symposium abstract bystep step · 2017-06-22 · we also devoted ourselves a collaboration between...

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The 5th Pan Pacific Trauma CongressThe 32nd Annual Meeting of the Korean Society of Traumatology

June 22 (Thu.) - 24 (Sat.), 2017

Seoul National University Bundang Hospital,Healthcare Innovation Park,Seongnam, Korea

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Giant Step toward Excellency of Trauma Care

Symposium Abstract

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Welcome Message

As a president of Korea Society of Traumatology, I deeply appreciate all the participants

joining this 5th Pan-Pacific Trauma Congress.

For last several years, we have put our whole effort in upgrading state-of-the-art trauma

care, education program, and scientific knowledge in traumatology. We also devoted

ourselves a collaboration between civil and military trauma system and as a result this

congress is co-hosted with Armed Forces Medical Command for many years. And we also

tried to have close cooperation with government to make our trauma care more faithful and

trustful to our people. I sincerely appreciate all the efforts made by all the members of our

society.

However, there are still a lot of works to do for the well-balanced maintenance of trauma

care, and pride for trauma surgeons. I truly believe that these problems can well improved

with our continuous efforts and dedication.

Thus, we are gathered here together to make a better understanding among us, and to

set a higher standard for the treatment of our patients. These efforts will surely result in

higher chance of survival in our patients, and eventually, better performance of our trauma

care. Moreover, which is expressed as a "Giant Step toward Excellency of Trauma Care"

slogan of this PPTC 2017, with our advanced skills, we will try to perform the best treatment

for trauma patients in Korea.

All renowned trauma surgeons and experts have gathered here from overseas or

domestically.

This conference will be giant step toward to excellency of trauma care.

I am also convinced that this conference will be best festive event for sharing cutting-

edge knowledge and deepening our friendship as well.

I hope all of you to enjoy this meeting.

Ho-Seong Han President of the Korean Society of Traumatology

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Welcome Message

It is a great pleasure for me to co-host the 5th Pan-Pacific Trauma Conference with the

Korean Society of Traumatology and to invite trauma experts in the Pan-Pacific region.

Armed Forces Medical Command, under close collaboration with the Korean Society

of Traumatology, has been putting its utmost effort in enhancing the trauma-treating

capabilities based on " Patient First ". This conference would be great opportunity for us to

see our outcomes so far and check the direction we go.

Currently, the globe has confronted with diverse threats including mass disasters

numerous terrorisms. In particular, the Pan-Pacific region is faced with frequent natural

disasters such as earthquake, volcano eruption, typhoons and also threats from North

Korea. Close collaboration and active response between relative institutions are inevitable to

minimize the damages from those disasters and threats.

In this point of view, the theme "Step by Step" of this year's conference is meaningful

to achieve people's health and national safety as common goals. As this confernce makes

academic exchanges between experts of both military and civilian possible, I believe it

will be a great opportunity to develop the bond of sympathy and reinforce the mutual

collaboration system that achieves the common goals. In addition, I am expecting that the

development of traumatology in military medicine through this conference can be a great

help to the establishments of Armed Forces Trauma Center and truthful medical support

system.

Thank you.

Jong-Seong Ahn Commanding General, Armed Forces Medical Command, ROK

5


Program at a Glance

22 June (Thu.)

23 June (Fri.)

Main Auditorium Seminar 1,2 Small Auditorium Seminar 5

08:00-08:30 Registration

09:00-10:30

5th NICE

(Nurse Intensive Care Education) Course 4th Military Trauma

Nurse Education Session

7th TREE

(Trauma Registry for Expert & Educator) Course

10:30-12:00

Military EMT Seminar12:00-13:00

13:00-16:00

16:00-18:00

18:00-

Main Auditorium Seminar 1 Seminar 2 Small Auditorium

Seminar 5


Poster Presentation

09:00-10:20Training Course 1 (KR)

Chest trauma/Hemorrhage

Training Course 2 (KR)Intensive Career Training

Course

Training Course 3 (KR)Traumatic

CardiopulmonaryArrest (TCPA)

10:20-10:40 Coffee Break

10:40-10:50 Opening Address

10:50-11:50Plenary Session 1

Step by Step 2017

11:50-12:00Congratulatory

Remark

12:00-12:30Plenary Session 2

Step by Step 2017

(KST/JAST) Leadership

Meeting

12:30-13:30 Luncheon 1

13:30-14:10Special Lecture

Intensive CareMedicine

Special Lecture Diaster

Special Lecture REBOA

Poster Presentation

14:10-15:50

Japan-Korean Symposium 1 Trauma System

Symposium 1 Treatment of Vulnerable

Orthopedic Trauma Patients

Symposium 2 Bleeding Control in Pelvic

Fracture

15:50-16:10 Coffee Break

16:10-17:50

Japan-Korean Symposium 2 Surgery and ICU

Care in Polytrauma Patients

Symposium 3 Trauma in Special

Population

Symposium 4 Common Questions about

Neurotrauma : Non-Neurosurgeon's View

18:00- Gala Dinner : 7F. Bulgok Hall

1F.

1F. 1F. 1F.

1F. 4F.

4F. 4F.

4F.

6


Program at a Glance

The session with this headphone sign will be translated.

24 June (Sat.)

Main Auditorium

Seminar 1 Seminar 2 Small Auditorium

Seminar 4 Seminar 5


Poster Presentation

09:00 - 10:30Plenary Session 3 Step by Step 2017

10:30 - 10:50 Coffee Break

10:50 - 12:30

Symposium 5 Trauma

Management Update

Symposium 6 Medical Treatment

Guidance Committee

Symposium 7 Nursing Roles in Trauma Center

Oral Presentation

1

12:30 - 13:30 Luncheon 2Trauma Center

Meeting

13:30 - 15:00Symposium 8

Trauma US

Symposium 9 The Future of Military

Trauma Care(Patient First in

Military Trauma)

Oral Presentation 2

Poster Presentation

Oral Presentation

3

15:00 - 15:30 Coffee break

15:30 - 17:00

Symposium 10 Current of Trauma

Center : Still Much to Be Improved

Oral Presentation 4

Oral Presentation 5

Oral Presentation

6

17:00 - 17:30 General Assembly

17:30 -Award & Closing

Ceremony

1F. 1F. 1F. 4F. 4F. 4F.

7



Scientific Program

Registration

Physiology of Chest Trauma : Non-Compressible Torso

Management of Life-Threatening Chest Trauma : Resuscitative Thoracotomy

Surgical Rib Fixation

Post-Traumatic ARDS

Coffee Break

Opening Remark

Opening Remark

The Pathophysiology of Shock

The Shock Index Revisited

Date : June 23, 2017 (Fri.) 08:30-17:50Main Auditorium

08:30-09:00

09:00-09:20

09:20-09:40

09:40-10:00

10:00-10:20

10:20-10:40

10:40~10:45

10:45-10:50

10:50-11:20

11:20-11:50

000

022

025

027

031

035

Jung Joo Hwang (Eulji Univ. Hospital)

Sung Wook Chang (Dankook Univ. Hospital)

Soon-Ho Chon (Jeju Halla Hospital)

Seon Hee Kim (Pusan National Univ. Hospital)

Ho-Seong Han (President, The Korean Society of Traumatology)

Jong-Seong Ahn (Commanding General, Armed Forces Medical Command, ROK)

Hiroyuki Hirasawa (Chiba Univ. Graduate School of Medicine)

Akio Kimura (Chief of JAST)

Training Course 1 (KR) - Chest Trauma/Hemorrhage

Plenary Session 1 - Step by Step 2017

Director : Seon Hee Kim (Pusan National Univ. Hospital)Moderator : Dong Kwan Kim (Ulsan Univ. Hospital) / Dong Seok Moon (Korea Univ. Guro Hospital)

Director : Sung-Hyuk Choi (Korea Univ. Guro Hospital)Moderator : Ho-Seong Han (President, The Korean Society of Traumatology) / Jong-Seong Ahn (Commanding General, Armed Forces Medical Command, ROK)

I Opening Address I

8



Congratulatory Remark

Congratulatory Remark

Suggestion of President for Traumatology

Antithrombin-III in the Treatment of Trauma Patients

Clinical Benefit of Volume Therapy with HES 130/0.4 in Trauma Patients

11:50-11:55

11:55-12:00

12:00-12:30

12:30-13:30

13:30-14:10

039

042

Keun-Young Yoo (President, Armed Forces Capital Hospital)



Hang Joo Cho (The Catholic Univ. Hospital)

Karim Asehnoune (Univ. Hospital of Nantes)


Luncheon Symposium (CJ) / Small Auditorium

Special Lecture - Intensive Care Medicine

Director : Young-Hoon Yoon (Korea Univ. Hospital)Moderator : Kang-Hyun Lee (Vice-President, The Korean Society of Traumatology)

Moderator : Kang-Hyun Lee (Vice-President, The Korean Society of Traumatology)

Director : Do Joong Park (Seoul National Univ. Bundang Hospital)Moderator : Do Joong Park (Seoul National Univ. Bundang Hospital)

I Congratulatory Address I


Scientific Program

9



Scientific Program

Prehospital Trauma Patients Management in Japan

Prehospital Trauma Patients Management in Korea

In Hospital Trauma Patients Management in Japan

In Hospital Trauma Patients Management in Korea

Coffee Break

Operative Management in Polytrauma Patients in Japan

Operative Management in Polytrauma Patients in Korea

Postoperative Management in Polytrauma Patients in Japan

Postoperative Management in Polytrauma Patients in Korea

14:10-14:35

14:35-15:00

15:00-15:25

15:25-15:50

15:50-16:10

16:10-16:35

16:35-17:00

17:00-17:25

17:25-17:50

18:00-20:00

045

044

050

052

1

056

058

062

064

Hayato Takayama (Nagasaki Univ. Hospital Regional Medical Support Center)

SungWoo Moon (Korea Univ. Hospital)

Takashi Fujita (Chairman, Committee on International Liaison, JAST Associate Professor, Trauma and Resuscitation Center, Teikyo University)

Hyun-min Cho (Pusan National Univ. Hospital)

Akihiro Usui (Sakai Municipal Hospital)

Chan Yong Park (Pusan National Univ. Hospital)

Nobuyuki Saito (Nippon Medical Univ. Chiba Hokuso Hospital)

Namyeol Kim (Korea Univ. Guro Hospital)

Japan-Korean Symposium 1 - Trauma System

Japan-Korean Symposium 2 - Surgery and ICU Care in Polytrauma Patients

Director : Gil Joon Suh (Seoul National Univ. Hospital)Moderator : Yasumitsu Mizobata (Osaka City Univ.) / Gil Joon Suh (Seoul National Univ. Hospital)

Director : Gil Joon Suh (Seoul National Univ. Hospital)Moderator : Yoshinori Murao (Kindai Univ.) / Chae-Hyuk Lee (COL, First ROK Army)

I Social Event (Gala Dinner) I - 7F. Bulgok Hall


10



Scientific Program

Date : June 23, 2017 (Fri.) 09:00-17:50Seminar 1

Hemodynamic Monitoring of the Injured Patient

Massive Pulmonary Embolism: Lyse, Suction or Operate?

