DOI:10.5125/jkaoms.2010.36.4.303 구강악안면손상후과도한출혈을보인정신지체응급환자에서신속지혈예 : 증례보고 모동엽 유재하 최병호 설성한 김하랑 이천의연세대학교치과대학원주기독병원구강악안면외과학교실 Abstract (J Korean Assoc Oral Maxillofac Surg 2010;36:303-8) Emergency bleeding control in a mentally retarded patient with active oral and maxillofacial bleeding injuries: report of a case Dong-Yub Mo, Jae-Ha Yoo, Byung-Ho Choi, Sung-Han Sul, Ha-Rang Kim, Chun-Ui Lee Department of Oral and Maxillofacial Surgery, Wonju Christian Hospital, College of Dentistry, Yonsei University, Wonju, Korea Excessive oral and maxillofacial bleeding causes upper airway obstruction, bronchotracheal and gastric aspiration and hypovolemic shock. Therefore, the rapid and correct bleeding control is very important for saving lives in the emergency room. Despite the conventional bleeding control methods of wiring (jaw fracture, wound suture and direct pressure), continuous bleeding can occur due to the presence of various bleeding disorders. There are five main causes for excessive bleeding disorders in the clinical phase; (1) vascular wall alteration (infection, scurvy etc.), (2) disorders of platelet function (3) thrombocytopenic purpura (4) inherited disorders of coagulation, and (5) acquired disorders of coagulation (liver disease, anticoagulant drug etc.). In particular, infections can alter the structure and function of the vascular wall to a point at which the patient may have a clinical bleeding problem due to vessel engorgement and erosion. Wound infection is a frequent cause of postoperative active bleeding. To prevent postoperative bleeding, early infection control using a wound suture with proper drainage establishment is very important, particularly in the active bleeding sites in a contaminated emergency room. This is a case report of a rational bleeding control method by rapid wiring, wound suture with drainage of a rubber strip & iodoform gauze and wet gauze packing, in a 26-year-old male cerebral palsy patient with active oral and maxillofacial bleeding injuries caused by a traffic accident. Key words: Active oral hemorrhage, Shock, Mentally disabled patient, Wound drainage, Emergency hemorrhage control [paper submitted 2009. 10. 19 / revised 2010. 6. 17 / accepted 2010. 6. 29] Ⅰ. 서론 과도한구강악안면부혈관손상에의한출혈은상기도폐쇄, 폐기관계와위장관내흡인및저혈량성쇼크 (hypovolemic shock) 를유발할우려가있다 1. 따라서신속하고정확한지혈법은응급실에서환자의생명을구하는데매우중요하다. 통상적으로악골골절부강선고정술, 창상봉합과압박법으로지혈을시도함에도불구하고다양한출혈성장애들이있어술후에도출혈이계속되어술자와환자가당황하기도한다 2,3. 구강악안면외과임상에서과도한출혈장애를보이는원인들에는 5 가지가고려되는데, 첫째 모동엽 220-701 강원도원주시일산동 162 연세대학교원주의과대학원주기독병원치과학교실구강악안면외과 Dong-Yub Mo Department of Dentistry, Wonju Christian Hospital, Wonju College of Medicine, Yonsei University 162 Il-San Dong, Wonju, Kangwon, 220-701, Korea Tel: +82-33-741-1434 Fax: +82-33-742-3245 E-mail: metalblack@hanmail.net 창상감염이나괴혈병등의혈관벽약화변형, 둘째혈소판기능의장애, 셋째혈소판감소성자반증, 넷째선천성응고결함, 다섯째간장질환이나쿠마린등의약물사용에따른후천성응고결함등이있다 4,5. 통상적으로특기할출혈성내과적질환이없는경우에는지혈처치에큰어려움이없지만, 정상인이라도전신건강상태가불량한장애자들 ( 장기간침상생활자, 정신지체장애인등 ) 인경우에는외상등손상으로출혈이발생하면전신적인약화상태 ( 만성 hypoxia, 산성증등 ) 로지혈기전이손상되어출혈이더지속되는경향이있다 1,5. 또한혈관과열창봉합술등으로지혈이달성되었다고하더라도, 술후창상감염등이발생되면감염창상부충혈과혈관미란 (erosion) 등으로후출혈이발생하여, 임상의를긴장하게하고환자의생명을위협한다 3,4. 시술후과도한출혈의가장빈번한원인은창상감염과관련있는데, 창상감염에관련된요소들은세균이나이물같은국소요소, 전신질환이나노인에서보이는전신요소, 환자와술자의위생상태와같은내인성요소, 수술실이나외래진료실의환경요소, 혈종이나수술술기와같은외 303
J Korean Assoc Oral Maxillofac Surg 2010;36:303-8 과적요소들이종합적으로관련이있다 6,7. 시술후출혈의예방을위해서는창상봉합시감염가능성에대비해혈종이나장액종배액로의조기설정으로창상감염방지가필요한데, 특히오염가능성이높은응급실환경에서과도한출혈을보이는창상관리에서중요한고려사항이다 8,9. 이에근거하여저자등은교통사고로과도한구강악안면출혈손상 ( 악골골절, 연조직열창및다수치아들손상 ) 을보인 26 세남자정신지체환자에서신속한강선고정과창상봉합시미리고무와요오드포름거즈 (iodoform gauze) 배농재및습윤거즈압박드레싱을통해과도한출혈조절과술후감염방지를달성했고, 나중전신상태개선후 2 차적인수술로적절한치료를시행했기에이를보고한다. Ⅱ. 증례보고 환자는 26 세남자로 2007 년 12 월 9 일오후 7 시경강원도원주시내에서교통사고로길가에쓰러져있어 119 구조대가본원응급실로이송해왔다. 초진시의식은혼미와혼몽 (stupor and drowsy) 상태였고방사선사진검사상상악치조골과하악골정중부복합골절소견이심했고, 주위연조직열창들도과도해서구강내출혈이과도했다.(Fig. 1) 먼저응급의학과에서저혈량성쇼크, 뇌손상, 출혈에의한상기도폐쇄의위험에대비해비인두기관내삽관과비위삽관을시행했고, 신경외과와 본구강악안면외과로협진을의뢰했다. 응급실내원시생징후는혈압 80/50 mmhg, 맥박 120 회 / 분, 차고끈적한피부등저혈량성쇼크상태에있었고동맥혈가스분석과일반혈액검사에서도빈혈, 낮은산소포화도등이관찰되었다 (Hg/Hct:8/23, ph 7.2, PO2 48, PCO2 31). 문제는환자의보호자가연락이안되고신원파악도지체되어 무명남 이라호칭된상태였는데, 신경외과의뇌진찰소견은뇌진탕 (concussion) 이경미할뿐과도한뇌손상은없는데, 의식은명료하지않고언어구사가되지않았다 ( 나중밝혀진바에의하면정신지체장애자였음 ). 구강악안면출혈손상부위를방치할수도없고, 단순히습윤거즈 (wet gauze) 압박전색술 (packing) 만시행하기에는손상범위가과도해지혈이어려워, 응급의학과에서전신상태 monitoring 을계속하면서수액약물요법, 수혈등전신관리를하였다. 구강악안면외과에서 Valium (Diazepam 10 mg, Daewon, Seoul, Korea) 1 ampule 과증류수 20 cc 혼합한진정제를정주한후국소마취하에응급처치를시행하기로결정했다 ( 전신마취하에응급수술은보호자가없어수술동의서를받지못하여실행불가능했음 ). 통상적인국소마취하에먼저하악골정중부복합골절부위에 1 차강선결찰고정술 (primary wiring) 과 2 차적인감염방지를위한혈종과장액종의배농을위해고무조각삽입에의한배농술을시행했다.(Fig. 2) 또한상악다수치아부발치창상내부, 치조골골절부, 인접치은과점막열창들도과도해서구강내출혈이심하기에발치창내부는요오드포름거즈 (Nu-gauze, Johnson & Johnson Medical Inc., Arlington, TX, USA) 의삽입으로압박지혈과배농효과를기대했고, 치조골절부와치은점막열창부위는신속한지혈을위해습윤거즈를길게펼치고접어서전색하는방법으로지혈처치를시행했고, 요오드포름거즈들의이탈 (displacement) 을방지하기위한신속한거친봉합술 (rough suture) 을시행했다.(Fig. 3) Fig. 1. Initial 3D-CT view of mandibular and maxillary compound fracture. (3D-CT: 3 dimensional computed tomography) Fig. 2. Primary wiring and rubber strip drainage view of a mandibular compound fracture. 304
