대한응급의학회지제 19 권제 3 호 Volume 19, Number 3, June, 2008 원 저 심폐소생술중제세동가능한심전도리듬으로의변화가예후에미치는영향 고려대학교의과대학응급의학교실 김정윤 홍윤식 이성우 장익진 백승원 최성혁 문성우 The Relationship of Shockable ECG Rhythm During Cardiopulmonary Resuscitation to Outcomes in Cardiac Arrest Patients. Jung Youn Kim, M.D., Yun Sik Hong, M.D., Sung Woo Lee, M.D., Ik Jin Jang, M.D., Seung Won Baek, M.D., Sung Hyuck Choi, M.D., Sung Woo Moon, M.D. Purpose: The purpose of this study was to investigate the relationship of ECG change during CPR to outcomes in cardiac arrest patients. Methods: A total of 170 patients who received cardiopulmonary resuscitation (CPR) in the emergency department from January 2005 to December 2006 were included for analysis. Medical records of study patients were reviewed, retrospectively. Age, sex, cause of arrest, location of arrest, arrest time, CPR time, initial ECG rhythme, changes in ECG during CPR, ROSC, 24 h survival, and number discharged alive were extracted from the medical records. Outcomes studied were ROSC rate and, survival rate at 24 h and at discharge. Student s t-test, the Chi-square test and one-way ANOVA were used for statistical analysis. Results: The patients were divided into three groups according to the initial EKG rhythm. The groups showed no difference in ROSC rate, but the initial VF/VT group and the initial PEA group showed higher survival discharge rates than the initial asystole group (p=0.002). Patients whose rhythm changed from asystole to VF/VT showed significantly higher ROSC and 24 h survival rates but showed no difference in the survival to discharge rate. Patients whose 책임저자 : 홍윤식서울특별시성북구안암동 5가 126-1 고려대학교의과대학안암병원응급의학과 Tel: 02) 920-5371, Fax: 02) 920-5269 E-mail: yshong@korea.ac.kr 접수일 : 2008년 3월 31일, 1차교정일 : 2008년 5월 2일게재승인일 : 2008년 6월 2일 288 rhythm changed from initial PEA to VF/VT showed no significance difference in ROSC rate, 24 h survival rate, or survival discharge rate. Conclusions: Although patients whose rhythm changed from initial asystole or PEA to shockable rhythm (VF/VT) showed no significant difference in survival discharge rate compared to those without change to shockable rhythm, in the long run, they may benefit from essential therapies to increase survival because of their higher ROSC rate and 24 h survival rate. Key Words: Cardiopulmonary resuscitation, Electrocardiography, Arrest rhythm Department of Emergency Medicine, College of Medicine, Korea University, Seoul, Korea 서 심폐소생술은인공호흡과인공순환을통하여조직으로의산소공급을유지하고, 궁극적으로는환자의심박동을회복시켜심폐정지환자의소생을위한치료기술로심폐정지환자에게시행되고있는중요한의료시술이다 1,2). 