Necrotizing Soft Tissue Infections: ICU Challenges

Update of New SCCM/ASPEN Critical Care Nutrition Guideline

Coffee Break

Trauma Management in Nuclear Warfare

09:00-09:20

09:20-09:40

09:40-10:00

10:00-10:20

10:20-10:40

13:30-14:10

067

070

074

076

085

Jin Wi (Yonsei Univ. Hospital)

Jae-Seung Jung (Korea Univ. Hospital)

(Gachon Univ. Gil Hospital)

Jae-Myeong Lee (Korea Univ. Hospital)

Chae-Hyuk Lee (COL, First ROK Army)

Training Course 2 (KR) - Management of Trauma Patients in ICU

Special Lecture - Diaster

Director : Namyeol Kim (Korea Univ. Hospital)Moderator : Jae Baek Lee (Chonbuk National Univ. Hospital) / Hee-Jin Yang (Seoul National Univ. Boramae Hospital)

Director : Hong-Chul Lim (Seoul Barunsesang Hospital)Moderator : Hong-Chul Lim (Seoul Barunsesang Hospital)

11



Scientific Program


Physiological Changes of Elderly Trauma Patients

Orthopedic Trauma Treatment of Elderly Patients

Orthopedic Trauma Treatment of Pediatric Patients

Painful Memory Case I

Painful Memory Case II

Painful Memory Case III

Painful Memory Case IV

Coffee Break

14:10-14:24

14:24-14:38

14:38-14:52

14:52-15:02

15:02-15:16

15:16-15:30

15:30-15:50

15:30-16:10

088

090

092

094

096

097

100

Byungchul Yu (Gachon Univ. Gil Hospital)

Hoon-Sang Sohn (National Medical Center)

Joon-Woo Kim (Kyungpook Univ. Hospital)

Hyung-Keun Song (Ajou Univ. Hospital)

Jae-Hoon Jang (Pusan National Univ. Hospital)

Youngwoo Kim (The Catholic Univ. Hospital)

Jin-Kak Kim (Korea Univ. Hospital)

Symposium 1 - Treatment of Vulnerable Orthopedic Trauma Patients

Director : Yong-Cheol Yoon (Gachon Univ. Gil Hospital)Moderator : Beom Koo Lee (Armed Force Capital Hospital) / Kichul Park (Hanyang Univ. Hospital )

12



Scientific Program


Management of Trauma in Pediatric Patients

Management of Trauma in Pregnant Women

Management of Trauma in Geriatric Patients: Rib Fracture in Octogenerian

Endovascular Treatment of Vascular Injury in the Military Soldiers

16:10-16:35

16:35-17:00

17:00-17:25

17:25-17:50

104

108

110

112

Min Koo Lee (Jeju Halla Hospital)

Seong Hwa Lee (Pusan National Univ. Hospital)

Chun Sung Byun (Yonsei Univ. Wonju College of Medicine)

Taeho Kim (Armed Forces Capital Hospital)

Symposium 3 - Trauma in Special Population

Director : Seon Hee Kim (Pusan National Univ. Hospital)Moderator : Kun Hwang (Inha Univ. Hospital) / Seogki Lee (Chosun Univ. Hospital)

13



Scientific Program


Traumatic Cardiac Arrest - Similar but Different

Airway Matters in Maxillofacial Injury

Cardiac Arrest Associated with Chest Injury

Prehospital eFAST : Evidence-Based Recommendations

Coffee Break

REBOA

09:00-09:20

09:20-09:40

09:40-10:00

10:00-10:20

10:20-10:40

10:40-11:20

115

117

119

121

124

Jun-Dong Moon (Kongju National Univ. Hospital)

Young Hoon Yoon (Korea Univ. Hospital)

Jaykey Chekar (Mokpo Hankook Hospital)

Oh Hyun Kim (Yonsei Univ. Wonju College of Medicine)

Junichi Matsumoto (St. Marianna Univ. JAPAN)

Training Course 3(KR) - Traumatic Cardiopulmonary Arrest (TCPA)

Special Lecture - REBOA

Director : Jun-Dong Moon (Kongju National Univ.)Moderator : Sun Joo Wang (Hallym Univ. Hospital) / Min Koo Lee (Jeju Halla Hospital)

Director : Chan Yong Park (Pusan National Univ. Hospital)Moderator : Chan Yong Park (Pusan National Univ. Hospital)

14



Scientific Program


Preperitoneal Pelvic Packing

Internal Iliac Artery Ligation

Bony Stabilization

Interventional Radiology

Panel Discussion

Coffee Break

Optimal BP & ICP & CPP in TBI Patients

Multimodality Monitoring in TBI Patients

Indications & Timing of Decompressive Craniectomy

Neurologic Sign and Neuroimaging Suggesting Poor Prognosis

Experiences of Spinal Trauma in Military Hospital

14:10-14:30

14:30-14:50

14:50-15:10

15:10-15:30

15:30-15:50

15:50-16:10

16:10-16:30

16:30-16:50

16:50-17:10

17:10-17:30

17:30-17:50

127

128

132

135

137

140

142

144

148

150

Ji Young Jang (Yonsei Univ. Wonju College of Medicine)

Ji Hoon Kim (Ulsan Univ. Hospital)

Ji Wan Kim (Inje Univ. Hospital)

Chang Won Kim (Pusan National Univ. Hospital)

Hwan Jun Jae (Seoul National Univ. Hospital)

Hyuck Jin Choi (Pusan National Univ. Hospital)

Jung-Ho Yun (Dankook Univ. Hospital)

Kum Whang (Yonsei Univ. Wonju College of Medicine)

Nam Kyu Yu (Ajou Univ. Hospital)

Sang Hoon Yoon (Armed Forces Capital Hospital)

Symposium 2 - Bleeding Control in Pelvic Fracture

Symposium 4 - Common Questions about Neurotrauma : Non-Neurosurgeon’s View

Director : Chan Yong Park (Pusan National Univ. Hospital)Moderator : Jeong Ho Kim (Gachon Univ. Gil Hospital) / Hang Joo Cho (The Catholic Univ. Hospital)

Director : Bo-Ra Seo (Mokpo Hankook Hospital)Moderator : In Ho Park (Mokpo Hankook Hospital) / Seong-Keun Moon (Wonkwang Univ. Hospital)

15



Scientific Program

Registration

Management of Traumatic Patients in Japan

Surgical Management in Traumatic Patients

Trauma System in San Antonio Military Medical Center (SAMMC)

Coffee Break

Should TEG/ROTEM be a Standard of Trauma Care?

Retrohepatic IVC Injuries

Open or Closed? The MIS Applied to Trauma

Damage Control Surgery. Light and Dark Side

Date : June 24, 2017 (Sat.) 08:30-17:00Main Auditorium

08:30-09:00

09:00-09:30

09:30-10:00

10:00-10:30

10:30-10:50

10:50-11:15

11:15-11:40

11:40-12:05

12:05-12:30

154

156

158

162

167

171

174

Takashi Fujita (Chairman, Committee on International Liaison, JAST

Associate Professor, Trauma and Resuscitation Center, Teikyo Univ.)

Kenneth Mak (Khoo Teck Paut Hospital)

Kurt Edwards (COL, San Antonio Military Medical Center)

Jae Hun Kim (Pusan National Univ. Hospital)

John Cook-Jong LEE (Ajou Univ. Hospital)


Namryeol Kim (Korea Univ. Hospital)


Symposium 5 - Trauma Management Update

Director : Jongbouk Lee (National Medical Center)

Moderator : Jongbouk Lee (National Medical Center)

Kang-Hyun Lee (Vice-President, The Korean Society of Traumatology)

Director : Namyeol Kim (Korea Univ. Hospital)Moderator : Jung Nam Lee (Gachon Univ. Gil Hospital) / Jungchul Kim (Chonnam National Univ. Hospital)

16



Scientific Program

Date : June 24, 2017 (Sat.) 08:30-17:00Main Auditorium

12:30-13:30

13:30-13:52

13:52-14:12

14:12-14:34

14:34-14:56

15:00-15:30

15:30-16:15

16:15-17:00

177

180

184

188

199

201

Luncheon Symposium (Green Cross) / Small Auditorium

Symposium 8 - Trauma US

Symposium 10 (KR) - Current of Trauma Center : Still Much to be Improved

Moderator : Gil Joon Suh (Seoul National Univ. Hospital)

Director : Oh Hyun Kim (Yonsei Univ. Wonju College of Medicine)Moderator : Il Ung Hwang (Former Commanding General, Armed Forces Medical Command, ROK) Young-Rock Ha (Bundang Jesaeng Hospital)

Director : Kang-Hyun Lee (Yonsei Univ. Wonju College of Medicine)Moderator : Hyun-min Cho (Pusan National Univ. Hospital) / Keum Seok Bae (Yonsei Univ. Wonju College of Medicine)

Fluid Resuscitation

Recent Updates in FAST from the Perspective of a Trauma Surgeon

Ultrasound Guided CVC in Trauma

The Role of POCUS in Cardiovascular Trauma

The Role of Lung US in Trauma

Coffee Break

Proposal for Improvement of the System for Dedicated Trauma Specialist

Outcomes of the Supporting Services for Installation of Regional Level 1 Trauma Centers

Kyu Seok Kim (Seoul National Univ. Bundang Hospital)


Han-Ho Do (Dongguk Univ. Ilsan Hospital)

Bo Seung Kang (Hanyang Univ. Guri Hospital)

Young-Rock Ha (Bundang Jesaeng Hospital)


Jong-Min Park (National Trauma System Management Office)

17



Scientific Program

Date : June 24, 2017 (Sat.) 10:50-15:00Seminar 1

CPR in Blunt Trauma Patients: Indication and Contraindication, How long?

