12-14-이동건

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1 대한외상학회지 Vol. 22, No. 1, June, 2009 원 저 단순외상팀활성화조건이중증외상환자의치료결과에미치는영향 연세대학교원주의과대학응급의학과 이동건 이강현 차경철 박경혜 최한주 현 황성오 Abstract Effectiveness of Simple Trauma Team Activation Criteria on Prognosis of Severe Trauma Patients Dong Keon Lee, M.D., Kang Hyun Lee, M.D., Kyoung Chul Cha, M.D., Kyoung Hye Park, M.D., Han Joo Choi, M.D., Hyun Kim, M.D., Sung Oh Hwang, M.D. Department of Emergency Medicine, Wonju College of Medicine, Yonsei University, Wonju, Korea Purpose: The goal of this study was to compare the outcome of the after trauma team (AfterTT) group to the before trauma team (BeforeTT) group. Methods: All trauma patients who visited to emergency room (ER) between July 1, 2006 and February 29, 2008 based on trauma registry, with systolic blood pressure (SBP) < 90 mmhg or GCS < 9 were included in this study. We compared the amount of packed RBC transfusion, the ER stay time, the ER visit to CT evaluation time, the ER visit to operation time, the length of ICU stay, the length of hospital admission and the survival discharge rate between the AfterTT group and the BeforeTT group. Patients with brain injuries had little chance of survival. Burn patients, who visited the ER 24 hours after injury and patients who were dead on arrival (DOA) were excluded from this study. Results: Total of 93 patients were included in this study: 42 in the AfterTT group and 51 in the BeforeTT group. The AfterTT group and the Before TT group showed no differences in Revised Trauma Score (RTS) and mean age. The amount of packed RBC transfusion was lower in the AfterTT group, but no statistically significant difference was noted (AfterTT 11±11units, BeforeTT 16±15units, p=0.136). The ER visit to operation time was shorter in the AfterTT group, but there were no statistically significant difference between the groups (AfterTT 251±223 minutes, BeforeTT 486±460 minutes, p=0.082). The length of ICU stay was shorter in the AfterTT group, but the difference was not statistically significant (AfterTT 11±12 days, Before TT 15±30 days, p=0.438). The length of Hospital admission was shorter in the AfterTT group (AfterTT 43±37 days, BeforeTT 68±70 days, p=0.032), but this difference was not statistically significant. Conclusion: Simple Trauma team activation criteria decreased the amount of packed RBC transfusion