구강악안면손상후과도한출혈을보인정신지체응급환자에서신속지혈예 : 증례보고 한편설하부와구강저의심부열창부의출혈은정확한열창봉합술이중요하지만쇼크상태에서치과적처치에장시간을소요함이환자의전신상태회복과안정에오히려악영향 ( 창상봉합자극도외상이어서원래의외상도회복되기전에또외상을가하는것으로, 환자의외상으로인한인체의신경내분비반응을더격화시킴등 ) 을초래할가능성이높아, 부득이신속한거친봉합술과고무조각배농재삽입술을시행했다.(Fig. 4) 이는혈종과장액종축적방지로차후의창상감염과출혈을예방하는것까지고려하는처치인것이다. 또한턱정중안면이부 (chin area) 의심부열창부도출혈이있고정확한봉합술에장시간이소요되므로전신상태안정후명확한치료를하기로하였다. 거친봉합술 (rough suture) 과술후감염방지를위한고무조각배농재삽입술을시행한다음압박드레싱을시행했는데 (Fig. 5), 신속한지혈위주의처치들이어서전체적인술식에소요된시간은약 1 시간이었다. 구강악안면손상부지혈이완료되고응급실도착후 2 일 째저혈량성쇼크는개선되었다. 환자가정신지체 1 급장애자임이보호자에의해확인되어, 신경정신과에협진의뢰를한결과술후창상관리에는특기할문제점이없을것으로판단되었다. 응급의학과로입원하여중환자실로환자를옮겨전신상태를 monitoring 하면서, 본치과 ( 구강악안면외과 ) 에서구강악안면손상부후처치를시행하기로하고환자를이동하였다. 그후환자는매일창상드레싱을시행하면서 5-7 일간격으로배농재교환술 (rubber strip drainage 는유지하고요오드포름거즈와 wet packing gauze 만교환 ) 을반복해시행하였다. 2-3 주일후모든배농재를제거하였고, 하악골절부는전신상태안정후진정요법 (Valium 1 ampule 과증류수 20 cc 를혼합해서서히정맥주사함 ) 시행하에국소마취를하고서 arch bar 장착을통한비관혈적정복고정수술을시행해골유합을달성하였다. 다른구강내거친봉합부는창상치유가매우양호해추가적인봉합술없이잔존치근들의발치후보철치료를시행하기로했으며 (Fig. 6), 이부열창봉합부만약 6 개월후에반흔제거성형술을시행하기로하였다. Fig. 3. Primary gauze packing and rough wound closure view by use of iodoform gauze, long wet gauze and black silk in the maxillary compound alveolar fracture regions. Fig. 4. Primary rough closure and rubber strips drainage view in the deep lacerated wounds of sublingual and mouth floor region. Fig. 5. Primary rough wound closure and rubber strips drainage view in the deep lacerated chin wounds. Fig. 6. Follow-up intraoral view of the mandibular arch bar application and the maxillary residual root rests with good healing of the adjacent soft tissue wounds. 305
J Korean Assoc Oral Maxillofac Surg 2010;36:303-8 Ⅲ. 고찰 사고로인한혈관손상이나전신질환에의한출혈성질환으로구강악안면부위에출혈이과도해지면혈액응괴의구강과인두부침착에따른상기도폐쇄, 흘러나온혈액을본인이직접목격함에따르는불안공포감으로신경내분비반응에의한실신가능성, 혈액을삼키는경우삼켜진혈액이위장관에자극 (gastric irritation) 을주어서위장관기능이상은물론구토의우려가크다 10,11. 특히구토를하는경우구토물에는산성도가높은위산이포함되어있어입맛이이상해질뿐만아니라구토물이폐기관지계로흡인되면질식 (asphyxia) 이나흡인성폐렴의가능성도있다 12,13. 따라서구강악안면부위의출혈을신속정확히관리함은모든치과의사, 특히당직생활을하는구강악안면외과의사에게는매우긴요한과제이다 14. 전신질환이없는정상인에서출혈의정상조절기전은혈관기전, 혈소판기전, 응고기전으로크게대별된다. 그러나전신질환이동반되거나정상인에서도감염등다양한원인들이작용하면출혈성장애 (bleeding disorders) 가발생하여구강악안면손상이나수술시과도한출혈로술자, 환자 ( 보호자 ) 모두가당황하게된다 3,7.(Table 1) 특히응급환자에서는전신상태의약화에따른저산소증상태와젖산등노폐물축적에따른산성증및저장혈액의수혈에따른이상출혈부작용등으로혈관수축력과응고기전에장애를초래할가능성이높아주의가필요하다 15,16. 본증례에서도환자가사고발생후신원파악등에시간이많이걸렸고출혈이과도하여수혈을다량시행했으며, 그로인한응고장애발생등으로지혈처치에난관이있었다. 특히창상자체가감염우려가높아술후감염에따른 2 차적인출혈에대한대비가필요했다. 구강악안면영역에서사고발생시출혈가능성이높은혈관들에는외경동맥의분지들인내상악동맥, 설동맥, 설하동맥, 천측두동맥, 상하치조동맥등과내경정맥의분지들인익돌정맥총, 상악정맥, 하악후정맥, 상하치조정맥, 설정맥, 설하정맥등이있다 1,2. 이들혈관들가운데많은분지들이상하악골내혈행과관련이있어서구강악안면손상특히상하악골골절에는골절편내부출혈이과도해지혈처치를위해골절편의 1 차적인정복고정술 ( 흔히골절편사이의치아들을이용한강선결찰고정술 ) 이긴요하다 8,10. 본증례에서도하악골정중부복합골절부위에서악골내출혈이과도해서신속한 1 차강선결찰고정술을시행해지혈에큰도움이되었는데, 우선은조기지혈이이루어진다고하여도나중발생될수있는혈종과장액종의축적으로인한감염가능성과창상감염시혈관충혈과미란 (erosion) 에의한후출혈도방지하기위해서고무조각배농재를삽입해봉합고정하는술식을추가했다. 한편혈관손상과관련된지혈방법에는습윤거즈에의 Table 1. Classification of bleeding disorders 1. Nonthrombocytopenic purpuras a. Vascular wall alteration (1) Scurvy (2) Infections (3) Chemicals (4) Allergy b. Disorders of platelet function (1) Genetic defects (2) Drugs (a) Aspirin (b) NSAIDs (c) Alcohol (d) Antibiotics (3) Allergy (4) Autoimmune disease (5) von Willebrand's disease (6) Uremia 2. Thrombocytopenic purpuras a. Primary-idiopathic b. Secondary (1) Chemicals (2) Physical agents (3) Systemic disease (4) Metastatic cancer to bone (5) Splenomegaly (6) Drugs (a) Alcohol (b) Thiazide diuretics (c) Estrogens (7) Vasculitis (8) Mechanical prosthetic heart valves (9) Viral or bacterial infections 3. Disorders of coagulation a. Inherited (1) Hemophilia A (2) Hemophilia B (3) Others b. Acquired (1) Liver disease (2) Vitamin deficiency (a) Biliary tract obstruction (b) Malabsorption (c) Excessive use of broad-spectrum antibiotics (3) Anticoagulation drugs (a) Heparin (b) Coumarin (c) Aspirin and NSAIDs (4) DIC (5) Primary fibrinogenolysis (NSAIDs: nonsteroidal anti-inflammatory drugs, DIC: disseminated intravascular coagulation) 306
구강악안면손상후과도한출혈을보인정신지체응급환자에서신속지혈예 : 증례보고 한압박지혈, 전기소작법에의한지혈, 손상혈관의결찰법, surgicel 이나 gelfoam 같은국소지혈제의사용, botropase, thrombokinase 등전신약제사용, 유출관 ( 배농재 : drain) 삽입에의한감염관리로지혈달성등의다양한방법이있다 9,17. 본환자의경우사고후신원확인이되지않아 무명남 의이름으로응급실에내원해보호자도없었고, 뇌손상으로의식이혼미하고정신지체로의사소통이되지않았다. 입원하여수술동의서를받고수술실로옮겨서전신마취하응급수술도시행할수없는상황이었다. 따라서증례보고에서언급한대로우선하악골절부 1 차강선결찰정복고정술과고무조각 (rubber strips) 배농재삽입술을진정요법과국소마취하에시행했고, 과도한상악의치은점막열창부는습윤거즈전색에의한압박지혈처치를, 이부 (chin), 설하구강저부위는신속한거친 1 차봉합술 (primary rough suture) 과고무조각배농재삽입으로지혈을달성했다. 특별히구강저와설하방부위를신속한습윤거즈전색대신에 1 차봉합술과고무조각배농재삽입술을시도한이유는해부학적구조상습윤거즈 packing 이설조직들을후방으로밀리게전위시켜서기도의폐쇄에기여할우려가있기때문이다. 또한설하구강저봉합부위에혈종과장액종의축적으로창상감염이발생되면지연성후출혈 (delayed post-operative bleeding) 의위험도있기때문이다 1,5,14. 추가로고려할사항은외상환자의면역성감소의문제인데, 특히출혈이과도하고조직세포의손상이광범위한경우에인체의신경내분비반응 (neuroendocrine response) 에영향을주어서전신면역성의약화가발생한다. 즉, 외상등의인체자극은교감신경계를자극하고부신수질에이르며부신수질은에피네프린을분비하고시상하부에전달되면, 시상하부는뇌하수체전엽을자극해부신피질호르몬인 corticosteroid 를방출하게되는데, 그정도가과중하면인체면역에중요한 T- 림프구기능을약화시켜면역력의감소가일어나게된다. 이런현상을 아네르기 (anergy)" 란용어로별도로정의하고있는데, 외상환자들중감정적인스트레스가가중되는환자에서더현저하다 10,16. 