Vascular Access in Shock Patients: Who, When, Where, What, How, Why?

Crystalloid versus Colloid: Which on is Better for Shock Patients?

Initial Response to Trauma Team Activation: Which Specialists Should be Involved?

Trauma Team Leader: Emergency Physician vs. Trauma Surgeon

2016 Combat Orthopedic Trauma

Epidemiology of Burn in Military

What’s New in Traumatic Hemorrhagic Shock

Sharing Experience of Forward Surgical Team in Afghanistan

10:50-11:10

11:10-11:30

11:30-11:50

11:50-12:10

12:10-12:30

13:30-13:52

13:52-14:14

14:14-14:36

14:36-14:58

218

220

223

227

229

233

239

242

256

Soon Chang Park (Pusan National Univ. Hospital)

Junsik Kwon (Ajou Univ. Hospital Trauma Center)

Do Wan Kim (Chonnam National Univ. Hospital)

Maru Kim (The Catholic Univ. Hospital)

(Gachon Univ. Gil Hospital)

Jeong Kook Baek (MAJ, Armed Forces Ildong Hospital)

Jang-Kyu Choi (MAJ, Armed Forces Capital Hospital)

Hohyung Jung (CPT, Armed Forces Capital Hospital)


Symposium 6 (KR) - Medical Treatment Guideline Committee

Symposium 9 - The Future of Military Trauma Care, Patient First in Military Trauma

Director : Jung Joo Hwang (Eulji Univ. Hospital)Moderator : Seok Ho Choi (Dankook Univ. Hospital) / Jung Joo Hwang (Eulji Univ. Hospital)

Director : Duck Hyun Ryu (Armed Force Capital Hospital)Moderator : Byung-Seop Choi (COL, Armed Forces Medical Command) Beomman Ha (COL, Armed Forces Capital Hospital)

18



Scientific Program

Date : June 24, 2017 (Sat.) 10:50-12:30Seminar 2

Trauma Bay

Trauma Intensive Care Unit

Physician Assistant

Registry

Performance Improvement

10:50-11:10

11:10-11:30

11:30-11:50

11:50-12:10

12:10-12:30

260

262

265

267

269

Sun Mi Kim (Pusan National Univ. Hospital)

Kyung Mi Kim (Dankook Univ. Hospital)

Myung Jin Jang (Gachon Univ. Gil Hospital)

Sang Mi Noh (Chonnam National Univ. Hospital)


Symposium 7 - Nursing Roles in Trauma Center

Director : Chan Yong Park (Pusan National Univ. Hospital)Moderator : Myung I Choi (Chonnam National Univ. Hospital) / Kyung Hag Lee (National Medical Center)

Training Course 1(KR)

Chest Trauma/Hemorrhage


Director


Moderator

Dong Kwan Kim (Ulsan Univ. Hospital)

Dong Seok Moon (Korea Univ. Guro Hospital)

1F. Main Auditorium

06-23 (Fri.), 2017

20


08/2012 - 03/2007 PhD. in Immunology

Graduate School of Medical Science and Engineering , KAIST, Daejeon, Korea

02/2002 - 03/1998 MS in Anatomy

School of Medicine, Yonsei University, Seoul, Korea

02/1996 - 03/1990 MD in School of Medicine, Yonsei University, Seoul, Korea

2016.10.1- Present: Trauma Center, Eulji University Hospital, Daejeon, Korea

2014.9.1 2016.9.30: Associate Professor, Department of Trauma Surgery, PNUH

Department of Cardiothoracic Surgery, Eulji University Hospital, Daejeon, Korea

Department of Cardiothoracic Surgery, Gangnam Severance Hospital, Seoul, Korea

The Korean Society of Traumatology

The Korean Society for Thoracic & Cardiovascular Surgery

The Korean Society and European society of Critical Care Medicine

The Korean Association for the Study of Lung Cancer

Education

AcademicAppointments

ProfessionalAssociations


Training Course 1(KR) - Chest Trauma/Hemorrhage

21


Physiology of Chest Trauma :

Non-Compressible Torso Hemorrhage


Hemorrhage is the leading cause of potentially preventable death in both military and civilian

trauma, accounting for over 80% of deaths in recent reports. Significant hemorrhage originating

within the torso is particularly challenging as there is no reliable method of control without an

operating room or interventional suite. Approximately 15% of patients admitted to Level 1 trauma

centers in the US from 2007-2009 in the National Trauma Data Bank had NCTI (non-compressible

torso injury). NCTH(non-compressible torso hemorrhage) was associated with an extremely high

mortality rate of 45%, with torso vessel and pulmonary injury identified as independent predictors

of death. The importance of uncontrolled torso hemorrhage has been re-emphasized by US military

studies analyzing data from the wars in Iraq and Afghanistan. Torso hemorrhage was found to be

the leading cause of potentially survivable death. A further analysis of US military deaths from 2003-

2004 and 2006 showed that hemorrhage accounted for 87% and 83% of all deaths, respectively.

Among patients with hemorrhage, 50% were due to NCTH and 33% were due to extremity injury.

Identification of patient and injury factors associated with this lethal, yet potentially survivable

injury may help to channel timely interventions to improve survival/outcomes. Early identification

of patients with non-compressible torso hemorrhage (NCTH) may assist in prompt interventions

leading to improved survival. More recent guideline from the Western Trauma Association

(WTA), published in 2016, describes several “complimentary, and not mutually exclusive, options”

including pelvic stabilization, pre-peritoneal packing, REBOA, and endovascular therapy without

clear superiority of any one strategy. Further studies are needed and we hope that new treatment

options will be emerging soon.

The 5th Pan Pacific Trauma Congress

The 32nd Annual Meeting of the Korean Society of Traumatology

22


Dankook University College of Medicine (Master of Medicine)

Resident in the Department of Thoracic Surgery, Dankook University Hospital

Clinical Instructor (fellowship), Seoul Samsung Hospital, Department of Thoracic

Surgery

Board of Trauma Surgery

Board of Critical Care Specialty

In Charge of General Affairs for The Korean Society for Thoracic & Cardiovascular

Surgery Congress

Korean Medical License

Director of Education Board in Korea Association for Research, Procedures and

Education on Trauma

Clinical Assistant Professor of Trauma Center, Thoracic Surgery in Dankook

University Hospital

Clinical Associate Professor of Trauma Center,Thoracic Surgery in Dankook

University Hospital

Education

Academic

Appointments



23


Management of Life-Threatening Chest

Trauma : Resuscitative Thoracotomy


In 1874, Moritz Schiff described open cardiac massage as a resuscitative maneuver, and in 1966,

Beall wrote the important role of thoracotomy regardless of the location of the patient. However,

the limited success of resuscitative thoracotomy(RT) prohibited the use of the procedure. Especial-

ly, RT is rarely performed for damage control resuscitation in South Korea.

The aim of RT is as follows: to relieve cardiac tamponade, to perform open cardiac massage, to

control life-threatening intrathoracic hemorrhage, to control air embolism or bronchopleural fistula

and to occlude the thoracic aorta for improving cerebral, coronary circulation and decreasing in-

tra-abdominal and pelvic hemorrhage.

In general, current indication and clinical pathway of RT is as follow. (7th TRAUMA)



24



And RT is contraindicated in the following situations:

1) Patients with no signs of life and blunt trauma requiring greater than 10 minutes of CPR

2) Penetrating trauma requiring greater than 5 min(non-torso), 15 minl(torso) of CPR

3) Severe brain injury

4) Pulseless to emergency department without signs of life after blunt

RT is a high-risk and low-survival procedure, but it may be a life-saving option for selected pa-

tients. RT remains unfamiliar procedures in South Korea, too. However, if education program is

provided to trauma physician, and consensus for RT is achieved, the probability of survival with RT

may be expected in South Korea.

25


Clinical Fellowship, Department of Thoracic and Cardiovascular Surgery

Puchon Sejong Hospital, Puchon, Korea 3/2000 to11/2000

Supervised by Young Tak Lee, M.D., Ph.D. (Presently Chief Cardiothoracic Surgeon

at Samsung Medical Center)

Korean Medical Association - Lifetime Member

Korean Thoracic and Cardiovascular Surgery Society - Lifetime Member

Korean Tracheobronchial and Esophageal Surgery Society - Member

Doctor of Philosophy in Medicine (Ph.D. - August 1999)

Department of Thoracic and Cardiovascular Surgery Hanyang University Seoul,

Korea

Korean Board of Thoracic and Cardiovascular Surgery License

License to Practice Medicine in Korea License

PostDoctoral Fellowshipand Internships

ProfessionalAssociations and boardCertifications

Education andProfessional Certifications

CertificationLicensure



26


Surgical Rib Fixation


Thoracic trauma is related to 25% trauma related mortality. Greater than 3 rib fractures is related

to higher risk of pulmonary complications and higher morbidity and mortality. Flail chest is a

generally accepted indication of rib fixation, however other indications are still a subject of debate.