and the hospital admission duration. Hemodynamic instability (SBP < 90 mmhg) and decreased mental state (GCS <9) are good indices for activating the trauma team. (J Korean Soc Traumatol 2009;22:71-76) Key Words: Trauma team, Prognosis Address for Correspondence : Kang Hyun Lee, M.D., Ph.D. Department of Emergency Medicine, Wonju College of Medicine, Yonsei University 162 Ilsan-dong, Wonju-si, Gangwon-do, Korea Tel : , Fax : , ed119@yonsei.ac.kr 접수일 : 2009 년 4 월 29 일, 심사일 : 2009 년 5 월 18 일, 수정일 : 2009 년 5 월 29 일, 승인일 : 2009 년 6 월 9 일 71

2 대한외상학회지제 22 권제 1 호 I. 서론 II. 대상및방법 외상은 40세이하사망의가장많은원인을차지하고있으며, 특히교통사고에의한사망은전체사망원인중 4 위를차지할정도로많은비중을차지하고있다.(1) 외상환자는중증도에따라적정수준의병원으로신속히이송하고응급실내원초기에적극적소생술의시행과신속한평가및치료방침의결정을하는것이환자의예후를결정하는데매우중요하다.(2) 현재우리나라외상환자의예방가능한환자사망률은 39.6% 으로일본 (11.2%) 등의선진국에비해매우높은편이며응급실에서의각과의대응과수술결정의지연이예방가능한사망률을증가시키는요인이된다.(3) 따라서외상환자의치료과정에서불필요한시간지연을줄이고효율적이고적절한치료를위해외상환자치료체계가필요하였고, 외상팀의구성이이루어지게되었다.(4) 외상팀의구성이외상환자발생시효율적이고적절한치료를함으로써환자의예후를좋게할수있다는보고는이미알려진사실이며 (5-7), 미국이나유럽에서는이러한결과를바탕으로외상팀구성을위주로한외상치료체계를지속적으로확대하고있다.(8) 하지만, 국내에서는외상팀의활성화가적절히이루어지는병원이거의없을뿐만아니라, 대다수의병원에는외상팀의구성조차되어있지않아서외상환자치료의적절성을파악하기힘들고외상팀의활성화가외상환자치료에미치는영향에대한국내보고또한적은실정이다. 이에저자등은외상팀구성이중증외상환자의치료결과에미치는영향을분석하고향후외상환자치료의적절성을극대화하기위해필요한요소들에대해알아보고자한다. 1. 연구대상 2006년 7월부터 2008년 2월까지 16개월동안연세대학교원주의과대학원주기독병원응급실로내원한외상환자중외상팀활성조건을만족하는 93명의환자를대상으로후향적으로조사를시행하였다. 2. 연구방법외상팀조직전인 2006년 7월부터 2007년 4월까지와외상팀조직후인 2007년 5월부터 2008년 2월까지의두그룹으로나누어각그룹에서성별, 나이, 혈압, Glasgow Coma Scale (GCS), Revised Trauma Scale (RTS), Injury Severity Score (ISS), 수술까지걸린시간, 응급실재원시간, 응급실내원후컴퓨터전산화단층촬영까지소요된시간, 전체입원기간, 중환자실입원기간, 농축적혈구수혈량을비교하였다. 3. 외상팀활성화방법응급실로외상환자가내원시당직전공의에의해외상팀이활성화된다. 외상팀활성화는 OCS (Order Communication System) 입력시 trauma team activation 명령과함께간단한정보를입력함으로써시작된다. 이정보는즉시 SMS (Short Message Service) 로각외상팀구성원들에게전달된다. SMS전송후응급의학과수석전공의또는당직전문의에의해 ATLS (Advanced Trauma Life Support) 가이루어지며일차평가가끝난후응급수술이필요한환자인경우응급수술을시행하였다 (Fig. 1). 응 Fig. 1. Trauma team activation algorithm. 72

3 이동건외 : 단순외상팀활성화조건이중증외상환자의치료결과에미치는영향 급수술이필요하지않은환자는이차평가 (secondary survey) 후각해당과에유선으로추가연락을하였다. 4. 외상팀구성및활성화조건외상팀은외과, 흉부외과, 신경외과, 정형외과, 성형외과, 마취과의전문의와수석전공의로구성되었다. 외상팀의활성화적응증은혈역학적으로불안정하거나 ( 수축기혈압 90 mmhg 미만 ) 의식이저하 (GCS 9점미만 ) 된경우로하였다. 예방가능한사망이거의없는중증뇌손상환자, 화상환자, 손상후24시간이후내원환자, 내원시사망환자는제외하였다. 5. 통계분석외상환자치료에대한적정성분석은 Trauma and injury severity score(triss) 방법을사용하였고 Z-statistics 는사망자를기준으로계산하였다.