심폐소생술에대하여많은연구들이진행되고있으며, 심폐소생술의효율성에대해서는대부분이의견을같이하고있으나그결과에대하여는보고자에따라많은차이가있다 3-7). 평균생존퇴원은 3%~27% 정도로알려져있으나, 최근에는더높은생존퇴원율을주장하는연구자도있고과거수십년간심폐소생술의성공율은큰변화가없었다는주장들도있다 8-14). 최근에는심폐소생술의성공에대한예측인자나예상사망에대한점수표등을통해심폐소생술의시도, 시간, 중단에참고하도록하는연구들도나오고있다 15). 그러나현재까지는심폐소생술의예후에대해명확하게영향을미치는인자나예측자료혹은점수표등이확정되어있지않다. 그중에서도심정지초기심전도리듬은예후와밀접한관련이있는것으로보고되고있으며, 심실세동 / 빈맥과같이제세동이가능한리듬을가진경우좋은 론
김정윤외 : 심폐소생술중제세동가능한심전도리듬으로의변화가예후에미치는영향 / 289 예후를보이는것으로보고되고있다 3,5). 이런사실에비추어심정지초기리듬이무수축이나무맥성전기활동이었으나심폐소생술중제세동이가능한심전도리듬으로변화할경우에도좋은예후를보일지에대한의문이있다. 그러나이에대한연구는거의없는실정이다 16). 이에저자는응급실에서전문적심폐소생술이시행된환자의일반적인특성과자발순환회복, 24시간생존, 생존퇴원을조사하여심정지초기심전도및심폐소생술도중제세동가능한리듬으로의심전도변화가예후에미치는영향에대해알아보고자하였다. 이러한결과를통해심정지환자의예후예측에도움이되는지표로사용할수있는지확인하고자하였다. 대상과방법 1. 연구대상 2005년 1월부터 2006년 12월까지고려대학교의료원안암병원응급센터에서심폐소생술을시행한 260명의환자의의무기록을후향적으로분석하였다. 이중외상성 38 명, 15세미만 15명, 심폐소생술시행기록이불충분한 37 명을제외한 170명을대상으로하였다. 2. 연구방법성별, 연령, 심정지원인, 심정지발생장소, 심정지의목격여부, 심정지시간, 심폐소생술시간을확인하였고, 예후인자로자발순환회복, 24시간생존, 생존퇴원을조사하였으며최종예후결정인자로는생존퇴원율을조사하였다. 심전도리듬은응급이송차량에서감시한심전도, 제세동기의심전도, 병원감시장치의심전도의의무기록을이용하였고, 인쇄된심전도가없는경우에는심전도에대한의무기록을참고하였다. 심전도의분석은응급의학과전문의및 3년차이상의전공의가시행하였고, 초기심전도를무수축, 심실세동 / 빈맥, 무맥성전기활동의세군으로나 Table 1. The characteristics of the arrest patients who received CPR Characteristics Number (%) Sex Male 119 (70) Female 051 (30) Mean age (year) 60.8±14.3 Male 58.6±14.7 Female 65.9±11.7 Cuases of the arrest Cardiac 127 (74.7) Non-cardiac 043 (25.3) Initial EKG rhythm Asystole 80 (47.1) VF/VT* 25 (14.7) PEA 65 (38.2) Rhythm change from initial asystole and PEA 33 (19.4) VF 25 (14.7) VT 08 (04.7) Location of arrest Out of hospital 102 (60) Pre hospital Basic Life Support 068 (40) In hospital 082 (36.5) Arrest witnessed 135 (79.4) Mean arrest time (min) 15.5±15.2 Mean CPR time (min) 23.5±20.3 ROSC 101 (59.4) 24 h survival 047 (59.4) Discharged alive 014 (08.2) * VF/VT: ventricular fibrillation/ventricular tachycardia PEA: pulseless electrical activity CPR: cardiopulmonary resuscitation ROSC: return of spontaneous circulation