The benefits of rib stabilization are becoming clear. There are shorter ICU and hospital stays,

lower rate of complications, shorter duration of mechanical ventilation, lower mortality rates, lower

risk of reintubation, decrease in need for tracheostomy, decrease in chest wall deformity, decrease

in pain, improved lung function, and increase in return to work. The suggested indications for

rib fixation are flail chest, 3 or more rib fractures with displacement, respiratory embarrassment,

uncontrolled pain in non-union fracture or overlapping fractures, lung impalement, open chest

defect, chest wall deformity, as adjunct to thoracotomy, and pulmonary herniation. The suggested

ideal timing for the operation is 24 to 72 hours after the traumatic event and 48 hours after

evaluation of head injury. VATS in rib stabilization is relatively new and the advantages will be

discussed. Common methods of rib fixation are relatively new. We have performed 31 cases in

Jeju in a 4 year period, 6 cases of which were performed in the last two months. A discussion of

some interesting cases will also be presented. More prospective and large multicentral studies are

needed to establish a standard in the indications for rib fixation.



27


Mar. 2012 - Feb. 2014

Completion the Course of Ph.D. of Medical Science

Pusan National University School of Medicine, Medical Research Institute,

Busan, Korea

Mar. 2011 - Feb. 2013

Fellowship in Department of Trauma Surgery

Pusan National University hospital, Pusan National University School of

Medicine

Medical Research Institute, Busan, Korea

May. 2013 -

Assistant professor, Trauma Surgery

Pusan National University Hospital, Pusan National University School of

Medicine

Medical Research Institute, Busan, Korea

Education

Post-Graduate

Training

Hospital

Appointments



28


Post-Traumatic ARDS


Acute respiratory distress syndrome (ARDS) is a potentially lethal problem in trauma

patients[1,2]. Based on the Berlin definition[3], the typical presentation of posttraumatic ARDS is

a hypoxemic status [an arterial oxygen tension(PaO2)/fraction of inspired oxygen (FiO2) ratio

≤ 300 mmHg with a positive end-expiratory pressure (PEEP) ≥5 cmH2O] that is accompanied

with bilateral pulmonary opacities, and occurs shortly after trauma. The common predisposing

factors of posttraumatic ARDS are blunt thoracic injuries, traumatic shock requiring massive blood

transfusion, and an injury severity score (ISS) ≥ 25 [2]. Similar to ARDS caused by nontraumatic

etiologies, posttraumatic ARDS is primarily treated with mechanical ventilation. To reduce the

injurious effects of cyclical inflation and deflation on the already injured lungs during positive

pressure ventilation, lung-protective ventilation is preferred among ARDS patients, using low tidal-

volumes (≤6 mL/kg/min) and optimal PEEPs to achieve an inspiratory plateau pressure(Pplt) ≤ 30

cmH2O [4,5]. However increases in FiO2, PEEP, and Pplt may be unavoidable when an acceptable

arterial oxygenation cannot be maintained. The hyperinflatedhyperoxic ventilation may exacerbate

pulmonary shunting and induce a repeated mechanical-biological trauma [6]. This ventilator-induced

lung injury may initiate a vicious cycle that leads to severe ARDS (PaO2/FiO2 ratio ≤100 mmHg)

with multiple organ dysfunctions [7]. Venovenous extracorporeal life support (VV-ECLS) may break

this vicious cycle by conducting a prepulmonary blood gas exchange to share the workload with

native lung, which enables physicians to continue lung-protective ventilation [8].



29



1. Salim A, Martin M, Constantinou C, Sangthong B, Brown C, Kasotakis G, Demetriades D,

Belzberg H: Acute respiratory distress syndrome in the trauma intensive care unit: Morbid but

not mortal. Arch Surg 2006, 141(7): 655-658.

2. Watkins TR, Nathens AB, Cooke CR, Psaty BM, Maier RV, Cuschieri J, Rubenfeld GD: Acute

respiratory distress syndrome after trauma: development and validation of a predictive model.

Crit Care Med 2012,40(8): 2295-2303.

3. Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, Camporota L,

Slutsky AS: Acute respiratory distress syndrome: the Berlin Definition. JAMA 2012, 307(23):

2526-2533.

4. ᅟ: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute

lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress

Syndrome Network 1. N Engl J Med 2000, 342(18): 1301-1308.

5. Brower RG, Lanken PN, MacIntyre N, Matthay MA, Morris A, Ancukiewicz M, Schoenfeld D,

Thompson BT: Higher versus lower positive end-expiratory pressures in patients with the acute

respiratory distress syndrome. N Engl J Med 2004, 351(4): 327-336.

6. Gattinoni L, Carlesso E, Caironi P: Stress and strain within the lung. Curr Opin Crit Care 2012,

18(1): 42-47.

7. Quilez ME, Lopez-Aguilar J, Blanch L: Organ crosstalk during acute lung injury, acute respiratory

distress syndrome, and mechanical ventilation. Curr Opin Crit Care 2012, 18(1): 23-28.

8. MacLaren G, Combes A, Bartlett RH: Contemporary extracorporeal membrane oxygenation for

adult respiratory failure: life support in the new era 1. Intensive Care Med 2012, 38(2): 210-220.

Nevertheless, because of its inherent thrombogenicity owing to the blood-surface interaction [9],

VV-ECLS requires systemic heparinization and involves a 40% risk of hemorrhage at intracranial,

surgical, and cannulation sites[10]. This risk may increase when VV-ECLS is administrated to patients

who have just sustained major trauma and damage-control interventions. These patients tend to

have the trauma-induced coagulopathy (TIC) [11] and may be vulnerable to heparinization

Plenary Session 1

Step by Step 2017


Director

Sung-Hyuk Choi (Korea Univ. Guro Hospital)

Moderator


Jong-Seong Ahn (Commanding General, Armed Forces Medical Command, ROK)

1F. Main Auditorium

06-23 (Fri.), 2017

31


Chiba University School of Medicine - form April, 1960 to March, 1966

Graduate School of Medicine, Chiba University - from April, 1967 to March, 1971

International Federation of Shock Societies (President, Congress President for

2016)

Society of Critical Care Medicine(Co-Chair for 2008 Meeting, Active Member)

The Shock Society (Active Member and Official Journal “Shock” Associate Editor)

European Shock Society (Active Member)

International Society for Artificial Organs (Active Member)

International Society of Blood Purification (Active Member)

Asia-Pacific Association of Critical Care Medicine (Council Member, Honorable

President for 2012 Congress)

Education

Membership in International Medical Society



32


The Pathophysiology of Shock


At the consensus conference on hemodynamic monitoring in shock being held in 2006,

three very important description concerning the definition of shock was proposed. Namely,

1) hypotension is not required to define shock, 2) As a result, assignment of the presence of

inadequate tissue perfusion on physical examination is important, 3) Only biomarker recommended

for diagnosis or staging of shock is blood lactate. Then in the next consensus conference on

hemodynamic monitoring on circulatory shock being held in 2014, it was proposed that shock

is best defined as a life-threatening, generalized form of acute circulatory failure associated with

inadequate oxygen utilization by the cells. They further described that shock is a state in which the

circulation is unable to deliver sufficient oxygen to meet the demands of the tissues, resulting in

cellular dysfunction. They also described that the result of such state is cellular dysoxia, i.e. the loss

of the physiological independence between oxygen delivery and oxygen consumption, associated

with increased lactate levels. Therefore, basically shock is the state of inadequate oxygen utilization

by the cell due to the circulatory failure which is best diagnosed with blood lactate level.

Traditionally shock was classified according to the causes of shock, such as hemorrhagic shock,

anaphylactic shock, neurogenic shock and septic shock. However, recent classification of the

shock is depend on the hemodynamic states of shock patients, and shock is classified into the

following four types: cardiogenic shock, hypovolemic shock, obstructive shock and distribute

shock. Among those four types of shock, distributive shock is most important. Distribute shock

may be subgrouped into two types: Septic shock and non-septic distributive shock. Vincent J-L

and colleagues reported that 62% of shock treated in ICU is septic shock and 4% is non-septic



33



distributive shock, which followed by cardiogenic shock (16%), hypovolemic shock (16%) and

obstructive shock (2%), respectively. So in clinical settings, the most important type of shock is

distributive shock, especially septic shock.

Among traumatized patients hypovolemic shock due to massive hemorrhage may be

developed immediately after injury. However, even traumatized patients often develop septic

shock during their clinical course through the complicated severe infection caused by post-injury

immunosuppression. Therefore, septic shock is important form of shock even to the trauma

surgeons.

Septic shock is developed basically through dysregulated host response by overwhelming

hypercytokinemia. Such hypercytokinemia is caused by overwhelming cytokine production

by many types of cells through the recognition of PAMPs (pathogen-associated molecular

patterns) such as LPS and the recognition of DAMPs (damage-associated molecular patters), or

sometimes referred to Alarmins, such as HMGB-1 by pattern recognition receptors such as toll-

like receptors. Furthermore such DAMPs include damaged tissues and damaged cells following

trauma and therefore, non-septic distributive shock could be developed following injury due

to hypercytokinemia through the recognition of DAMPs such as damaged tissues by pattern

recognition receptors. In the recent consensus statement (Sepsis-3), sepsis is defined as life-

threatening organ dysfunction caused by a dysregulated host response to infection and septic

shock is defined as a subset of sepsis in which underlying circulatory and cellular/metabolic

abnormalities are profound enough to substantially increase mortality.

Thus, the main pathophysiological features of septic shock are hypercytokinemia. And therefore,

some countermeasures against hypercytokinemia should be considered following the effective

therapeutic approaches to infection such as administration of adequate antibiotics and surgical

removal and/or drainage of infectious foci. We have reported that continuous hemodiafiltration

with cytokine-adsorbing hemofilter is an effective therapeutic approach to hypercytokinemia and

therefore to septic shock following the adequate approach to infectious foci.

34



References

1) Antonelli M, Levy M, Anderws PJD, et al: Hemodynamic monitoring in shock and implications

for management. International Consensus Conference, Paris, France, 7-28 April 2006.

Intensive Care Med 2007; 33: 575-90.

2) Cecconi M, De Backer D, Antonelli M, et al : Consensus on circulatory shock and

hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine.

Intensive Care Med 2014; 40: 1795-815.

3) Vincent J-L, De Backer D: Circulatory shock. N Engl J Med 2013; 369: 1716-34.

4) Vincent J-L, Opal SM, Marshall JC, et al: Sepsis definitions: Time to change. Lancet 2013; 381:

774-5.