(9) 통계학적분석은 Windows for SPSS 13.0의 t-test, Mann-Whitney test, chisquare test를이용하였고, p값이 0.05 미만일때유의한것으로판단하였다. III. 결과 1. 외상팀구성전후내원환자의특성 2006년 7월부터 2008년 2월까지연세대학교원주의과대학원주기독병원으로내원한외상환자중외상팀활성화의적응증을만족하는환자는총 93명이었으며외상팀구성전이 51명, 외상팀구성후가 42명이었다. 외상팀구성전환자군과외상팀구성후환자군의평균나이는각각 52± 52세와 42±47세로차이가없었고 (p=0.240), 내원시수축기혈압은각각 75±16 mmhg와 79±24 mmhg로역시유의한차이가없었다 (p=0.364). ISS는외상팀구성전이 24 ±12점, 외상팀구성후가 30±12점으로외상팀구성후가높았다 (p=0.025). GCS는외상팀구성전이 12±3점, 외상팀구성후가 12±4점으로차이가없었다 (p=0.379). RTS는외상팀구성전이 9.06±1.09점, 외상팀구성후가 8.90±1.41 점으로차이가없었다 (p=0.540). 평균동맥압도외상팀구성전이 51±17 mmhg, 외상팀구성후가 42±20 mmhg으로차이가없었다 (p=0.678) (Table 1). 분당호흡수는외상팀구성전이 20±2회, 외상팀구성후가 19±3회로유의한차이가없었고, 체온은외상팀구성전이 36±0C, 외상팀구성후가 35±1C 로역시차이가없었다. 2. 외상팀구성전후환자군의치료결과농축적혈구수혈을받은환자는외상팀구성전이 44예, 외상팀구성후가 35예로총수혈량은외상팀구성전 16± 15unit, 외상팀구성후 11±11unit으로감소하였으나통계학적으로유의한차이가없었다 (p=0.136). 응급실재원시간은외상팀구성전이 778±703분, 외상팀구성후가 983±635 분으로외상팀구성후응급실재원시간이통계적으로유의하게증가하였다 (p=0.045). 응급실내원후진단을위해컴퓨터전산화단층촬영을시행한환자는외상팀구성전이 41예, 외상팀구성후가 37예였으며, 컴퓨터전산화단층촬영까지소요된시간은외상팀구성전이 165±146분, 외상팀구성후가 195±187분으로통계적으로차이가없었다 (p=0.435). 내원 24시간내에응급수술을시행한경우는외상팀구성전이 17예, 외상팀구성후가 12예였으며, 수술까지걸린시간은외상팀구성전 486±460분 (n=17), 외상팀구성후 251±223분 Table 1. Demographic data *BeforeTT group AfterTT group p value Age 52±52 42± SBP (mmhg) 75±16 79± ISS 24±12 30± GCS 12±30 12± RTS 9.06± ± **MAP(mmHg) 51±17 42± * BeforeTT: before trauma team AfterTT: after trauma team SBP: systolic blood pressure ISS: Injury severity score GCS: Glasgow coma scale RTS: Revised trauma scale ** MAP: mean arterial pressure 73

4 대한외상학회지제 22 권제 1 호 (n=12) 으로외상팀구성후감소하는경향을보였으나, 통계학적으로유의하진않았다 (p=0.082). 중환자실에서입원치료를받은환자는외상팀구성전이 23예, 외상팀구성후가 28예였으며, 중환자실입원기간은외상팀구성전 15±30일, 외상팀구성후 11±12일로감소하였으나통계학적으로유의한차이를보이지않았다 (p=0.438). 전체입원기간은외상팀구성전 68±70일, 외상팀구성후 43±37일로유의한차이를보였다 (p=0.032). 치료후호전되어퇴원한환자는외상팀구성전이 44예, 외상팀구성후가 32예로두군간의유의한차이는없었다 (p=0.211) (Table 2). 사망한환자는외상팀구성전이 7예로골반골손상 3예, 혈복강 1예, 복막염 1예, 혈흉 1예, 신손상 1예였으며외상팀구성후가 8예로혈복강이 3예, 경추손상이 2예, 복막염 1예, 대동맥박리 1예, 혈기흉 1예였다. 외상환자의치료의적정성을평가하기위해산출한 Z-statistics는외상팀구성전에서 4.01, 외상팀구성후에는 4.30으로두군에서모두기대치보다높은사망률을나타냈다. IV. 고찰예방가능한외상사망의원인은치료시간의지연과의료진의판단착오가가장많은요인을차지한다.(3) 따라서이러한예방가능한사망률을감소시키기위해서는응급의료체계의효율적운영및외상팀의운영이무엇보다중요하다. 외상팀의운영은중증외상환자에서사망률뿐만아니라진단을위한검사시간, 수술결정시간, 응급실재원시간을줄이는데결정적인역할을한다.(10-11) 본연구에서도비록통계적으로유의한차이는없었으나, 외상팀구성후에농축적혈구수혈량, 수술까지걸린시간, 중환자실입원기간이감소하는경향을보였고전체입원기간은통계적으로유의하게감소하였다. 이러한결과는외상팀의운영이응급실에서해당각과에연락을하면서초래되는시간지연을감소시킴으로써환자의치료방침을결정하는시간을단축시킬뿐만아니라적절한 치료가빠른시간에이루어짐에따라환자의예후를좋게하는결과를나타낸것으로해석할수있다. 