다. 여러학문분야의전문가검토에의한개정이었지만, Champion 등은전복사고가비전복사고에비해사망위험이 15배이상높기때문에외상환자의현장분류에서전복사고가제외된것은적절치않다고주장하였다.(3) 차량전복사고에서탑승자의손상중등도는전복의종류및탑승자의안전벨트착용여부에따라다르다. 통학버스전복으로안전벨트미착용탑승자였던 9세에서 14세사이의학생 12명의손상에관한보고가있는데, 흔한손상부위는상지, 하지, 경부, 두부순으로저자들의연구결과와유사하게상지가가장흔한손상을보였고, 또한좌측전복사고로인해탑승자의손상이신체왼쪽부위, 두부, 경부, 견부에많이발생하였다.(11) 이통학버스전복사고에서는두부손상으로인한 1명의사망사례가있었는데전복당시에창문위금속재질에부딪힌것으로조사되었다. 전복횟수를 1/4 회전 ( 전도, one quarter turn), 1/2 회전 ( 뒤집힘, two quarter turn), 3/4 이상 ( three quarter turn) 의중증회전으로나눌때, 1/4 회전에서는사망률이낮고중증회전의경우사망률이더높다고한다.(12) 이는 1/2이상전복될때발생할수있는지붕의찌그러짐과도관련이있을것이다. 54