5) Singer M, Deutschman CS, Seymour CW, et al: The third international consensus definitions

for sepsis and septic shock (Sepsis-3). JAMA 2016; 315: 801-10.

6) Shiga H, Hirasawa H, Nishida O, et al: Continuous hemodiafiltration with a cytokine-

adsorbing hemofilter in patients with septic shock: a preliminary report. Blood Purif 2014; 38:

211-8.

35


Mar. 1984: Graduated from Gifu University, School of Medicine

May 1984: Obtained the M.D. Degree

Dec. 1992: Obtained the Ph.D. Degree in Medical Science

Apr. 2005~: Granted the Guest Professor of Gifu University, School of Medicine

Apr. 2006~: Granted the Guest Professor of Tokyo Medical and Dental University,

School of Medicine

Apr 2014~: Professor of the Postgraduate School of Juntendo University, School of

Medicine

Faculty Member of Japanese Association for Acute Medicine

Chair of Executive Board of Japanese Association of Surgery for Trauma

Corresponding Member of American Association for the Surgery of Trauma

Member of International Association for Trauma Surgery and Intensive Care

Member of the Asian Association of EMS

AcademicBackground

Membership ofAcademicSociety



36


The Shock Index Revisited


Introduction: The shock index (SI) is heart rate (HR) divided by systolic blood pressure (SBP)

has been reported to be a more sensitive marker for shock than standard vital signs alone. The

revers shock index (rSI), namely SBP divided by HR, may be more suitable for practitioners.

Moreover, in patients aged >55 years, SI multiplied by age (SIA) might be a better predictor of early

post-injury mortality． On the other hand, the Glasgow Come Scale (GCS) Score has been proven

to be a strong predictor for mortality. For further development of all above ideas, we hypothesize

that the rSI multiplied by GCS score (rSIG) or the rSIG divided by age (rSIG/A) can be a better

predictor of survival or of requirement for early blood transfusion (BT).

Methods: This is a retrospective, multicenter study using 168,517 patients’ data obtained from

the JTDB for 2006-2015. calculated the areas under (AU) the receiver operating characteristic curves

(ROCC) to measure the ability of SI, SIA, SI/G, SIA/G, sSIG and rSIG/A to predict the hospital

mortality outcome and the 24-hour BT outcome. We compared AUROCCs and determined cut off

value of each predictor

Results: Among the caliculated values, the rSIG had the highest AUROCC for survival in

younger patients (<55 years old) and for 24-hour BT. The cut off values were six for survival and

nine for BT. In older patients (≥55 years old), The ROCC of the rSIG/A was the most sensitive for

survival with the cut off value of 0.2.



37



Conclusions: The rSIG is easy to calculate at bed side and is a good predictor for both survival

and for early BT, with the cut off value of six and nine, respectively. In patients aged ≥55, The

rSIG/A should be used with the cut off value of 0.2.

Plenary Session 2

Step by Step 2017


Director

Young-Hoon Yoon (Korea Univ. Hospital)

Moderator


1F. Main Auditorium

06-23 (Fri.), 2017

39


1978-1984 M.D., Seoul National University College of Medicine

1986-1988 M.S., Seoul National University College of Medicine

1989-1993 Ph.D., Seoul National University College of Medicine

1984-1985 Intern, Seoul National University Hospital

1985-1989 Resident, Department of Surgery Seoul National University Hospital

1989-1993 Assistant professor, Department of Surgery, Gyeongsang

National University College of Medicine

1993-2003 Associate professor & Chairman of Department of Surgery,

Ewha Womans University College of Medicine

2003- Present Professor of Department of Surgery Seoul National University

College of Medicine

2012- Present Director of Comprehensive Cancer Center Vice President in

Cancer and Neuroscience Seoul National University Bundang Hospital

2015- Present President, Korean Society of Traumatology

2008- Present President, Korean Study Group of Laparoscopic Liver Surgery

2012- 2014 Past President, Korean Study Group of Pancreas Surgery

2014- 2016 Past President, Korean Society of Surgical Metabolism and Nutrition

2014- 2016 Past Chairman of Board of Directors, Korean Society of Surgical Oncology

2016- Present Chairman of Board of Directors, Korean Society of Laparoscopic &

Endoscopic Surgeons*

2009- 2011 Chairman of Public Relations Committee, Korean Society of

Hepatobiliary Pancreas Surgery

Education &Degrees

Positions

Membership



40


Suggestion of President for Traumatology




Special Lecture

Intensive Care Medicine


Director

Do Joong Park (Seoul National Univ. Bundang Hospital)

Moderator

Do Joong Park (Seoul National Univ. Bundang Hospital)

1F. Main Auditorium

06-23 (Fri.), 2017

42


Karim Asehnoune got his degree as MD in 1999 at University René Descartes Paris, France. After

completing his PhD in immunology in 2001, he spent one year in the lab of Edward Abraham in Denver,

USA (2002). He was appointed Professor of Anaesthesiology and Critical Care Medicine in the University

of Nantes in 2009. Professor Asehnoune is the head of the Anaesthesiology department of Hospital Hotel-

Dieu, and the director of the 30-bed surgical Intensive Care Unit at the University hospital of Nantes,

France. He is currently member of the scientific committee of the French Society of Anaesthesiology and

Critical Care Medicine, and the director of a French network of ICUs (www.ATLANREA.org). Professor

Asehnoune was involved as the coordinator of several multi-centre trials, and he is the director of a lab

dedicated to the study of host-pathogen interactions (http://www.ea3826.univ-nantes.fr/). His main

focuses of interests are, severe trauma, and pulmonary complications, and immunodepression-induced

pneumonia after traumatic brain injuries. He has published more than 155 peer-reviewed articles.



43


Clinical Benefit of Volume Therapy with HES

130/0.4 in Trauma Patients





Director

Gil Joon Suh (Seoul National Univ. Hospital)

Moderator

Yasumitsu Mizobata (Osaka City Univ.)


1F. Main Auditorium

Japan-Korean Symposium 1

Trauma System

06-23 (Fri.), 2017

45


1986: Graduated from Nagasaki University School of Medicine

1986: Junior Resident, National Hospital Nagasaki Central Hospital

1988: Surgeon, the Medical Union of Nagasaki Prefecture Hospitals

1996: Chief of Critical Care Medicine, National Hospital Nagasaki Medical Center

2010: Director of Critical Care Medicine, National Hospital Nagasaki Medical

Center

2016: Current Position

Medical Control Council of Nagasaki Prefecture

JPTEC Council Research Subcommittee,

JPTEC Kyushu Representative

Japanese Association for Acute Medicine

Japanese Society for Aeromedical Services Director

Conference for Emergency Medical in Rural Areas and Isolated Islands

Representative

Education

Professional

Experiences

Committee

Members

Hayato Takayama

(Nagasaki Univ. Hospital Regional Medical Support Center)

Japan-Korean Symposium 1- Trauma System

46


Prehospital Trauma Patients Management

in Japan

Hayato Takayama (Nagasaki Univ. Hospital Regional Medical Support Center)

Background

The beginning of Pre-hospital Trauma care Japan (PTCJ) was brought to Japan in Nov. 1999, at

the workshop of the paramedic hold in Hiroshima. It was based on 2 American existing systems,

"Basic Trauma Life Support (BTLS)" and "Pre-hospital Trauma Life support (PhTLS)". Before this

introduction, Japanese pre-hospital system was based on paramedic's experience. The first PTCJ

seminar was hold on 2000, paramedics of all over Japan attended as students. On the next year,

2nd Seminar is learned by 16 leading ER doctor and paramedics in Japan.

For the making of system

We proceeded with the adaptation of PTCJ on "Ministry of health, labor and welfare" and

"Foundation for ambulance service development". PTCJ also in a request program of the Medical

control (MC) doctor, on examination committee of "Japanese Association for Acute Medicine." Two

groups surround Japanese emergency trauma system ware appeared on this time. "JPTEC council

" is in charge of pre-hospital field, they provide "JPTEC course". On the other one, " JTCR (Japan

trauma care and Research)" is in charge of in-hospital field.

Expansion of JPTEC

JPTEC council started operation as a lower branch of "Japanese Association for Acute Medicine."

Holding seminar for the sake of make a standard JPTEC course as part of medical control. JPTEC

became a standard of pre-hospital activity today. It spread to paramedics and also use in text of fire



47



academy.

Revised JPTEC guidebook was published on last year. 2 new courses, "first responder course "

for general public and "mini-course" for medical stuff are rolled on July 2016.

Our goal of future

JPTEC council will continue our effort to reduce traumatic death can be prevented, raise the

quality of paramedics, and disseminate not only whole health care workers, but also general

public.

48


1996 : Korea University, College of Medicine, Seoul, Korea (Bachelor of medicine, MD)

2001-2003: Korea University Graduate School of Medicine (Master’s Degree)

2005-2008: Korea University Graduate School of Medicine (Ph.D.)

March 1996 - February 1997: Rotating Internship Korea University Medical Center,

Seoul, Korea

March 1998 - April 2001: Military service as an Army Doctor (Lieutenant)

May 2001 - February 2005: Residency, Emergency Department, Korea University

Ansan Hospital

March 2005 - February 2006: Clinical & Research Fellow, Emergency Department,

Korea University Ansan Hospital

March 2006 - February 2009: Clinical Assistant Professor, Emergency Department,

Korea University Ansan Hospital

March 2011 - August 2016: Associate Professor, Emergency Department, Korea

University Ansan Hospital

September 2016 - at present: Professor, Emergency Department, Korea University

Ansan Hospital

The Korean Council of EMS Physicians; Education Committee Chair

Gyunggido Emergency Medicine Service Center: Director

Ansan Fire Department: Medical Director

Education

Postdoctoral

Training and

Position

Professional

Societies



49


Prehospital Trauma Patients Management

in Korea


In Korea, pre-hospital care for trauma patients is provided by EMS providers of fire department

(119), which is government agency. Korea has two level of EMS provider’s certification. Level 1

emergency medical technicians (EMTs) is compatible with emergency life-saving technician in

Japan, and they provide advanced skills including advanced airway, intravenous access and fluid

infusion. However, scope of practice for EMTs is relatively narrow compared to western country

such as US.