본연구에서는외상팀구성전보다외상팀구성후응급실재원시간이증가하였는데, 이러한결과는기존의보고와상반된것으로그원인은두군의환자구성의차이때문으로생각된다. 외상팀구성후군에서 ISS 점수가더높았는데, 이것은외상팀구성후환자들의중증도가더높았음을의미하며이로인해환자의초기소생술에걸린시간이증가하여응급실재원시간이증가한것으로생각된다. 또한외상팀구성후 24시간내에응급수술을시행한경우가외상팀구성전보다적은반면, 중환자실입원치료를한환자는더많아서중환자실입원을위해응급실에서대기하는시간이응급실재원시간에포함되어상대적으로응급실재원시간을증가시킨원인이라할수있다. 외상팀구성후응급실에서진단을위해소요된시간을알아보기위해전산화단층촬영까지소요된시간을비교하였으나, 두군에서차이가없었다. 이러한결과는이전에발표되었던논문과같은결과로서응급실재원시간을줄이고수술적처치를빠른시간내에시행하는것이환자의예후에더욱많은영향을끼친다는것을반영하는결과라할수있겠다.(10) 비록두군에서 Z-statistics는외상팀구성전에서 4.01, 외상팀구성후에는 4.30으로측정되어두군간의치료의적정성은차이가없는것으로나타났으나, 이러한결과는각군의환자구성이다르기때문으로생각된다. 앞서언급한것과같이외상팀구성후군에서 ISS가통계학적으로유의하게높았기때문에환자의중증도가더높았고이것이외상팀구성전과치료방법의차이가없음에도불구하고높은사망률을나타내는결과를초래하여 Z-statistics가상대적으로높게나오게되었을것으로추측된다. 하지만, 외상팀구성후에환자의중증도가더높았음에도치료의적정성에차이가없는결과역시외상팀의운영이환자예후에긍정적으로작용했다고생각할수있겠다. 외상팀활성화의적응증은국가와지역별로많은차이 Table 2. Outcome comparison between BeforeTT and AfterTT group *BeforeTT group AfterTT group p value Packed RBC transfusion (units) 16±15 11± ER visit to operation time (minutes) 486± ± ICU stay days (days) 15±30 11± Hospital admission duration (days) 68±79 43± Survival discharge rate (%) 86.3 (n=44) 76.2 (n=32) * BeforeTT: before trauma team AfterTT: after trauma team OR : operation room ER: emergency room ICU: intensive care unit 74

5 이동건외 : 단순외상팀활성화조건이중증외상환자의치료결과에미치는영향 를보인다.(4,10-19) 그러나, 대부분적응증의항목이너무많고복잡하여빠른시간내에적용하기어렵고적응증에따라환자를분류하였을경우과분류 (overtriage) 되는경향이있다. 외상팀의효율적인운영과예방가능한사망률을낮출수있는적절한과분류의비율은 25~50% 로알려져있다.(20-22) 이는외상팀의개념이성립된초기지침으로그개념을재정립할필요가있다. 따라서최근에는분류항목을줄이거나, 각각의항목을다시분석하여새로운적응증을제시하려는시도들이늘고있다.(23-24) 본연구에서는혈역학적불안정과 GCS만을외상팀활성화의적응증으로정하였는데, 이는적응증의간결화로외상팀을조기에활성화하고환자분류및초기처치시간을감소시켜치료의적절성을극대화하기위함이었다. 외상팀구성후의과분류비율또한 23%(8명 ) 로적정비율을보여환자분류에효과적이었다. 하지만, 이결과는과거개념에견주어적정성을평가한것으로앞으로외상팀활성화적응증의항목에대한다방면의연구를통해더욱정확하고간결한적응증의개발이필요하다고생각한다. 외상팀의필요성이대두된초기에는외과의사를중심으로외상팀이구성되었다.(4) 하지만, 최근에는외상팀의팀장이외과의사여야하는당위성에대한논란이많다. 이는비록외과의사가아니더라도응급의학과의사를비롯한여러분야의의사들이중증외상환자의소생술을충분히수행할수있으며진단을위한여러가지검사와장비가꾸준히개발됨으로써외상팀의팀원및팀장의구성에변화가생기고있기때문이다.(25-27) 최근의연구에서는외상팀의팀장은팀원들이환자를초기안정화하는데, 각자의역할을지정하고서로유기적으로역할을수행할수있도록지도하는것이며, 본인이집도의가되어수술을시행할필요는없다고정의하고있다.(27-28) 이번연구역시외상팀의구성은각과전문의또는수석전공의를팀원으로하고당직응급의학과전문의나응급의학과수석전공의가팀장이되어외상팀을활성화하는구조로이루어졌으며연구기간동안각팀원이유기적으로환자진료에참여하여환자의예후가기존보다좋아지는경향을보였다. 향후외상팀의개념이확대되어입원또는수술후의치료에도외상팀이적극개입하여최선의치료를시행한다면환자의예후는더욱좋아질것으로생각된다. 본연구는짧은시간에비교적적은수의환자를대상으로시행하여통계학적으로유의한차이를보이는특정지표나뚜렷한결과를도출해내지는못하였지만, 외상팀의구성이환자의예후를호전시키는데중요한요소로작용할것임을기대할수있었다. 추후외상팀의운영에긍정적으로작용하는요소들을꾸준히개발하고지속적으로임상자료를수집하여세밀하게분석한다면우리나라실정에맞는표준형외상팀및외상전문센터를제안할수 있을것으로기대한다. V. 