Flight of Idea As an Emergency Physician Kyuseok Kim, MD. Department of Emergency Medicine Seoul National University Bundang Hospital
Agenda Appendicitis Pneumonia Acute Pyelonephritis Cardiac arrest Chest pain Laboratory studies
History of NEJM 순조홍경래의난 (1811-1812)
Factors for Successful Publish Good Luck! 삐딱 : 학문 Do it by the book, But be the author!!! -P.Safar- Being prepared! Have an Impossible Dream! 있는그대로 : 사람 Cooperation!
Factors for Successful Publish 2000 CT for appendicitis: Blame Pubmed 2002-2003: 수도병원 2004: Retrospective study 2005: Prospective study 2006: Another Prospective study 2007: Small RCT 2009: Big RCT
CT reading at that time Probably appendicitis Probably not appendicitis Possibly appendicitis Can not rule out appendicitis Maybe appendicitis Equivocal appendicitis Rec) Clinical correlation No evidence of appendicitis Appendicitis Rec) Operation
Grading System Clinical Grading Gr V: 80-100% Gr IV: 60-80% Gr III: 40-60% Gr II: 20-40% Gr I: 0-20% CT Grading: Discuss with Dr Lee Gr V: 80-100% Gr IV: 60-80% Gr III: 40-60% Gr II: 20-40% Gr I: 0-20%
Pain Control in Suspicious Appendicitis CJEM, 2015 2006-2010 SNUBH Idea: Pain control in suspicious appendicitis Taboo??? Randomized Controlled trial Pain control vs. no pain control Primary outcome: Diagnostic performance Sensitivity 0.00 0.25 0.50 0.75 1.00 Compared ROC curve of clinical probability 0.00 0.25 0.50 0.75 1.00 1-Specificity ROC area of Placebo : 0.6077 ROC area of Morphine : 0.6261 Reference Pr =0.8060
Pneumonia
학문 ( 일 ) 은삐딱하게 폐렴입원 ( 이전 ) 그날그날달라요주치의따라달라요혈액배양은무조건! 폐렴 ( 현재 ) 치료지침에따라입원 혈액배양은선택적으로
Bacteremia prediction model: External Validation, Multi-center Blood culture guideline No evidence right now! USA: 30-40% In Korea: 90% 10 hospitals 서울대 ( 연건, 보라매, 분당 ) 삼성, 아산, 연세대 ( 신촌, 강남 ), 고려대 ( 안암, 구로 ), 서울성모, 아주대 Retrospective: external validation & new model development RCTs
Laboratory findings (n=2001) WBC count, X10 3 /mm 3 12.1 ± 8.4 Hematocrit, % 36.3 ± 6.3 Platelet count, X10 3 /mm 3 237.1 ± 116.9 Glucose, mg/dl 150 ± 75 Albumin, mg/dl 3.5 ± 0.6 BUN, mg/dl 21.9 ± 17.4 Creatinine, mg/dl 1.2 ± 1.4 Sodium, mmol/dl 136.4 ± 8.1 C-reactive protein, mg/dl 12.7 ± 10.1 Bacteremia 57 (2.8)
Acute Pyelonephritis
학문 ( 일 ) 은삐딱하게 급성신우신염 ( 이전 ) 65 세이상입원 당뇨환자입원 혈액배양에서뭐가자라면입원 급성신우신염 ( 현재 ) 나이무시당뇨무시혈액배양무시
Acute pyelonephritis Previously DM, Old age, bacteremia admission with IV antibiotics
Chest Compression Position
심정지환자연구
심폐소생술은언제까지? 심폐소생술을얼마동안해야하나? 15분? 20분? 30분? 1시간? 지침이없음환자따라다를수밖에젊은환자, 기저질환 (-), 쓰러지자마자소생술시작노인, 암말기, 쓰러진채로발견
CPR: Prognostication
Prognostic Factor 1. Underlying conditions or injury severity 2. CPR procedures 3. Neurological Assessment 4. EEG: Maybe helpful without HT (Class IIb, LOE B) 5. Evoked Potential 6. Neuroimaging 7. Biomarker 8. Etc
Underlying conditions or injury severity Resuscitation 2012
Underlying conditions or injury severity Resuscitation 2013
Underlying conditions or injury severity
CPR Procedures Resuscitation 2014
Neuroimaging Cannot be recommended alone as prognostic factor yet MRI, CT Timing: 48h(?) Globally, No extensive studies yet! Poor Prognosis Functional study: Function(-) Imaging study: Lesion(+) Functional study: Fx(-) might be (+) Imaging study: Lesion(+) Lesion(-)(?), more useful? E.g. Functionally R. side weakness(+) Same prognosis?
Neurocrit Care 2012
Resuscitation 2013
Resuscitation 2013
Resuscitation 2013
Resuscitation 2016
How about combination? MRI & NSE NSE 78.9 ADC 615 Neurocrit Care 2012
Chest pain
급성심근경색증 (STEMI) 수련의 응급의학과전공 의 내과전공의 심장내과 전임의 심장내과교수
Ischemia/Reperfusion
Ischemia/Reperfusion Injury Local I/R injury Acute myocardial infarction Stroke Intestinal: SMA obstruction Transplantation Systemic I/R injury Hemorrhagic shock Cardiac arrest
ROS 감소
J Trauma 2014
Stepwise Resuscitation J Surg Res 2016
Methods Male, cross breed, domestic pigs weighing 35-40 kg Sedation atropine (0.05mg/kg) I.M. zoletil (5 mg/kg) + xylazine (4 mg/kg) I.M. Intubation & MV apply FiO 2 0.21, PEEP 10 cm H 2 O, TV 8 ml/kg. RR 10 12/min apco 2 taget 35 40 mm General anesthesia 1-2% sevoflurane inhalation (dose was not changed throughout the experiment) Temp. taget: 36.5-37.5 C Monitoring ECG, capnography, oximeter, rectal temperature probe
Methods BP monitor Masterflex Rt. Femoral artery 6-Fr catheter for BP monitoring Rt. Femoral vein balloon-tipped thermodilution catheter To measure CVP, MPAP, PAOP, SmvO 2 and CO Lt. Femoral artery 6-Fr catheter insertion for blood withdrawal and infusion
혼자하는것은가치가낮다 신약개발 서울대약대 L교수님서울대공대 H교수님 KAIST G교수님 KAIST P교수님 UNIST K교수님 바이오마커개발 서울대약대 K교수님한국화학연구소 S교수님 의료기기개발 KAIST O교수님 KAIST B교수님 KAIST P교수님
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