One of integral part in pre-hospital trauma care system is medical direction (direct and indirect).

Direct (on-line) medical direction is performed by certified medical directors at the central fire

agency office of each province. By on-line medical direction, EMS providers could make better

decision for severely injured patient care, destination hospital designation, etc. A total of 196

physicians are appointed as medical directors for 198 community fire departments, and they

actively involve quality improvement activities, including education and performance measure.

Inclusive trauma system derived from the idea that trauma care should be community based

rather than trauma center based, encompassing injury prevention, pre-hospital emergency medical

care, acute care hospitalization, and subsequent rehabilitation. EMS system is one of the important

parts in the inclusive trauma care system. In Korea, EMS system have been developed as an

important part for system of trauma care. Proper medical directorship, continuing effort for quality

improvement have been integral part for pre-hospital trauma care improvement in Korea.



50


1999-2008 Research Fellow in Nagoya University Graduate School of Medicine

2010 The Degree of “Doctor of Medical Science (PhD)” was Awarded

from Teikyo University

2011-Present Associate Professor in Trauma and Resuscitation Center

Department of Emergency Medicine, Teikyo University

2009-2011 Assistant Professor in Trauma and Resuscitation Center


2000 Board Certificate Member of the Japanese Association of Acute

Medicine (Present; Senior Fellow of he Japanese Association of

Acute Medicine)

2008 Board Certification Member in the Japanese Organization of Cancer

Therapy

2013-Present Active Member - International Surgical Society ( ISS/SIC)

2013-Present General Secretariat of in International Association of Trauma and

Intensive Care(IATSIC) - Japan chapter in International Surgical

Society ( ISS/SIC)

Course Coordinator International Association of Trauma and

Intensive Care(IATSIC)

Education

Professional

Training and

Employment

Licensure and

Certification

Profesessional

Activity


Takashi Fujita (Chairman, Committee on International Liaison, JAST Associate Professor, Trauma and Resuscitation Center, Teikyo Univ.)

51


In Hospital Trauma Patients

Management in Japan




52


Medical College, Yonsei University (MB)

Graduate School of Medicine, Seoul National University (ABD)

Life Member of The Korean Society of Traumatology

Life Member of The Korean Society for Thoracic & Cardiovascular Surgery

2003.03 - 2011.02 : Assistant Professor, Department of Thoracic & Cardiovascular

Surgery (Konyang Univesity Hospital, Daejeon, Korea)

2011.03 - 2013.11 : Associate Professor, Department of Thoracic & Cardiovascular


2013.12 - 2014.04 : Associate Professor

2014.04 - Present : Fund Professor

2015.03 - Present : Director of Trauma Center, Pusan National University Hospital,

Busan, Korea

2013.06 - Present : Secretary general, The 2nd & 3rd PPTC

2014.03 - Present : Councilor of KARPET(Korean Association of Research, Procedure

and Education on Trauma) Faculty of ESPIT(Essential Surgical

Procedures In Trauma)

2014.09 - Present : Director of BESPIT

Academic

Background

Work

Experience



53


In Hospital Trauma Patients Patients

Management in Korea


Trauma is a leading cause of deaths for the working age population under 44 years old and a

source of expensive socioeconomic losses in Korea. Moreover, the preventable trauma death rate

in Korea is still higher than in developed countries. Korean government has been making a major

effort to establish a trauma system since 2000, but inadequacies of the current trauma system still

result in many preventable deaths from accidental injuries. For this reason, national support for

the establishment of regional trauma centers was launched in 2012 by the Ministry of Health and

Welfare. The purpose of this project is to designate 17 regional trauma centers distributed evenly

across the country and provide adequate care for seriously injured patients 24 hours a day, 7 days

a week. At present, 16 regional trauma centers have been designated and 9 of them have officially

opened.

In PNUH trauma center, all trauma patients admitted to the hospital were more than 2,500 and

900(36%) of them were severe trauma patients. The proportion of severe trauma patients (ISS >

15) directly transferred to TER (trauma center emergency room) was 74% (662). In spite of field

triage system, many severely injured patients (238, 26%) were transferred to ER (emergency center

emergency room). The results of treatment for severe trauma patients were ICU (416, 46.2%),

operation room (369, 41%), general ward (72, 8%), death (23, 2.6%) and transfer (20, 2.2%). The

proportion of LOS (length of stay) less than 3 hours of TER and ER was 78%, however, that of TER

only was 89%. Furthermore, indices of preventable trauma death rate (O:E ratio and W-score) were

dramatically improved after opening of regional trauma center.

Regional trauma centers must play a key role in a regionally inclusive trauma system that



54



integrates emergency medical systems and healthcare delivery systems to deliver optimal medical

care for injured patients. If the project is completed as planned, the quality of trauma care

(prehospital, transport, and hospital) will be high, and the lives of seriously injured patients can

more often be saved and their disabilities minimized.


Director


Moderator

Yoshinori Murao (Kindai Univ.)


1F. Main Auditorium

Japan-Korean Symposium 2

Surgery and ICU Carein Polytrauma Patients

06-23 (Fri.), 2017

56


1995 Graduated from Hokkaido University, Medical School

National Board of Medicine,

Japanese Board of Surgery

Japanese Board of Emergency Medicine

1995-1999 Kobe City General Hospital, as a Surgical Resident

1999-2002 Senshu Critical Care Medical Canter

2002-2010 Hokkaido University Hospital and Group Hospitals

2010-2014 Hyogo Emergency Medical Center

2014-2015 Sakai City Hospital

2015- Sakai City Medical Center

Education

Licensure and

Certification

Work Expeience



57


Our “Acute Care Surgery” System in Japan:

an Experience from a Regional Hospital


Traffic and industrial accidents are decreasing in Japan. Accordingly, surgical trauma cases are

declining. So those experiences are not enough for Japanese “ trauma surgeon”, especially for

surgical trainees.

The concept of “Acute Care Surgery”, which contains “trauma surgery”, “emergency general

surgery” and “critical care”, is spreading from the United States. I am willing to accept that idea, but

I would like to add three points in surgical area;

1. dealing with trauma patients constantly

2. doing emergency general surgery vigorously

3. also participating in elective surgical cases

Sakai City Medical Center is a 500-bed acute-care hospital opened in July, 2015. And our

emergency medical center is covering a medical area where 90 million people live. We serve as a

regional emergency medical center, which has 4089 trauma visits and 1728 admission a year.

It goes without saying that an exposure to trauma cases is very important. But our surgical

cases on trauma are only 90 cases a year. I think these are so small that every surgeon cannot keep

or develop his surgical skills. We also take care of patients who need emergency general surgery.

Those number are more than 350 cases a day. Through both surgical fields, we can maintain our

skill and motivation.

Surgical technique and its technology are evolving everyday. We have to keep up with those.

So I think it necessary to do electives. Our member is to rotate other surgical subspecialities. So

we can adapt current techniques (ex. endoscopic surgery) in emergency cases and keep good

relationship with other surgical colleagues.



58


Ph.D. Chonnam National University

M.D. Chonnam National University

Residentship, Department of General Surgery, Chonnam National University Hospital

Director of Division of Trauma Surgery, Chonnam National University Hospital

Director of Education, Trauma Center, Pusan National University Hospital

現) Director of TICU3, Trauma center, Pusan National University Hospital

現) Assistant Professor, Pusan National University

現) JAST member

現) JSACS member

現) Director of Trauma Education, SECCI

現) Director of General Affair, KARPET

現) Director of Education, KST

現) Associate Editor, Trauma Image and Procedure (TIP), KARPET

Education

Professional

Experience

Medical Committee

Membership



59


Operative Management in Polytrauma

Patients in Korea




60



61



62


March 2001: M.D., Toyama university

Received a Medical License No. 420057 in May 2001

March 2017: Ph.D. in Medicine, University of Tsukuba

March 2017: M.P.H., University of Tsukuba

April. 2006-

Assistant Professor : Department of Emergency and Critical Care Medicine

Chiba-Hokusoh Hospital, Nippon Medical School

June. 2017-

Visitting Reseacher : Facalty of Medicine, University of Tsukuba Clinical Trial and

Clinical Epidemiology

European Society for Intensive Care Medicine　　　

Japanese Society of Anesthesiologist

Japanese Association for Acute Medicine

The Japanese Society of Intensive Care Medicine

Japan Society of Respiratory Care Medicine

The Japanese Association for the Surgery of Trauma

73th Annual Congress of American Association Surgery for Trauma International Report

Award

Education

Academic

Appointments

Activities of

Professional

Societies

Award


Nobuyuki Saito Nippon (Medical Univ. Chiba Hokuso Hospital)

63


Postoperative Management in Polytrauma

Patients in Japan

Nobuyuki Saito Nippon (Medical Univ. Chiba Hokuso Hospital)

Blunt trauma, which is accounts for the majority of injuries in Japan, is not a “single disease”

because it involves multiple sites. Perioperative management is very important for improving

the survival rate in polytrauma patients who need emergency surgery. Although the location

of treatment moves from the emergency department (ED) to operating theater and intensive

care unit (ICU), the concept of perioperative management is consistent, and involves sequential

resuscitation. The underlying principle of its management is to grasp the pathophysiology

peculiar to trauma and combine tactics adapted to each treatment stage. Organ dysfunction may

occur from the moment of injury until the start of treatment. The most feared complication of

polytrauma is systemic circulatory failure due to hemorrhagic shock. Damage control resuscitation

including urgent surgical hemostasis and massive transfusion (MT) may help solve this problem.

After surviving the shock period, we must prevent acute lung injury associated with MT and

other complications, including sepsis, and venous thrombosis. If the patient does not recover

from the shock state after hemostasis in the ICU, a trauma team including surgeons, intensivists,

nurses, and paramedics must estimate the cause of shock from a multidisciplinary approach.