결론 단순외상팀활성화조건에의한외상팀활성화는중증외상환자의농축적혈구수혈량, 수술까지걸린시간, 중환자실입원기간및전체입원기간을감소시킨다. 내원시혈역학적불안정 ( 수축기혈압 90 mmhg 미만 ) 과의식저하 (GCS 9점미만 ) 은외상팀을활성화하는좋은지표가된다. REFERENCES 01) Baker SP, O Neil B, Ginsburg MJ. The injury fact book. New York: Oxford university press, ) George CV, Demetrios Demetriades, William CS, Linda SC. Endpoints of resuscitation of critically injured patients: normal or supranormal? Ann Surg 2000;232: ) Teixeira PG, Inaba K, Hadjizacharia P, Brown C, Salim A, Rhee P, et al. Preventable or potentially preventable mortality at a mature trauma center. J Trauma 2007;63: ) Surgeons committee on trauma-american college of surgeons. Resources for optimal care of the injured patient. Chicago: IL. Bull Am Coll Surg, ) Cales RH. Trauma mortality in orange county: the effect of implementation of a regional trauma system. Ann Emerg Med 1984;13: ) Clemmer TP, Orne JF Jr, Thomas FO, Brooks KA. Outcome of critically injured patients treated at level I trauma center versus full-service community hospital. Crit Care Med 1985;13: ) Shackford SR, Hollingworth P, Cooper GF Eastman AB. The effect of regionalization upon the quality of trauma care as assessed by concurrent audit before and after institution of a trauma system. J Trauma 1986;26: ) Eastman AB. Blood in our streets: the status and evolution of trauma care systems. Arch Surg 1992;127: ) Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. J Trauma 1987;27: ) Petrie David, Lane Peter, FRCPC Stewart, Tanya Charyk. An evaluation of patient outcomes comparing trauma team activated versus trauma team not activated using TRISS analysis. J Trauma 1996;41: ) Mullins RJ, Veum-stone J, Helfand M, Zimmer-gembeck M, Hedges JR, Southard PA, et all. Outcome of hospitalized injured patients after institution of a trauma system in an urban area. JAMA 1994;271: ) Brooks AJ, Phipson M, Potgieter A, Koertzen H, 75

6 대한외상학회지제 22 권제 1 호 Boffard KD. Education of the trauma team: video evaluation of the compliance with universal barrier precautions. Eur J Surg 1999;165: ) Sugrue M, Seger M, Kerridge R, Sloane D, Deane S. A prospective study of the performance of the trauma team leader. J Trauma 1995;38: ) Esposito TJ, Offner PJ, Jurkovich GJ, Griffith J, Maier RV. Do prehospital trauma center triage criteria identify major trauma victims? Arch Surg 1995;130: ) Cook CH, Muscarella P, Praba AC, Melvin