또한외상의스트레스로인한에피네프린의방출은인슐린의분비를억제하고 glucagon 의분비를자극하며, 방출된 corticosteroid 와함께포도당신생 (gluconeogenesis) 을촉진시키게된다. 이런현상은결국혈장내혈당량의비정상적상승을야기하여감염에대한감수성의증가를가져오게되므로임상에서반드시유념할사항들이다 18,19. 본증례에서도이런면들을고려해서 1 차응급지혈처치를시행했고 2 일간응급실에머무르는동안보호자가내원하여환자가정신지체장애자임을확인하여신경정신과상의가필요했다. 우선은응급의학과에서저혈량성쇼크에대한관리를하기로하고중환자실로환자를옮겼다. 그후본치과 ( 구강악안면외과 ) 에서구강악안면손상처치부관리드레싱을시행했는데, 다행히 2 차적인창상감염의소 견은없었다. 통상적으로외상에의한혈관손상에의한저혈량성쇼크은구강악안면손상자체로는발생하는경우가매우드물고, 대부분다발성손상으로흉부, 복부, 두경부, 대퇴부혈관손상이연합되어유발하는경향이있다. 그러나본증례의경우는사고후병원까지전원되는데에도시간이많이소요되었고, 병원에도착해서도보호자가없어 무명남 으로행정처리되면서정신지체자인것을몰라의사소통도불가능했던관계로, 실혈량이많아저혈량성쇼크까지진행된면이있어앞으로이에대한대비도필요하리라생각한다. Ⅳ. 결론 저자등은구강악안면손상후과도한출혈로저혈량성쇼크를보인응급실정신지체환자에서하악골복합골절부의인접치아들을이용한신속한강선결찰정복고정술과고무조각배농재삽입술, 상악다수치아들발치창과치조골복합골절부의요오드포름거즈배농술과봉합, 습윤거즈압박및봉합술을이용한전색술, 다발성구강내외열창부의신속한 1 차거친봉합술과배농술등으로응급지혈처치와술후창상감염및출혈을방지할수있었고, 시일이경과되면서전신상태가안정을회복해서정상적인후관리를시행할수있었다. References 1. Conley JJ. Blood vessel complications, In: Conley JJ, ed. Complications of head and neck surgery. 1st ed. Philadelphia: WB Saunders; 1979:66-80. 2. Kruger GO, ed. Textbook of oral and maxillofacial surgery, 6th ed. St. Louis: Mosby; 1984. 3. Little JW, Falace DA, Miller CS, Rhodus NL. Bleeding disorders. In: Little JW, Falace DA, Miller CS, Rhodus NL, eds. Dental Management of the Medically Compromised Patient. St. Louis: Mosby; 2002:332-64. 4. Dembo JB. Diagnosis and management of oral surgical complications. In: Falance DA, ed. Emergency dental care: diagnosis and management of urgent dental problems. 1st ed. Baltimore: Lippincott Williams and Wilkins; 1995:227-53. 5. Koury ME. Complications in the treatment of mandibular fractures. In: Kaban LB, Pogrel MA, Perrott DH, eds. Complications in oral and maxillofacial surgery. 1st ed. Philadelphia: WB Saunders; 1997:121-63. 6. Goldberg MH. Prevention and control of infection in the surgical patient. In: Topazian RG, Goldberg MH, eds. Management of infections of the oral and maxillofacial regions. 1st ed. Philadelphia: WB Saunders; 1981:329-50. 7. Alling CC 3rd, Alling RD. Bleeding disorders and injuries. Dent Clin North Am 1982;26:71-86. 8. Schultz RC. The problems of beginning. In: Schultz. RC, ed. Facial Injuries. 2nd ed. Chicago: Year Book Medical Publishers; 1977:41-64. 9. Min BI. Color atlas of maxillofacial plastic surgery. Seoul: Koon Ja Publishing; 1990. 10. Bonn GE, Davis CL. Shock. In: Fonesca RJ, Walker RV, eds. Oral and maxillofacial trauma. Philadelphia: WB Saunders; 307
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