6 Sang Min Park, et al.: Injury Analysis of a 25-passenger Bus Left-quarter Turn Rollover Accident 버스전복이 1/4 회전이었지만탑승자의평균손상중증도계수가 9.6점으로높았던것은탑승자대부분이고령이었고, 운전자를제외한모든탑승자가안전벨트를착용하지않았기때문이다. 또다른버스전복사례로좌측 1/4 회전으로인한 46명의탑승자손상사고가있었는데, 탑승자의중증손상에의한진단명으로골반골절, 혈흉, 지주막하출혈의두부손상이있었고, 2명의사망자가발생하였던사고이었다. 이전복사례연구에서는 65세이상의고령의탑승자, 차량이전복된방향인좌측에위치한탑승자가좌측전복사고시중증손상을입을위험이더높은것으로판명되었다.(13) 차량전복사고의연구에서탑승자의체질량지수가높을수록경추손상및중증손상이높다고알려져있는데, 체질량지수가 30이상이면체질량지수가 25이하인탑승자에비해경추손상위험이 3.2배, 사망위험이 5.9배높다고한다.(7) 이연구에서도체질량지수에따른손상중증도가비례하는경향성은보였으나운전자를제외한모든탑승자들의체질량지수가 30이하이었고평균체질량지수가 22.4로낮아통계적으로유의한결과는보이지않았다. 차량사고에서안전벨트착용의중요성에대해서는잘알려져있는데, 전복사고시벨트를착용하지않은탑승자가중증손상발생률이 5배더높다.(4) 특히안전벨트미착용상태에서전복사고가발생하게되면옆좌석승객에게손상을가할가능성이발생한다. 이연구결과에서도같은좌석행에서단독탑승자의손상중증도가낮았고, 복수탑승자가있었던행의나란히앉은탑승자는우측탑승자에의한것으로추정되는신체오른쪽부위손상이있었다. 46명의버스전복사례에서도좌측으로전복되면서차량좌측좌석탑승자는차량내부충격에의해입은손상과더불어바로우측좌석탑승자에의해깔리면서발생한손상으로더심한손상이발생하였다.(13) Parentuau은차량전복실험을통한실험에서탑승자의두부손상은천장, pillar, 버스손잡이등의내부구조에의해발생하고, 흉부손상은운전대나의자, 바닥구조등에의해발생하는데, 안전벨트를장착하지않은상태에서는승객간의상호충돌에의해추가적인손상이발생할수있다고했다.(14) 따라서전복사고시안전벨트를착용하지않으면자신뿐아니라타인에게도손상을가할수있게되므로, 2012년 11월 24에개정된여객자동차운송사업법시행령의규정에따라광역급행형시내버스및시외버스탑승시에도반드시안전벨트를착용해야한다. 버스는탑승자가많을수록차량무게중심높이가증가하여정적안정성이낮아지게되어전복위험이높아진다.(15) 또한, 버스전복사고에서는버스의탑승인원에따라대량재해로연결될수있으므로현장중증도분류도고려해야한다. 안전벨트미착용으로인한차량에서튕겨난탑승자, 전복시원심력이더크게작용하는좌석, 차량전복시회전수및지붕의찌그러짐유무는전복사고에서중증손상과관련 있는요소로알려져있다.(8,9,16,17) 그리고, 안전벨트를착용하지않은상태에서는전복의방향에따른탑승자의손상차이와승객의상호작용에의한손상가중가능성도생각해야한다. 25인승버스전복사고로인한 14명의탑승자손상에대한분석결과를전복사고에관한이론으로일반화하기에는다소무리가있으나, 저자들의연구결과를바탕으로향후차량전복사고의국내역학적특성및현장환자중증도분류를위한위험요소파악을위한연구가진행되어야할것이다. V. 결론 25인승버스의운전석측 1/4 회전 (one quarter turn) 전복사고에서조수석열탑승자의손상중증도가높은경향을보였고, 상지손상이흔했으며안전벨트미착용에의한승객간상호작용에의해동일좌석행복수탑승자의손상중증도가더높았다. 버스전복사고에서탑승자상호간의충격에의한손상을줄이기위해전좌석안전벨트착용이반드시필요하다. REFERENCES 01) Available at do Accessed May ) Bidez MW, Cochran JE Jr, King D, Burke DS 3rd. Occupant dynamics in rollover crashes: influence of roof deformation and seat belt performance on probable spinal column injury. Ann Biomed Eng 2007; 35: ) Champion HR, Lombardo LV, Shair EK. The importance of vehicle rollover as a field triage criterion. J Trauma 2009; 67: ) Singleton M, Qin H, Luan J. Factors associated with higher levels of injury severity in occupants of motor vehicles that were severely damaged in traffic crashes in Kentucky, Traffic Inj Prev 2004; 5: ) O Connor P. Injury to the spinal cord in motor vehicle traffic crashes. Accid Anal Prev 2002; 34: ) O Connor PJ, Brown D. Relative risk of spinal cord injury in road crashes involving seriously injured occupants of light passenger vehicles. Accid Anal Prev 2006; 38: ) Funk JR, Cormier JM, Manoogian SJ. Comparison of risk factors for cervical spine, head, serious, and fatal injury in rollover crashes. Accid Anal Prev 2012; 45: ) Jehle D, Kuebler J, Auinger P. Risk of injury and fatality in single vehicle rollover crashes: danger for the front seat occupant in the outside arc. Acad Emerg Med 2007; 14: ) Digges K, Eigen A. Classification of rollovers according to crash severity. Annu Proc Assoc Adv Automot Med 2006; 50: ) Available at Common/retrieveResearchDetailPopup.do?research_id= Accessed May

7 - Journal of Trauma and Injury Vol. 27, No. 3-11) Lapner PC, Nguyen D, Letts M. Analysis of a school bus collision: mechanism of injury in the unrestrained child. Can J Surg 2003; 46: ) Matolcsy M. Lessons and Conclusions-Learned from the Analysis of Bus Rollover Accident Available at GRSG-84-inf04e.pdf Accessed May ) Chang WH, Guo HR, Lin HJ, Chang YH. Association between major injuries and seat locations in a motorcoach rollover accident. Accid Anal Prev 2006; 38: ) Parenteau CS, Viano DC, Shah M, Gopal M, Davies J, Nichols D, et al. Field relevance of a suite of rollover tests to real-world crashes and injuries. Accid Anal Prev 2003; 35: ) Kallan MJ, Jermakian JS. SUV rollover in single vehicle crashes and the influence of ESC and SSF. Ann Adv Automot Med 2008; 52: ) Parenteau, CS, Shah M. Driver injuries in US single-event rollovers. Society of Automotive Engineers Available at Accessed May ) Conroy C, Hoyt DB, Eastman AB, Erwin S, Pacyna S, Holbrook TL, et al. Rollover crashes: predicting serious injury based on occupant, vehicle, and crash characteristics. Accid Anal Prev 2006; 38:

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical