대한응급의학회지제 20 권제 1 호 Volume 20, Number 1, February, 2009 원 저 외상성두부손상환자의상급병원전원을위한이차중증도분류개발 서울대학교의과대학응급의학교실, 서울대학교보라매병원응급의학과 1 홍원표 김유진 신상도 정성구 서길준 송경준 1 Development of Secondary Triage Rules for Interfacility Transfer of Patients with Traumatic Brain Injury Won Pyo Hong, M.D., Yu Jin Kim, M.D., Sang Do Shin, M.D., Sung Koo Jung, M.D., Gil Joon Suh, M.D., Kyoung Jun Song, M.D. 1 Purpose: This study was aimed to develop secondary triage rule for decision of interfacility transfer to higher level of trauma center for patients with traumatic brain injury (TBI). Methods: In a prospective observational study from August 2006 to December 2007 conducted in an urban tertiary emergency department, data were obtained from patients more than 15 years old and with TBI. Primary outcome was defined as meaningful positive CT findings. Secondary outcome was defined as meaningful intervention. Non-adjusted univariated logistic regression model was derived from result of chi-square test and adjusted model was derived using stepwise selection manner. Hosman-Lemeshow test for the goodness of fit was used. Results: Total number of eligible patients with traumatic brain injury was 653. Primary outcome was positive in 103 patients and secondary outcome was positive in 42 patients. In univariate logistic regression, risk factors were age over 65(OR: 2.40), history of cerebrovascular disease(or: 7.08), fall over two meter(or: 6.28), pedestrian struck(or: 18.5), headache(or: 2.18), vomiting(or: 3.03), disorientation(or: 5.37), any evidence of open fracture(or: 24.03), Glasgow coma sacle less than 13(OR: 4.97), 책임저자 : 송경준서울특별시동작구신대방동 425 서울대학교보라매병원응급의학과 Tel: 02) 870-2661, Fax: 02) 831-0207 E-mail: drsong@snu.ac.kr 접수일 : 2008년 7월 22일, 1차교정일 : 2008년 8월 8일게재승인일 : 2008년 11월 4일 1 Racoon s eye sign (OR: 2.50). These 10 risk factors were statistically significant in adjusted model which was derived using stepwise selected manner. Hosman-Lemeshow test for the goodness of fit was used and chi-square was 1.307(p=0.86). This decision rule had a sensitivity of 93.48%, a specificity of 41.13%, and a negative predictive value of 97.32%. Conclusion: A sensitive clinical decision rule with high negative predictive value for detection of abnormal CT lesions which need transfer to higher level of trauma center was developed. Key Words: Traumatic brain injury, Transfer, Triage Department of Emergency Medicine, Seoul National University College of Medicine, Department of Emergency Medicine, Seoul National University Boramae Hospital 1 서 외상성두부손상은미국에서연간 140만명의외상성두부손상이보고되고있으며, 이중 5만명이사망하고, 23만명이입원하는등장애와사망의주요원인으로보고되고있다 1). 우리나라에서는연간 140만명의두부손상이보고되고있으며, 인구백만명당표준화발생율을 2만 8천여명, 표준화사망률은 177명으로보고되고있으며, 이러한손상의고위험군은주로 20대부터 50대사이에분포하고있어, 다른질환에비해실질적사회적비용이클것으로추정된다 2,3). 현재까지우리나라에서는외상분류체계가확립되어있지않으며, 또한외상환자중증도분류에관한지침도마련되어있지않다. 외상성두부손상의경우빠른시간이내에수술적치료를요하기도하며, 수상수시간이내에이차적손상이발생할수있어적절한의료기관으로의빠른후송에대한중증도지침이다른여타손상보다도시급한상황이라는것이이미외국에서는잘알려진바있다 4,5). American College of Surgeons Committee on 론
2/ 대한응급의학회지 : 제 20 권제 1 호 2009 Truma (ACS Committe) 에서는외상환자의일차중증도분류를위한 Field Triage decision scheme을 1999년제공하였다. 여기에서환자는생체적 (physiologic), 해부학적 (anatomic) 요인과사고기전 (mechanistic indicator) 과기저질환 (comorbid factors) 을기준으로분류하고있다 6). 또한이기준에따라중증도외상환자가응급실에도착시에외과의가대기하고있도록권하고있다. Steele 등 7) 은이러한 major resuscitation criteria의환자의경우에도착 1시간이내에수술을받을가능성의유의하게증가되는것을보임으로써중증외상환자의병원간전원에있어서선택적으로사용될수있음을제시하였다. 그러나 ACS Committe의권고는모든외상환자를대상으로한것으로두부손상에특이적이지않으며, 따라서두부손상환자에있어적용하는데한계를가지고있다. 또한 Level I~IV까지의외상체계 (trauma system) 를가지고있으며, 응급의료체계기반의일차중증도분류가활발한미국에비해, 우리나라의경우병원전단계에서의환자분류의어려움등으로인해, 일차내원병원에서의환자평가에따른이차중증도분류및적절한전원이더욱중요할수밖에없다 8). 본연구는외상성두부손상환자에서중환자실입원이나고급신경외과적처치가시행가능한상급병원으로의전원이필요한환자를효과적으로선별할수있도록하는전원환자중증도분류지침을개발하는것을목적으로하였다. 대상과방법 1. 연구대상의선정과자료수집본연구는 2006년 8월부터 2007년 12월까지일개권역응급의료센터로내원한 15세이상의외상성두부손상환자를대상으로하였다. 외상성두부손상환자의정의는국제질병분류제 10판 (International Classification of Disease 10th Edition, ICD-10) 의 S01.0~S04.0, S06.0~S07.9, S09.7~S09.9, T01.0, T02.0, T04.0, T06.0, T90.1~T90.9에해당하는코드가하나라도있는환자를연구의대상으로하였다. 타원에서전원된환자의경우초기진료정보부족으로제외하였으며, 진료결과가전원인경우최종진료결과에대하여확인할수없어제외하도록하였다. 또한의사의권고에반하여퇴원한환자 (discharge against medical advice) 와내원시사망한환자 (death on arrival) 도본연구에서제외하도록하였다. 자료수집은응급실기반손상감시체계를토대로이루어졌으며, 응급실기반손상감시체계의내용은, 손상감시항목으로손상외인에관한국제분류체계 (International Classification of External Causes of Injuries, ICECI) 에서제안한핵심자료체계 (Core dataset) 를기반으로하였다 9). 응급실기반손상감시체계의손상등록정보는환자성별, 나이, 기저질환등을포함한 6가지신상정보 (Demographic Appendix 1. Core dataset for ED-based in-depth injury surveillance system Variables Demographic findings Age Sex Drug intoxication Alcohol intoxication Coagulopathy Past medical history Hypertension Diabetes Tuberculosis Liver disease Cerebrovascular disease Cardiovascular disease Malignancy Injury intent Unintentional Self-inflicted Assultive Injury mechanism Motor vehjcle crash Motor vehicle collision Pedestrian struck Motorcycle collison Fall Collison Stab wound Burn Gun shot Asphyxia Drowning Intoxication Inappropriate energy Foreign body Vital sign Blood pressure Pulse rate Respiration rate Body temperature Glasgow coma scale Eye opening Verbal response Motor response
홍원표외 : 외상성두부손상환자의상급병원전원을위한이차중증도분류개발 / 3 findings), 3가지의손상의의도성 (Injury intent), 교통사고, 추락등의 11가지의손상기전 (injury mechanism) 을포함하고있으며, 환자의내원정보로는혈압, 맥박수를포함한 4가지생체징후 (Vital sign), 의식소실, 기억상실등을포함한 7개의증상및증후 (Symptoms and signs), 뇌척수액비루, 안와주위반상출혈등을포함한신체검진소견 (Physical examination), 동공반사및운동및감각등의신경학적손실 (Focal neurologic deficit) 이포함되어있다 (Appendix 1, 2). 2. 결과요인의평가 결과요인의평가는 Stiell 등 10) 이 2001년 The Canadian CT head rule 에서사용한기준을적용하여일차결과 (primary outcome) 로는전산화단층촬영상의의미있는이상소견이양성인경우로정의하였고이차결과 (secondary outcome) 는신경학적치료가필요한경우로정의하였다. 임상적으로중요한전산화단층촬영상의이상소견이라함은, 임상적으로신경학적이상이없는환자에있어서다 Appendix 2. Dataset for in-depth injury surveillance in Traumatic Brain Injury Symptom Loss of consciousness Amnesia Dizziness Headache Vomiting Disorientation Post traumatic seizure Signs Diplopia Burred vision Numbness on face CSF otorrhea Racoon eyes Palpable depressed skull Any evidence of open fracture Hemotympanum CSF rhinorrhea Battle s sign Hyphema Neurologic examination Pupil size Light reflex Motor power Sensory power Deep tendon reflex 음과같은전산화단층촬영양성소견은의미없는소견이라판단하였으며 (5 mm이하의단일뇌좌상, 1 mm 두께이하의고립된뇌기저막하출혈, 4 mm 두께이하의경막하출혈, 단독적인기뇌증 (Isolated pneumocephalus), 피부가열리지않은두개내부골판을포함하지않는함몰골절 (Closed depressed skull fracture not through the inner table), 이를제외한전산화단층촬영상의이상소견은임상적으로의미가있는것으로판단하였다. 이차결과에서언급된신경학적치료의필요성은 7일이내사망하였거나개두술 (craniotomy), 두개골함몰정위술 (elevation of skull fracture), 두개내압모니터링 (Intracranial pressure monitoring), 기관삽관 (intubation) 등의처치가필요했던환자로정의하였다. 3. 통계분석위험요인과 1차 2차결과요인간의관련성을 chisquare test로검정하여 p-value 0.1 이하의유의한인자들에대하여단변량로지스틱회귀분석을사용하여승산도 (odds ratio) 와 95% 신뢰구간 (95% CI) 를구하였으며 (non-adjusted model), 순차적선택방법을통하여다변량로지스틱회귀분석이이루어졌다 (adjusted model). 회귀분석을통한위험인자분석의적합도 (goodness of fit) 를확인하기위하여 Hosmer-lemeshow test를사용하였으며, 일차결과와이차결과에대한민감도와특이도및음성예측률과각각의 95% 신뢰구간을계산하였다. 결과 1. 연구대상의일반적특성 2006년 8월 1일부터 2007년 12월 31일까지 2400명의외상성두부손상환자가내원하였으며, 이중 15세이상은 1686명이었다. CT를시행하지않은 665명을제외한 1021명의환자가운데, 타병원에서전원온환자와타병원으로전원된환자, 내원시사망한환자 482명을제외한 653명의환자가최종적으로연구에포함되었으며, 이중임상적으로의미있는 CT 양성소견을보인일차결과양성환자는 103명 (15.77%), 신경외과적수술이나중환자실치료가필요한이차결과양성환자는 42명 (6.43%) 이었다 (Fig. 1). 평균연령은 47.2세 (±18.9) 였으며, 일차결과양성환자의평균연령은 55.4세 (±19.3). 이차결과양성환자의평균연령은 56.3세 (±19.5) 였다. 이중남자는 488명 (74.7%), 여자는 165명 (25.3%) 으로관찰되었으며과거력및손상의의도성, 손상기전의일반적특성은다음과같
4/ 대한응급의학회지 : 제 20 권제 1 호 2009 았다 (Table 1). 내원시생체징후, 환자가호소하는증상및신체검진소 견의일반적인특성은다음과같았다 (Table 1). 도를확인하기위하여시행한 Hosmer-lemeshow goodness of fit 검정결과 chi-square 값은 1.3068(p value=0.86) 으로적합하다고확인되었다. 2. 로지스틱회귀분석을통한위험인자의분석 3. 전원기준의선정 위험요인과결과요인간의관련성에대한카이스퀘어검정을통해 p value 0.1이하의 49개의위험인자들에대하여단변량로지스틱회귀분석을사용하였으며, 승산도의 95% 신뢰구간이 1이상인의미있다고판단된위험인자들로는, 65세이상의연령 (OR: 2.40, 95% CI: 1.48~3.84), 뇌졸중의과거력 (OR: 7.08, 95% CI: 2.64~19.34), 2미터이상의추락 (OR: 6.28, 95% CI: 2.39~16.53), 보행자교통사고 (OR: 18.5, 95% CI: 2.24~8.43), 두통 (OR: 2.18, 95% CI: 1.40~4.43), 구토 (OR: 3.03, 95%CI: 1.53~5.77), 지남력상실 (OR: 5.37, 95% CI: 2.94~9.78), 신체검진상두개의개방성골절 (OR: 24.03, 95% CI: 3.51~472.99), 글라스고우혼수척도 13점미만 (OR: 4.97, 95% CI: 2.80~8.75), 안와부반상출혈 (Racoon s eye) 의검진소견 (OR: 2.50, 95% CI: 1.06~5.46) 등 10가지였으며, 이들은순차적선택법을통한다변량로지스틱회귀분석에서도유의미한위험인자로확인되었다 (Table 2). 이러한로지스틱회귀분석의적합 로지스틱회귀분석결과유의미한 10가지의위험인자가운데하나라도양성이있는환자들을전원하였을때임상적으로이상이있는 CT소견이나올확률에대한민감도와특이도및음성예측률을계산하였으며, 이에대한민감도는 93.48%(95% CI: 13.83~99.04), 특이도는 41.13%(95% CI: 35.05~49.84), 음성예측률은 97.32%(95% CI, 35.05~99.04) 로높은민감도와음성예측률을가지는것이확인되었다. 또한이러한환자들이신경학적수술이나중환자실입원치료등을받을민감도는 100%(95% CI: 13.83~99.04), 특이도는 38.36%(95% CI: 35.05~49.84), 음성예측률은 100%(95% CI: 36.01~100) 로확인되었다 (Table 3). 고찰본연구에서는외상성두부손상환자들가운데전산화 Fig. 1. Flowchart of patient population used in analysis.
홍원표외 : 외상성두부손상환자의상급병원전원을위한이차중증도분류개발 / 5 단층촬영상임상적으로의미있는이상소견이예상되거나신경외과적처치가필요할것으로판단하여상급의료기관으로의전원이필요한환자를선별해내기위한 10가지위험인자를제시하였으며, 높은민감도와음성예측률을가지는것이확인되었다. 이러한 10가지위험인자가운데한가지라도가진환자의경우전산화단층촬영소견에대한전문적판단및난이도가높은신경외과적치료를위한상급의료기관으로의전원이권고된다. 하지만, 단일병원에서시행한연구의한계점, 적은표본수로인한한계점을가지고있으며, 또한회귀적분할알고리즘 (Recursive partioning algorithm) 같은통계적방법이아닌단순순차적선택법의결과만으로전원기준으로확립하기에는부족한면이있는것이사실이다. 또한, 많은일차병원이전산화단층촬영을시행할수있는우리나라의현실에서는그임상적의미가제한적일수있겠다. 본연구는미흡하나마외상성두부손상환자의병원간전원을위한이차중증도분류를위한지침마련에대한첫번째시도라는점에서큰의의를둘수있겠다. 현재까지의대부분의연구에서제기된경증두부손상환자의 CT 촬영필요성여부나중증두부손상환자의생존율에미치는인자들이이차중증도분류에의거한전원여부결정에도움이될수는있겠으나, 직접적으로전원기준을제시한연구는처음이며, 앞으로이러한이차중증도분류지침에대한내적및외적타당성평가가추후의연구에서필요하겠다. 외상성두부손상환자의중증도를평가하는데있어서현재까지전산화단층촬영상의두개내병변이나생존율에영향을미치는요인으로는, 연령, 약물남용, 혈액응고질환등의과거력과손상의의도성가운데폭행에의한경우, 손상기전가운데보행자교통사고와오토바이사고, 환자가호소하는증상가운데두통, 구토, 의식소실, 기억상실, 외 Table 1. Demographic findings of traumatic brain injury patients TBI patients Primary outcome Secondary outcome (N=653) positive (N=103) positive (N=42) N % N % N % Age, Year (±SD) 47.2 (±18.9) 55.4 (±19.3) 56.3 (±19.5) Age>=65 144 22.05 38 36.89 15 35.71 Sex Male 488 74.73 81 78.64 32 76.19 Female 165 25.27 22 21.36 10 23.81 Past medical history Hypertension 084 12.86 17 16.50 08 19.05 Diabetes 047 07.20 13 12.62 06 14.29 Tuberculosis 006 00.92 03 02.91 01 02.38 Liver disease 009 01.23 03 02.91 01 02.38 Cerebrovascular disease 017 02.60 09 08.74 04 09.52 Cardiac disease 029 04.44 07 06.80 05 11.90 Malignancy 021 03.22 06 05.83 03 07.14 Intoxication 149 22.82 14 13.59 03 07.14 Coagulopathy 004 00.61 02 01.94 01 02.38 Injury intent Unintentional injury 492 75.34 84 81.55 35 83.33 Assultive 134 20.52 13 12.62 03 07.14 Self-inflicted injury 005 00.77 01 00.97 01 02.38 Unknown 022 03.37 05 04.85 04 09.52 Mechanism of injury Motor vehicle crash 124 18.99 29 28.16 14 33.33 Motor vehicle collison 036 05.51 02 01.94 01 02.38 Pedestrian struck 046 07.04 19 18.45 11 26.19 Motorcycle collison 035 05.36 08 07.77 02 04.76 Others Fall 326 49.92 54 52.43 23 54.76 Collison 172 26.34 15 14.56 03 07.14 Others 031 04.74 05 04.85 02 04.76
6/ 대한응급의학회지 : 제 20 권제 1 호 2009 상후발작등이있으며, 환자의신체검진소견가운데는글라스고우혼수척도, 저혈압, 신경학적손실등이제시되어왔다 11-19). 2005년 Brain Trauma Foundation 에서는중증두부손상환자의초기예측인자로글라스고우혼수척도와연령, 동공의크기및대광반사, 90 mmhg이하의저혈압과전산화단층촬영상의이상소견을들고있다 11). 글라스고우혼수척도는현재까지도외상성두부손상환자의중증도를평가하는데있어서가장유용한도구가운데 하나이며 BTF에서발표한중증외상성두부손상환자의초기지표가운데에서도글라스고우혼수척도가감소함에비례하여예후가나쁜것으로알려져있다 11). 본연구에서도글라스고우혼수척도를 13점미만인환자들의일차결과요인에대한승산도 (OR) 는 3.187 (95% CI: 1.571~6.321), 이차결과요인에대한승산도 (OR) 는 7.427 (95% CI: 3.046~18.111) 로유의한위험인자로확인되었다. 연령이증가함에따라예후가나쁜것으로알려져있으나 10,12-15), 갑작스럽게위험성이증가하는뚜렷한나이는밝 Table 1. Demographic findings of traumatic brain injury patients (continuous) Vital Sign TBI patients Primary outcome Secondary outcome (N=653) positive (N=103) positive (N=42) Blood pressure < 90 009 01.38 03 02.91 03 05.66 Pulse rate <60 or >120 042 06.43 12 11.65 16 30.19 Respiration rate <8 or >30 009 01.38 06 05.83 13 24.53 Glasgow Coma Scale GCS < 13 070 10.72 30 29.13 32 60.38 GCS < 9 049 07.50 20 19.42 14 33.33 Pupil examination Pupil size 5 mm 013 01.99 08 07.77 06 14.29 Anisocoric pupil 012 01.84 07 06.80 04 09.52 No light reflex 012 01.84 08 08.74 08 19.05 Symptoms N=634 % N=96 % N=40 % Loss of conciousness 227 35.80 37 38.54 21 52.50 Amnesia 112 17.67 21 21.88 07 17.50 Dizziness 106 16.72 26 27.08 14 35.00 Headache 241 38.01 51 53.13 20 50.00 Vomiting 049 07.73 17 17.71 07 17.50 Disorientation 055 08.68 24 25.00 16 40.00 Post traumatic seizure 007 01.10 03 03.13 03 07.50 Signs N=621 % N=92 % N=38 % Diplopia 010 01.61 01 01.09 00 0 Burred vision 021 03.38 02 02.17 01 02.63 Numbness on face 007 01.13 02 02.17 01 02.63 CSF otorrhea 003 00.48 02 02.17 02 05.26 Racoon eyes 031 04.99 09 09.78 03 07.89 Palpable depressed skull 002 00.32 02 02.17 02 05.26 Any evidence of open fracture 005 00.81 04 04.34 03 07.89 Hemotympanum 004 00.64 02 02.17 01 02.63 CSF rhinorrhea 003 00.48 02 02.17 01 02.63 Battle s sign 001 00.16 01 01.09 01 02.63 Hyphema 014 02.26 00 0 00 0 EOM abnormality 012 01.93 00 0 00 0 Subconjunctival hemorrhage 023 03.70 03 03.26 02 05.26 Epistaxis 064 10.31 14 15.22 06 15.79 Any evidence of skull base fracture 036 05.80 11 11.97 04 10.53 SD: standard deviation, TBI: traumatic brain injury, GCS: Glasgow coma scale, EOM: extraocular movement, CSF: cerebrospinal fluid
홍원표외 : 외상성두부손상환자의상급병원전원을위한이차중증도분류개발 / 7 혀져있지않다. Arienta 등 13) 은경증두부손상환자의고위험인자가운데하나로 60세이상의연령을제시하였으며, Stiell 등 10) 의경우65세를위험인자로제시하였다. 본연구에서는 65세의환자의경우일차결과요인에대한승산도 (OR) 가 2.193(95%CI: 1.484~3.844), 이차결과요인에대한승산도 (OR) 는 1.834(95%CI: 0.744~ 6.977) 로확인되어, 65세이상의환자가 CT상유의한뇌손상을받을확률은유의하게증가하여여타의연구와같은결과를보여주었으나, 신경학적수술이나중환자실치료를받을확률은유의하게증가하지는않았다. 손상의의도성에따른분류가운데폭행 (assult) 의경우 Herad와 Kerstein 16) 의연구와 Jeret 등 14) 의경우두개내손상이의미있게증가하는것으로보고하고있으나, 본연구에서는의도적폭행이두개내손상및신경학적수술등을받을위험인자는아닌것으로확인되었다. 손상기전에따른분류로는 Brokzuck 12) 과 Jeret 등 14) 이보고한보행자교통사고의경우본연구에서도승산도 (OR) 가 5.086(95%CI, 2.341~10.836) 으로의미있는소견을보였으며, 오토바이사고의경우상관관계가관찰되지않았다. 손상기전가운데 Herad와 Kerstein 16) 이제시한총상 (gunshot wound) 의경우본연구에서는한명의환자가있었으며 CT상이상소견은관찰되었으나, 신경외과적수술이나중환자실치료는받지않았다. 손상의의도성및기전에따른분류는 Servadei 등 17) 이제시하였듯이국가마다사회문화적환경에따라손상의기전및중증도가다르므로우리나라의경우이에대한고려가필요할수있다. 신체활력징후가운데 Brain trauma foundation 에서발표한조기위험인자가운데하나로혈압 ( 수축기혈압 90 mmhg미만 ) 을들고있으며 18,19), 신체활력징후의이상소견의기준을본연구에서는수축기혈압 90 mmhg이상과맥박수 60회 ~120회, 호흡수 8회 ~30회를정상으로하였을때각각의일차결과양성에대한승산도 (OR) 가, 혈압의경우승산도 (OR) 0.503(95%CI: 0.039~6.464), 맥박수의승산도 (OR) 1.507(95%CI: 0.465~4.882), 호흡수의승산도 (OR) 0.658(95%CI: 0.044~9.791) 로유의있는결과는확인되지않았으며, 본연구에서는저산소증에대하여는분석하지못하였다. 환자의증상가운데두통및구토는외상성두부손상환자가호소하는흔한증상가운데하나이며, Lee 등 15) 은두통과구토가 GCS 15점인환자에있어서의미있게증가하는것을보인바있다. 본연구 Table 2. Multivariate logistic regression model for the primary and seconday outcome Primary outcome, Positive (n=92)* Secondary outcome, positive (n=38) Risk Factors Non-adjusted model Adjusted model Non-adjusted model Adjusted model n % OR 95%CI OR 95%CI n % OR 95%CI OR 95%CI Age over 65 38 36.9 02.401 (1.484~3.844)0 02.193 (1.216~3.899) 15 35.7 02.164 (1.063~4.256)0 01.834 (0.744~6.997)00 History of Cerebrovascualr disease 08 08.7 07.075 (2.635~19.344) 03.795 0(1.268~11.665) 04 09.5 05.167 (1.399~15.522) 03.598 (0.889~14.566)0 Fall over 2 m 09 09.8 06.277 (2.386~16.526) 06.656 0(2.019~21.330) 07 18.4 11.762 (4.086~32.042) 12.404 (3.173~48.489)0 Pedestrian struck 19 18.5 04.394 (2.243~8.428)0 05.086 0(2.341~10.836) 11 26.2 05.963 (2.572~13.010) 07.461 (2.710~20.541)0 Headache 51 53.1 02.184 (1.398~3.427)0 02.575 (1.534~4.381) 20 50.0 01.879 (0.971~3.661)0 03.010 (1.307~6.934)00 Vomiting 49 07.7 03.032 (1.533~5.772)0 02.458 (1.129~5.146) 07 17.5 02.483 (0.895~5.909)0 02.282 (0.746~6.977)00 Disorientation 24 25.0 05.366 (2.938~9.771)0 03.368 (1.640~6.757) 16 40.0 09.114 (4.344~18.773) 04.676 (1.794~12.187)0 Any evidence of open fracture 04 4.34 24.027 0(3.508~472.994) 19.01500(1.340~487.007) 03 7.89 24.943 0(4.013~194.034) 13.892 (0.669~288.585) GCS less than 13 30 29.1 04.972 (2.797~8.748)0 03.187 (1.571~6.321) 32 60.4 12.581 (6.191~25.701) 07.427 (3.046~18.111)0 Racoon s eye sign 09 09.8 02.504 (1.062~5.463)0 02.732 (1.014~6.793) 03 07.9 01.702 (0.394~5.116)0 01.416 (0.279~7.182)00 * Primary outcome was defined as abnormal CT lesions except: solitary contusion less than 5 mm in diameter; localised subarachnoid blood less than 1 mm thick; smear subdural hematoma less than 4 mm thick; isolated pneumocephaly, or closed depressed skull fracture not through the inner table Secondary outcome was need for neurological intervention as either death within 7 days or the need for any of following procedures withi in 7 days: craniotomy, elevation of skull fracture, intracranial pressure monitoring, or intubation for brain injury Each risk factor in non-adjusted model was selected on the basis of the result of chi-square test and adjusted model was derived using stepwise selection manner Hosmer-Lemeshow test for the goodness of fit was used and chi-square was 1.307 (p=0.86)
8/ 대한응급의학회지 : 제 20 권제 1 호 2009 Table 3. Sensitivity, specificity and negative predicitive value for secondary triage rule for traumatic brain injury Sensitivity (95%CI) Specificity (95%CI) Negative predictive Value (95%CI) Primary Outcome postive* 93.48 (13.83~99.04) 41.13 (35.05~49.84) 97.32 (35.05~99.04) Secondary Outcome Positive 100 (6.11~100) 38.36 (36.01~42.12) 100 (36.01~100)0 * Definitions as in Table 2 에서는두통이승산도 (OR) 2.575(95%CI: 1.534~4.381), 구토가승산도 (OR) 2.458(95%CI: 1.129~5.146) 으로유의한위험인자로확인되었다. 의식소실은 Teasdale 등 20) 이연구한바에의하면두개내혈종 (intracranial hematoma) 이있을확률이 5배로늘어난다고보고하였으며, Arienta 등 13) 도유의한것을확인한바있다. 반면에 Broczuk 12) 은의식소실의질문에대한대답과 (questionable LOC) CT상의병변과상관관계가없는것으로보고하였다. 본연구에서는의식소실환자의 CT상이상소견이관찰될확률은그리높지않으나, 중환자실이나신경외과적수술을받을확률은높아지는것이확인되었다. 