290 / 대한응급의학회지 : 제 19 권제 3 호 2008 누어각군간에예후와관련된인자와예후인자를비교하였다. 그리고, 초기심전도가무수축, 무맥성전기활동이었던환자중제세동이가능한심실세동 / 빈맥으로심전도의변화가있었던환자의특성과자발순환회복, 24시간생존, 생존퇴원을비교조사하였다. 각용어의정의는 Utstein style을따랐다 4,17). 모든자료값은평균 ± 표준편차로표시하였으며통계는 Student t-test 및 Chi square test, Fisher s exact test, 일원배치분산분석을이용하였고, 유의확률이 0.05 미만일때의미있는것으로간주하였다. 통계프로그램은윈도우용 SPSS 12.0을사용하였다. 결과 1. 대상환자의일반적특성및예후 (Table 1) 2. 대상환자의심전도리듬변화와예후 (Fig. 1) 초기심정지리듬에따른결과를분류해보면무수축 80 명 (100%) 중 28명 (35%) 은심전도변화없이사망하였고, 36명 (45%) 은자발순환회복이되었으며, 16명 (20%) 은심폐소생술중심전도가심실세동 / 빈맥으로변화되어제세동을시행받았다. 제세동을시행받은 16명중 14명 (87.5%) 이자발순환회복을보였으나생존퇴원한환자는없었다. 초기심실세동 / 빈맥을보인환자는 25명이었고이중 14명 (56.0%) 이자발순환회복을보였으며이중 4명 (28.6%) 이생존퇴원하였다. 무맥성전기활동을보인환자는 65명이었으며 17명 (26.1%) 이심실세동 / 빈맥으로의심전도변화를보였다. 17명중 8명 (47.1%) 이자발순환회복되었으며이중 2명 (11.8%) 이생존퇴원하였다. 대상환자 170명중남자 119명 (70.0%), 여자 51명 (30.0%) 이었으며평균연령은 61세 (16~90세) 였고심인성심정지가 127명 (74.7%) 으로비심인성심정지 43명 (25.3%) 에비하여많았다. 101명 (59.4%) 에서자발순환회복을보였으며이중 14명 (8.2%) 이생존퇴원하였다. 3. 초기심전도리듬에따른환자의특성및예후비교 (Table 2) 심실세동 / 빈맥군에서심인성심정지 (92%, p=0.042) 가많았으며무맥성전기활동군에서병원내심정지가많았고 (70.8%, p<0.001) 짧은심정지시간 (9.2±15.7분, Fig. 1. Outcome * CPR: cardiopulmonary resuscitation VF/VT: ventricular fibrillation/ventricular tachycardia PEA: pulse-less electrical activity ROSC: return of spontaneous circulation 24 h: survival to 24 hours DA: discharged alive
김정윤외 : 심폐소생술중제세동가능한심전도리듬으로의변화가예후에미치는영향 / 291 p<0.001) 을보였다. 초기심전도에따른세군간자발순환회복률에는차이 가없었으나생존퇴원율은심실세동 / 빈맥과무맥성전기활동군에서무수축군보다높았고 (p=0.002), 심실세동 / 빈맥군과무맥성전기활동군간에생존퇴원율의차이는없었다. 4. 초기무수축이나무맥성전기활동심정지환자중심실세동 / 빈맥으로심전도변화여부에따른특성및예후비교 (Table 3) 초기무수축이었으나심실세동 / 빈맥으로변화를보인환자는그렇지않은환자에비해나이가젊고, 심인성심정지가많았으며, 병원내심정지의비율이높았다. 예후인자로서자발순환회복률과 24시간생존율은의미있게높았으나생존퇴원율에는의미있는차이가없었다. 초기무맥성전기활동에서심실세동 / 빈맥으로변화를보인환자는그렇지않은환자군에비해나이가젊었으며심폐소생술시간이의미있게길었다. 그러나자발순환회복률, 24시간생존율, 생존퇴원율에서는의미있는차이는없었다. 고 초기심전도소견은자발순환회복률과생존율에영향을미치는요인으로알려져왔다. 본연구에서초기심전도소견은무수축 80례 (47.1%) 로가장많았고, 그다음으로무 찰 맥성전기활동 65례 (38.2%), 심실세동 / 빈맥 25례 (14.7%) 의순서였다. 2001년 Ryoo 등 18) 은병원내방송에의해시행된심폐소생술의분석에대한보고에서총 46 례의심폐소생술을대상으로하여무수축 30례 (65.2%), 무맥성전기활동 14례 (30.4%), 심실세동 2례 (4.3%) 의순서를나타내어본연구와같은순서를보였으나같은해에 Song 등 19) 이보고했던 3차응급의료기관에서의병원내심정지환자에대한심폐소생술성적보고에서는다른양상을보이는데, 이들은총 42례의심폐소생술을대상으로하여무맥성전기활동이 73.8%(31례 ) 로가장많은분포를차지하고있었고, 그다음으로심실빈맥및세동 (14.3%), 무수축 (11.9%) 순서였다. 또한 1999년 Lee 등 20) 의 Utstein Style에의한병원내심정지환자의분석에서도무맥성전기활동이 61.2%(148례 ) 로가장많은빈도로보고되었다. 본연구에서는병원외심정지및병원내심정지가모두포함되어다른결과가나타난것으로보이며이들연구가모두초기심전도의분류를심실세동 / 빈맥, 무맥성전기활동, 무수축의세가지로만분류하고있어서맥성부정맥은모두무맥성전기활동으로포함되었으리라여겨지며, 병원전단계심정지와는달리병원내심정지의경우즉각적인발견이가능하므로초기심전도분류에서맥성부정맥이포함되어있으나많은연구에서무맥성전기활동과구분하지않고있으며이에대한것도연구의결과에차이를준것으로보인다 21). 