Unfortunately, even if careful evaluation is done in the ED, missed injuries often happen because

of nonspecific findings due to unconsciousness and shock. Thus, appropriate information sharing

and communication in the team can help patients to recover. Recently, it is recommended to start

rehabilitation even from the acute phase to prevent post intensive care syndrome and to improve

functional outcome.

In this lecture, we refer to our recent findings on postoperative management after the aortic

occlusion method including resuscitative endovascular balloon occlusion of the aorta with attention

to western countries.



64


2002.2 : Master, Korea University of Graduate School (Medicine)

2005.2 : Doctor, Korea University of Graduate School (Medicine)

2016.2 ~ : Head of Critical Care Department at Korea University Guro Hospital

2016.7 ~ : Board Member of Korean Surgical Infection Society

2014.4 ~ 2014.5 : Trauma Surgeon, Agok MSF Trauma Hospital, South Sudan

2014.3 ~ : Manager of Trauma Surgery at Korea University Guro Hospital

2014.3 ~ : Board Member of MEDICINS SANS FRONTIERES KOREA

2013.6 ~ : Director, Korea Disaster Surgical Response Team

2014.3 ~ 2016.3 : Board Member of MEDICINS SANS FRONTIERES JAPAN

2013.3 ~ : Associate Professor of General Surgery at Korea University Guro Hospital

2011.10 ~ 2012.11 : Manager of Trauma surgery at Cheju Halla General Hospital

2011.1 ~ 2011.5 : Field Medical Doctor / Medical Consultant in MSF-CH Yanbian

2010.10 ~ 2010.11 : Trauma Surgeon, Hangu MSF Trauma Hospital, Pakistan

Education

Qualification &

Experience



65


Postoperative Management in Polytrauma

Patients in Korea





Director

Namyeol Kim (Korea Univ. Hospital)

Moderator

Jae Baek Lee (Chonbuk National Univ. Hospital)

Hee-Jin Yang (Seoul National Univ. Boramae Hospital)

1F. Seminar 1

Training Course 2 (KR)

Management of Trauma Patients in ICU

06-23 (Fri.), 2017

67


Yonsei University College of Medicine B.S. (Medicine)

Yonsei University Graduate School of Medicine M.S. (Medicine)

Yonsei University Graduate School of Medicine M.D. (Medicine)

2005. 3 ~ 2006. 2 Internship at Yonsei University’s Severance Hospital

2006. 3 ~ 2010. 2 Resident in Department of Internal Medicine at Yonsei University’s

Severance Hospital

2010. 3 ~ 2011. 2 Lecturer on Internal Medicine of Heart at Yonsei University’s

Severance Hospital

2011. 3 ~ 2013. 2 Clinic Assistant Professor of Internal Medicine of Heart at Yonsei

University’s Severance Hospital

2013. 3 ~ Head of Department of Internal Medicine of Heart Intensive Care

Unit at Yonsei Cardiovascular Hospital

Member of The Korean Association of Internal Medicine

Member of The Korean Society of Cardiology

Member of The Arrhythmia Research in Korean Society of Cardiology

Education

Experience

Society



68


Hemodynamic Monitoring of the

Injured Patient


Increasingly, echocardiography is being used to monitor hemodynamics and direct therapy in

critically ill patients. Case reports, observational studies, and state-of-the-art literature reviews have

demonstrated the potential role of echocardiography in care and decision making for medical

and surgical patients. Intensivists, trauma physicians, cardiologists, and anesthesiologists are now

using echocardiography to provide hemodynamic assessments in patients with life-threatening

illnesses such as sepsis, respiratory failure, congestive heart failure (CHF), shock, and traumatic

injuries, as well as patients with significant respiratory and cardiac diseases undergoing noncardiac

surgery and high-risk noncardiac procedures. The clinical impact on diagnosis, decision making,

and management has led governing bodies to address the potential value of echocardiography

in unstable medical and noncardiac surgical patients. The recent consensus statement and the

standardization of the basic perioperative transesophageal echocardiographic examination have

led to the need for guidelines regarding when, and how, to use echocardiography as a quantitative

monitoring tool. Echocardiography is being used as a monitoring tool if, after a diagnostic

assessment, repetitive hemodynamic or anatomic assessments are being made over a period of

minutes, hours, or days in the same patient to guide management.

Echocardiography has the ability to noninvasively evaluate and track both RV and LV

hemodynamic status. Echocardiography can be used to manage the response to fluid resuscitation

in critically ill patients who are at risk for shock or tissue hypoperfusion. Traditional monitors, such

as central venous catheters or pulmonary artery (PA) catheters, have not been found to improve

survival or decrease length of stay in hospitalized patients. PA catheters, when used to estimate

left atrial (LA) pressure (LAP), can cause PA rupture. They are typically calibrated with saline-filled



69



transducers at the bedside and therefore can be inaccurate in the assessment of LV filling pressures

because of waveform artifacts, damping, and airway pressure, especially in ventilated patients.

Furthermore, PA catheters and central venous catheters do not accurately measure LV diastolic

dysfunction, which is more predictive of mortality in hospitalized patients. Echocardiography has

the potential to noninvasively measure left-sided filling pressures and guide volume assessments

in hospitalized patients who may be at risk for both systolic and diastolic heart failure. Serial

examination of two dimensional (2D) and Doppler indices can be used to monitor stroke

volume (SV) and overall volume status. Several studies have recently shown the benefits of goal-

directed fluid therapy in surgical patients. In this setting, 2D echocardiography with Doppler can

measure changes in SV in response to either a fluid bolus or the administration of a diuretic, while

monitoring LAP with transmitral and tissue Doppler imaging (TDI) as well as right atrial pressure

(RAP) using vena cava respiratory dynamics. The limitation of echocardiography in this setting

is that it cannot perform continuous monitoring, and it requires meticulous attention to sample

volume placement. In this lecture, I will discuss about all areas in which echocardiography is

monitoring a therapeutic guidance, whether it is fluid resuscitation, pericardial effusion monitoring,

or during perioperative care in the injured patients.

70


2002.3 - 2007.2 Ph.D. in Medical Science

Graduate School of Korea University, Seoul, Republic of Korea

[Ph.D. Thesis]

The Flow of Non-Pulsatile Pump to Maintain an Equal Coronary Flow on

Ibrillating Heart by Pulsatile Pump. (Director: Prof. Kyung Sun)

2013.3.1~3.31 ECMO and Cardiac Surgery Training

Regensburg University Hospital, Regensburg, Germany

2013.4.1~4.14 Minimal Invasive Surgery and TAVI Training

Leipzig University Heart Center, Leipzig, Germany

2013.5.27~5.31 Clinical and Research Training in ECMO

Michigan University ECMO Center, Ann arbor, USA

2015. 3 - present Associate Professor,

Dept. of Thoracic and Cardiovascular Surgery

Advisor of Organ Transplantation Center,

Anam Hospital, Korea University Medical Center, Seoul, Republic

of Korea

Education

List of Training

Employments



71


Massive Pulmonary Embolism:

Lyse, Suction or Operate?


The majority (70%) of patients with acute PE are normotensive and have normal RV function.

Prognosis is excellent in this subgroup when treated with anticoagulation alone. Patients with PE

and normal blood pressure, but who have evidence of RV dysfunction, are categorized as having

submassive PE. Submassive PE accounts for one quarter of all cases of acute PE and is associated

with an increased risk of adverse outcomes and early mortality.1 Patients with acute PE, sustained

hypotension, cardiogenic shock, syncope, respiratory failure, or cardiac arrest are classified as hav-

ing massive PE and have the highest risk of mortality.2 Though massive PE is less common (5% of

PE cases), patients with PE and hemodynamic instability have significantly higher death rates (58%)

than stable patients and warrant advanced therapy.3

Acute massive pulmonary embolism(AMPE) is life-threatening. Despite advances in diagnosis

and therapy, AMPE is still associated with exceptionally high mortality and morbidity rates. Patients

presenting with AMPE are at high risk of circulatory collapse, medical and mechanical reanimation

and late pulmonary hypertension. Prompt treatment should be undertaken when dealing with

AMPE. However, optimal management remains debated, and there is no consensus regarding the

best therapeutic method. Although in recent studies the results of surgical embolectomy have been

satisfying, current guidelines suggest thrombolytic therapy as the treatment of choice. Therefore

surgical management is placed in reserve for critically ill and high-risk patients, in whom thrombol-

ysis is absolutely contraindicated or has failed.4



72



Lyse (Systemic Fibrinolysis)

If no contraindications exist and the patient has a low risk of bleeding, systemic fibrinolysis may

be considered for patients with massive PE or a subset of patients with submassive PE. Systemic

thrombolysis is the standard therapy for acute massive PE; however, systemic thrombolysis carries

an estimated 20% risk of major hemorrhage, including a 3% to 5% risk of hemorrhagic stroke. Es-

pecially, patients who underwent SE after thrombolytic therapy failure clearly demonstrate a crit-

ically high mortality rate. It is suggested that surgical embolectomy should not be delayed for the

critically ill patients with AMPE

Suction (Catheter-directed therapy)

The potential for lower bleeding risk is catheter-assisted “pharmacomechanical” therapy. Cathe-

ter-assisted embolectomy is a technique that combines low-dose “local” fibrinolysis and mechanical

thrombus manipulation. One strategy, ultrasound-facilitated, catheter-directed, low-dose fibrinoly-

sis requires only a fraction of the systemic fibrinolytic dose and rapidly improves RV function while

minimizing the risk of intracranial hemorrhage. The subsequent U.S.-based Submassive and Mas-

sive Pulmonary

Embolism Treatment with Ultrasound Accelerated Thrombolysis Therapy (SEATTLE II) trial as-

sessed the use of catheter-based lowdose fibrinolysis for 150 patients with submassive(79%) and

massive PE(21%). The RV/LV diameter ratio was reduced by 25% from baseline to 48 hour after

73



start of the procedure. Both mean pulmonary artery systolic pressure and Modified Miller Index

(measure of angiographic obstruction) were reduced by 30% from baseline to follow-up at 48

hours. There was no difference in response between submassive and massive PE patients. Major

bleeding occurred in.