WS, Martin LC. Reducing overtriage without compromising outcomes in trauma patients. Arch Surg 2001;136: ) Long WB, Brachulis BL, Hynes GD. Accuracy and relationship of mechanism of injury, trauma score, and injury severity score in identifying major trauma. Am J Surg 1985;151: ) Koehler JJ, Baer LJ, Malafa SA, Meindertsma MS, Navitskas NR, Huizenga JE. Prehospital index: a scoring system for field triage of trauma victims. Ann Emerg Med 1986;15: ) Knopp R, Yanagi A, Kalsen G, Geide A, Doehring L. Mechanism of injury and anatomic injury as criteria for prehospital trauma triage. Ann Emerg Med 1988;17: ) Phillips JA, Buchman TG, Optimizing prehospital triage criteria for trauma team alerts. J Trauma 1993;34: ) Chen B, Mario RF, Green PE, Burney RE. Geographic variation in preventable deaths from motor vehicle crashes. J Trauma 1995;38: ) Kane G, Wheeler NC, Cook S, Englehardt R, Pavey B, Green K, et all. Impact of the Los angeles county trauma system on the survival of seriously injured patients. J Trauma 1992;32: ) Kreis DJ Jr, Fine EG, Gomez GA, Eckes J, Whitwell E, Byers PM. A prospective evaluation of field categorization of trauma patients. J Trauma 1988;28: ) Uleberg O, Vinjevoll OP, Erksson U, Aadahl P, Skogvoll E. Overtriage in trauma-what are the causes? Acta Anaesthesiol Scand 2007;51: ) Lehmann RK, Arthurs ZM, Cuadrado DG, Casey LE, Beekley AC, Martin MJ. after trauma team: simplified criteria safely reduces overtriage. Am J Surg 2007;193: ) Green SM. Is there evidence to support the need for routine surgeon presence on trauma patient arrival? Ann Emerg Med 2006;47: ) The trauma Association of Canada. Trauma system accreditation guidelines. Toronto, Canada: Trauma association of canada, ) Jennifer M, John M, David A. Trauma management outcomes associated with nonsurgeon versus surgeon trauma team leaders. Ann Emerg Med 2007;50: ) Adam Brooks, Tom Burton, James Williams, Peter Mahoney. Trauma team. Trauma 2001;3:

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<283732372D3733312920B4D9C3CAC1A120BCD2C7C1C6AEC4DCC5C3C6AEB7BBC1EEC0C720B3EBBEC8C0C720BDC3B7C2BAB8C1A4BFA120B4EBC7D120C0AFBFEBBCBA20C6F2B0A1283035292E687770> 대한안과학회지 제 49 권 제 5 호 2008 J Korean Ophthalmol Soc 49(5):727-731, 2008 DOI : 10.3341/jkos.2008.49.5.727 다초점 소프트콘택트렌즈의 노안의 시력보정에 대한 유용성 평가 김현경 1 김효명 2 정성근 1 가톨릭대학교 의과대학 성모병원 안과학교실 1, 고려대학교 의과대학 안암병원 안과학교실