또한지남력상실 (Disorientation) 의경우타연구에서는따로논의된바가없었으나, 본연구에서는일차결과에대한승산도 (OR) 3.368(95%CI: 1.640~ 6.757), 이차결과에대한승산도 (OR) 4.676(95%CI: 1.794~12.187) 로유의한상관관계를보여, 외상성두부손상환자의지남력상실소견이중요한임상소견임을확인할수있었다. 외상후발작은 Arienta 등 13) 은유의한위험인자로, Steill 등 10) 은통계학적유의성이없는것으로보고하고있으며, 본연구에서는단변량회귀분석에서는의미있는위험인자로확인되었으나다변량분석에서는유의성이확인되지못했다. 두개기저부골절에대하여 Steill 등 10) 은 Coefficient 1.65, OR 5.2(95% CI: 3.4~8.0) 으로보고하고있으며, 본연구에서는 Racoon s eye sign 소견만이 OR 2.732(95%CI: 1.104~6.793) 으로유의한결과를보였고이는다른두개기저부골절소견의표본이적은수 (1~4) 에서기인한다고사료되어, 임상적으로는주의를요하는위험인자로고려해야할것으로사료된다. 결론전산화단층촬영의시행이불가능한일차병원에내원한외상성두부손상환자가운데, 65세이상의고연령이나뇌졸중의과거력이있는경우, 손상기전이 2미터이상의추락이나보행자교통사고에의한두부손상인경우, 두통, 구토, 지남력상실등의증상을호소하거나, 신체검진상두개의개방성골절, 글라스고우혼수척도 13점미만, Racoon s eye의검진소견을가진환자의경우전산화단 층촬영상의미있는이상소견을가질위험이높아상급병원으로의전원을고려해야할것으로권고된다. 추후연구에서는이러한이차중증도분류지침에대한타당성평가가필요하겠다. 참고문헌 01. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injury in the United States. Emergency department visits, hospitalizations, and deaths. Atlanta: Centers for Disease Control and Prevention, Nation Center for Injury Prevention and Control; 2004. 02. Ahn KO. Association between socioeconomic status and the incidence and severity of traumatic brain injury. Dissertation of master s degree. Kangwon National University. 2007. 03. Kim JY, Seo DW, Kim NS, Ko SB, Kang DM, Kim DJ, et al. Assessment of the epidemiologic characteristics of injuries to estimate the burden of disease in Korea. Korea Institute for Health And Social Affairs; 2002. 04. Marion DM. Traumatic Brain Injury. Thieme Medical Publishers: New York 1999. 05. Servadei F, Nanni A, Nasi MT, Zappi D, Vergoni G, Giuliani G, et al. Evolving brain lesions in the first 12 hours after head injury: analysis of 37 comatose patients. Neurosurgery 1995;37:899-906. 06. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient. Chicago: American College of Surgeons; 1999. 07. Steele R, Green SM, Gill M, Coba V, Oh B. Clinical decision rules for secondary trauma triage: predictors of emergency operative management. Ann Emerg Med 2006; 47:135. 08. Kim Y, Jung KY, Cho KH, Kim H, Ahn HC, Oh SH, et al. Preventable trauma deaths rates and management errors in emergency medical system in Korea. J Korean Soc Emerg Med 2006;17:385-94. 09. Available at: http://www.cdc.gov/ncipi/tbi/. Accessed June 1, 2008. 10. Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, et al. The Canadian CT head rule for patients with minor head injury. Lancet 2001;357:1391-6. 11. Available at: http://www.braintrauma.org/site/pageserver?
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