본연구에서 2년간시행된심폐소생술의결과는자발순환회복률 59.4%, 24시간생존율은 27.6%, 생존퇴원율은 8.2% 를나타냈다 (Table 1). 자발순환회복률과 24시간 Table 2. Comparison of the prognostic relating factors and outcomes of arrest patients according to initial EKG Asystole VF/VT PEA p-value Patients (n) 80 25 65 Mean age (year) 57.7±13.7 58.8±16.5 65.4±13.2 <0.004 Sex Male, n (%) 58 (72.5) 17 (68) 44 (67.7) b <0.798 Female, n (%) 22 (27.5) 08 (32.0)0 21 (32.3) b Causes of arrest Cardiac, n (%) 54 (67.5) 23 (92.0)* 50 (76.9) b <0.042 Non-cardiac, n (%) 26 (32.5) 02 (08.0)0 15 (23.1) b Location of arrest Out of hospital, n (%) 66 (82.5) 17 (68.0)0 19 (29.2) b <0.001 In-hospital, n (%) 14 (17.5) 08 (32.0)0 46 (70.8) b Arrest time (min) 19.2±12.5 17.4±17.3 9.2±15.7, <0.001 CPR time (min) 21.9±14.5 21.5±16.7 26.3±26.9 <0.383 ROSC, n (%) 50 (62.5) 14 (56.0)0 37 (56.9) b <0.739 24 h survival, n (%) 17 (21.3) 12 (48.0)* 18 (27.7) b <0.049 Discharged alive, n (%) 0 (0) 04 (17.4)* 10 (15.4) <0.002 * aystole vs VF/VT (p<0.05) aystole vs PEA (p<0.05) VF/VT vs PEA (p<0.05)
292 / 대한응급의학회지 : 제 19 권제 3 호 2008 생존율은일반적으로알려진바 (40%, 25%) 와비슷하였으나, 생존퇴원율은일반적으로알려진바 (15%) 보다낮았다 3,5,6,8,9,13-15). 심폐소생술에서국제적으로보고된생존율은매우다양하게나타난다. 이는아마도연구의설계나표본의크기, 평가방법등의차이에기인한것으로생각된다 5,6,8,9,15). 초기심전도에따라분류한환자의특성을보면초기심전도가무수축이었던환자군의평균연령이다른군에비하여통계학적으로유의하게낮게나타났으며, 심정지시간은무맥성전기활동군에서유의하게낮게나타났는데, 이는병원내심정지환자군에서무맥성전기활동을보인경우가많아무맥성전기활동군의심정지시간이낮게나타난것으로생각된다. Rankin 22) 은 1998년 133례의병원내심정지환자의심폐소생술에서초기심전도가심실세동 / 빈맥인환자군에서기타리듬인환자군에비해자발순환회복률 (58%, 25%) 과생존퇴원율 (47%, 17%) 및 1년생존율 (44%, 12%) 이모두높아초기심전도가심실세동 / 빈맥인환자군에서예후가좋았다고보고하였다. Rea 등 23) 은병원전심정지환자를대상으로한연구에서초기심정지리듬에따른생존퇴원율은전체대상환자에서 8.4% 이고, 심실세동 / 빈맥환자에서 17.7% 로보고하여심실세동 / 빈맥을가진심정지에서높은생존퇴원율을보였다. 본연구에서도심정지환자의초기심전도가심실세동 / 빈맥을보이는경우 24시간생존율 (48%) 및생존퇴원율 (17.4%) 이무수축심전도군에비해높게나타나같은결과를보였다. 그러나본연구에서는무맥성전기활동군에서도생존퇴원율이무수축심전도 군보다의미있게높았다. 이러한결과는무맥성전기활동을보인군에서병원내심정지가많아심정지시간이짧았던것에영향을받았을것으로보인다. 또한본연구에서는생존퇴원율이기존연구와비교하여상대적으로낮은결과를보였는데이는본연구에서병원전심정지가많은부분을차지한것이그원인의하나로생각된다. 심정지환자에있어서무맥성전기활동이나무수축인경우보다심실세동 / 빈맥이예후가더좋은것으로보이므로심폐소생술중심전도가무수축이나무맥성전기활동으로지속되는경우보다심실세동이나빈맥으로의변화가있을경우예후가더좋을것이라는가정을세워볼수있고, 실제심폐소생술에서도제세동가능리듬일경우심장압박을중단하고제세동을할것을권장하고있다. 그러나, 심폐소생술중심전도의이런변화의차이에따른예후에대하여연구된바는많지않고초기심전도가제세동가능리듬일경우심폐소생술을시행하였을때예후가좋다는보고는많이있다 1.3.5.6.8-11,15). Hallstrom 등 16) 은병원외심정지환자에서제세동과생존율에대한분석을보고하였는데, 초기심전도가무수축이거나무맥성전기활동인환자를대상으로하여제세동가능한심전도로변화가있어제세동을시행하였음에도불구하고제세동이필요하지않은군보다생존율이낮았다고하였다. Hallstrom 등 16) 은이러한결과들에대해심전도분석및제세동에관심을집중하게되어기본흉부압박등에충실한양질의심폐소생술을시행하지못해그런것이라설명하고있다. 본연구에서는초기심정지리듬이무수축이나무맥성전기활동이었으나제세동가 Table 3. Comparison of the outcomes according to change of EKG Asystole Aystole PEA PEA VF/VT no shock VF/VT no shock Patients (n) 16 64 17 48 Mean age (year) 48±12* 60±13 59±18 68±11 Sex Male, n (%) 13 (81.3)* 45 (70.3) 11 (64.7) 33 (68.8) Female, n (%) 03 (18.8)* 19 (29.7) 06 (35.3) 15 (31.3) Causes of arrest Cardiac, n(%) 14 (87.5)* 40 (62.5) 13 (76.5) 37 (77.1) Non-cardiac, n (%) 02 (12.5) a 24 (37.5) 04 (23.5) 11 (22.9) Location of arrest Out of hospital, n (%) 10 (62.5)* 56 (87.5) 08 (47.1) 11 (22.9) In-hospital, n (%) 06 (37.5)* 08 (12.5) 09 (52.9) 37 (77.1) Arrest time (min) 17.0±9.9 19.6±13.0 11.2±16.4 8.4±15.5 CPR time (min) 18.5±8.9 22.7±15.5 40.1±36.6 21.2±20.5 ROSC, n (%) 14 (87.5)* 36 (56.3) 08 (47.1) 29 (60.4) Transfer out, n 2 2 0 2 24h survival, n (%) 06 (42.9)* 11 (17.7) 06 (35.3) 12 (26.1) Discharged alive, n (%) 0 (0) 0 (0) 02 (11.8) 08 (16.7) * asystole VF/VT vs asystole no shock (p<0.05) PEA VF/VT vs PEA no shock (p<0.05)
김정윤외 : 심폐소생술중제세동가능한심전도리듬으로의변화가예후에미치는영향 / 293 능한심실세동 / 빈맥으로변화한경우궁극적으로생존퇴원율에있어서는차이가없었다. 그러나비록궁극적생존퇴원율에는차이가없었지만무수축심정지의경우제세동가능한리듬으로의변화한경우자발순환회복률과 24시간생존율이의미있게높았다. 최근에는체외순환기를이용한심폐소생술, 순환보조, 저체온치료등궁극적으로환자의예후를향상시킬수있는전문적심폐소생술기술이개발되고발전하는점을고려하면심정지로부터순환회복된기간동안환자의생존율을향상시키기위한전문적치료를시행할수있을것이다 24). 본연구의제한점으로는후향적인연구인관계로 Utstein style의중요한권장사항인 4가지기간인심정지로부터소생술의시작, 첫번째제세동, 기관삽관, 첫번째약물투여까지의기간을구할수없었다는점과심폐소생술이시행되지않은심정지와거짓심정지 (false arrest) 는제외되었다는점이다. 또한심정지이전의주질환이외의동반된질환이있을경우예후에영향을줄수있는데, 중증도를반영할만한기저질환등에대한자료가없었다는점과표본의크기가작다는점도제한요인으로생각된다. 결 응급센터에서시행한전문적심폐소생술에서초기심전도가심실세동 / 빈맥을보일경우 24시간생존율및생존퇴원율이높고, 초기심정지리듬이무수축이거나무맥성전기활동을보였으나심폐소생술중제세동가능한심실세동 / 빈맥으로변화한경우변화가없었던군에비해생존퇴원율에는차이가없었다. 그러나무수축으로부터심실세동 / 빈맥으로변화한경우자발순환회복률과 24시간생존율이높으므로궁극적으로환자의생존율을향상시키기위한전문적치료술을적용할수있을것으로생각되며향후이분야에대한전향적연구가필요할것으로사료된다. 론 참고문헌 01. ECC committee, Subcommittees and Task Forces of the American Heart Association. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005;112:IV1-203. 02. Jacobs I, Callanan V, Nichol G, Valenzuela T, Mason P, Jaffe AS, et al. The chain of survival. Ann Emerg Med 2001;37(4 Suppl):S5-16. 03. Cooper S, Janghorbani M, Cooper G. A decade of in-hospital resuscitation: outcomes and prediction of survival? Resuscitation 2006;68:231-7. 04. Cummins RO, Chamberlain D, Hazinski MF, Nadkarni V, Kloeck W, Klamer E, et al. Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the in-hospital Utstein style. Ann Emerg Med 1997;29:650-79. 05. Cooper S, Evans C. Resuscitation Predictor Scoring Scale for inhospital cardiac arrests. Emerg Med J 2003;20:6-9. 06. Cohn EB, Lefevre F, Yarnold PR, Arron MJ, Martin GJ. Predicting survival from in-hospital CPR: meta-analysis and validation of a prediction model. J Gen Intern Med 1993;8:347-53. 07. McDonald KM, Hlatky MA, Saynina O, Geppert J, Garber AM, McClellan MB. Trends in hospital treatment of ventricular arrhythmias among Medicare beneficiaries, 1985 to 1995. Am Heart J 2002;144:413-21. 08. Parish DC, Dane FC, Montgomery M, Wynn LJ, Durham MD. Resuscitation in the hospital: differential relationships between age and survival across rhythms. Crit Care Med 1999;27:2137-41. 09. Rosenberg M, Wang C, Hoffman-Wilde S, Hickam D. Results of cardiopulmonary resuscitation: failure to predict survival in two community hospitals. Arch Intern Med 1993;153:1370-5. 10. Taffet GE, Teasdale TA, Luchi RJ. In-hospital cardiopulmonary resuscitation. JAMA 1988;260:2069-72. 11. Herlitz J, Bang A, Alsén B, Aune S. Characteristics and outcome among patients suffering from inhospital cardiac arrest in relation to the interval between collapse and start of CPR. Resuscitation 2002;53:21-7. 12. McGrath RB. In-house cardiopulmonary resuscitationafter a quarter of a century. Ann Emerg Med 1987;16: 1365-8. 13. DeBard ML. Cardiopulmonary resuscitation: analysis of six years experience and review of the literature. Ann Emerg Med 1981;10:408-16. 14. Cooper S, Duncan F. Reliability testing and update of the Resuscitation Predictor Scoring (RPS) Scale. Resuscitation 2007;74:253-8. 15. Hallstrom A, Rea TD, Mosesso VN Jr, Cobb LA, Anton AR, van Ottingham L, et al. The relationship between shocks and survival in out-of-hospital cardiac arrest patients initially found in PEA or asystole. Resuscitation 2007;74:418-26. 16. Cummins RO, Chamberlain DA, Abramson NS, Allen M, Baskett PJ, Becker L, et al. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style. Circulation 1991;84:960-75. 17. Ryoo JH, Jeong KU, Wee JS, Moon JM, Jun BJ, Moon WS, et al. Analysis of cardiopulmonary resuscitation in ward of tertiary hospital. J Korean Soc Emerg Med 2001;12:369-78. 18. Song KJ, Lee JH, Sung IS, Jeong YK, Choi SW.
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