10% of the patients. No patient suffered intracranial hemorrhage. Based on these data, the FDA

approved ultrasound-facilitated, catheter-directed, low-dose fibrinolysis with the EkoSonic Endo-

vascular System for treatment of PE on May 21, 2014.

Operate (Surgical pulmonary embolectomy)

Surgical pulmonary embolectomy achieves best results in patients with large, centrally located

thrombi. The procedure requires a median sternotomy and cardiopulmonary bypass and can be

performed expeditiously with low operative mortality in experienced hands. In patients with sub-

massive PE, surgical pulmonary embolectomy is considered when patients are not eligible for cath-

eterdirected therapy, systemic fibrinolysis is contraindicated or has failed and in patients who have

thrombus in the right atrium or ventricle (clot-in-transit).

1. Piazza G, Goldhaber SZ. Management of submassive pulmonary embolism. Circulation. 2010;

122: 1124-1129.

2. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the

International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999; 353: 1386-

1389.

3. Agnelli G, Becattini C. Acute pulmonary embolism. N Engl J Med. 2010; 363: 266-274.

4. Fukuda I, Taniguchi S, Fukui K, Minakawa M, Daitoku K, Suzuki Y. Improved outcome of

surgical pulmonary embolectomy by aggressive intervention for critically ill patients. Ann

Thorac Surg. 2011; 91(3): 728e732.

5. Wadhera RK, Piazza G. Treatment options in massive and submassive pulmonary embolism.

Cardiology in Review 2016; 24: 19-25).

74


Bachelor of Medicine, Kyunghee University (2004)

Master of Medicine, Gachon University of Graduate School (2008)

Doctor of Medicine, Gachon University of graduate School (2015)

Internship, Resident in Department of Surgery at Gachon University Gil Medicine

Center (2004~2009)

Army Surgeon (27th Division of Medical Corps, the Service Support Group) (2009~2012)

Trauma Surgeon at Gachon University Gil Medicine Center (2012~2013)

Clinic Assistant Professor of Trauma Surgeon at Gachon University Gil Medicine Center

(2014~2015)

Assistant Professor of Traumatology at Gachon University of Medicine (2016~ )

Medical Doctor's License (2004)

Surgery Specialist (2009)

Traumatic Surgical Specialist (2014)

Critical Care Specialist (2015)

Education

Experience

License


Giljae Lee (Gachon Univ. Gil Hospital)

75


Necrotizing Soft Tissue Infection


Necrotizing soft tissue infections (NSTI) are rare and life-threatening bacterial infections charac-

terized by the rapid progression of infection in any layer of the skin and soft tissue, resulting in ex-

tensive tissue necrosis. NSTI represents high rates of morbidity and mortality, and impaired quality

of life among the survivors.

NSTI can affect any part of the body but the extremities particularly of lower limbs are most

commonly involved. The infection may be monomicrobial with group A streptococcus and Staph-

ylococcus aureus being the most frequently isolated pathogens. However in most cases, the infec-

tion is polymicrobial, involving gram-positive cocci, Enterobacteriaceae, nonfermenting bacilli as

well as anaerobic bacteria.

The management of NSTI includes rapid surgical debridement and broad-spectrum antibiotics,

and intensive care. Early diagnosis allowing for early surgical debridement improves survival.

However, diagnosis at the initial disease stage is difficult and NSTI may be misdiagnosed in more

than half of patients.

Source control of infection is paramount and serial surgical debridements are generally required.

The frequency and number of required debridements varies based on aggressiveness of infection,

but generally patients should return to the operating room for debridement every 24-48 h until

there is no evidence of continued or progressive skin and soft tissue necrosis. Wound dressing

changes should be carried out at least daily to look for evidence of ongoing infection that would

require repeat debridement. In addition to wound appearance, clinical deterioration as measured

by increased requirements for intensive care support or laboratory parameters suggestive of wors-

ening infection should prompt discussion of repeat debridement.



76


1997 - 2003 Ajou University of Medicine

2007 - 2009 Ulsan University of Graduate School of Medicine

2009 - 2011 Ajou University of Graduate School oｆMedicine

2013 .03 ~ 2016 .02

Ajou University Hospital / Surgery /Assistant Professor, Head of Surgery Intensive

Care Dept

2017.1.1. ~

Korea University Anam Hospital / Surgery / Clinic Assistant Professor

Korean Medical License / 2003.03 / Ministry of Health and Welfare

Surgical Specialist / 2008.03 / Ministry of Health and Welfare

Critical Care Medicine Specialist / 2011.06 / Ministry of Health and Welfare

Education

Experience

License



77


Update of New SCCM/ASPEN Critical Care

Nutrition Guideline




78



79



80



81



82



83




Director

Hong-Chul Lim (Seoul Barunsesang Hospital)

Moderator

Hong-Chul Lim (Seoul Barunsesang Hospital)

1F. Seminar 1

Special Lecture

Diaster

06-23 (Fri.), 2017

85


· Graduated from Yonsei University College of Medicine

· Internship and Residency at Severance Hospital, Yonsei Medical Center

· Board certified in Cardiovascular and Thoracic Surgery

· Medical Research Fellowship at Walter Reed U.S. Army Institute of Research, Division of Trauma

Resuscitation

· Board certified in Trauma Surgery

· Director of Dept. of Clinical Support Services, Armed Forces Health Services School

· Director of Clinical Services, Armed Forces Capital and Chung-Pyung Hospital

· CO, Armed Forces Ildong, Wonju, Chung-pyung, and Yangju Hopital.



86


Trauma Management in Nuclear Warfare


Besides the magnitude of the potential damage, radiological and nuclear warfare may pose a

unique set of problems. Radiation dispersal devices or radiation exposure devices are expected

to produce minimal, if any, conventional trauma victims, among the survivors. But in case of a

nuclear detonation, conventional physical trauma, due mostly to blast wave and wind, burns and

ionizing radiation exposure will occur in combination mostly and separately. The relative extents

of respective damage wound depend on the size of the nuclear weapon.

A nuclear weapon, upon detonation will distribute its energy in forms of blast and shock (50%),

thermal radiation (35%), and nuclear radiation (15%). Thus the blast and thermal effects of detona-

tion would produce by far the greatest number of immediate human casualties, and superimposed

exposure to ionizing radiation complicates the problem even further. Essentially the effect of ion-

izing radiation is apoptosis and failure to regenerate and repopulate the damaged cells, and would

produce Acute Radiation Syndromes (ARS), namely in increasing order of exposure dose, hemato-

poietic, intestinal and neurovascular syndrome.

Casualties whose radiation doses are most amenable to medical treatment will be those who

receive between 2 to 6 Gy. For these casualties, if they also have burns or trauma, cytokine and

antibiotic therapy are warranted. Many casualties whose doses exceed 6 to 8 Gy will probably also

have significant blast and thermal injuries that will preclude survival when combined with radiation

insult. In case of coexisting trauma in a radiation exposed victim, wound closure should be per-

formed within 24 to 36 hours.




Director

Yong-Cheol Yoon (Gachon Univ. Gil Hospital)

Moderator

Beom Koo Lee (Armed Force Capital Hospital)

Kichul Park (Hanyang Univ. Hospital )

1F. Seminar 1

Symposium 1

Treatment of Vulnerable Orthopedic Trauma Patients

06-23 (Fri.), 2017

88


1998-2004 Medical Doctor Gachon Medical School, Inchoen, Korea

2004-2009 Resident Gachon University Gil Medical Center

2009-2012 Chief of General Surgery Department Armed Forced Wonju Hospital

2012-2014 Fellowship of Trauma Surgery Gachon University Gil Medical Center

2016- Assistant Professor Gachon University Gil Medical Center

Education

Professional

Positions



89


Physiological Changes of Elderly

Trauma Patients




90


March 2008 - February 2010 Ewha Univ. Mok-Dong Hospital (Fellowship)

March 2010 - August 2013 The Graduate School, Yonsei University Degree of Doctor

of Philosophy

August 2013 - July 2014 Clinical Fellowship in Level 1 Trauma Center, Hannover

Medical School, Germany

National Faculty of AO Ttauma

Editorial Board member of Journal of the Korean Orthopaedic Association

Editorial Board member of the Journal of the Korean Fracture Society

Editorial Board member of the Journal Minimally Invasive Ortopedics

Education

Main Professional

Memberships



91


Orthopedic Trauma Treatment of

Elderly Patients




92


July, 2017 : AOTrauma Visit-the-Expert Fellowship, Regions Hospital, St. Paul,

Minnesota, USA (Under the Mentoring of Prof. Peter Cole)

Nov., 2013 ~ Dec., 2013: AOTrauma fellowship, Kantonsspital, Luzerne, Switzerland

(Under the Mentoring of Prof. Dr. med. Reto Babst)

Mar., 2016 ~ : Assistant Professor, Kyungpook National University, School of Medicine

Division of Musculoskeletal Trauma

Department of Orthopaedic Surgery & Regional Trauma Center

Mar., 2012 ~ Feb., 2016 : Instructor, Clinical professor, Kyungpook National University

Hospital

Department of Orthopaedic Surgery & Regional Trauma Center

Operation Committee Member of Regional Trauma Center

The License of Korean Board of Trauma Surgery (Feb. 2015, No. 2015-39)

Journal of Trauma and Injury

Education and

Training

Appointment

Licenses



93


Orthopedic Trauma Treatment of

Pediatric Patients


For the treatment of multiple fracture or trauma in children, pediatric-related anatomy and

pathophysiology should be well understood. Multidisciplinary approach of the pediatric specialists,

such as a pediatrician, pediatric trauma surgeon, pediatric intensive care physician, is requisite for

initial assessment, procedure and resuscitation.

The severity of head injury is a major determinant of the prognosis and the mortality rate. The

operation of abdominal injuries is rarely needed compared with adults, but evaluation and discov-

ery is essential. Spinal and pelvic injuries, as well as limb fractures, require age-appropriate surgical

treatment.

Although children sustain very severe, multiple injury, they often show markedly excellent

recovery. Therefore, the best treatment should be provided all the time on the assumption that

complete recovery is achieved. Despite pediatric patients with large numbers of multiple injuries

survive, they often have long-term complications. The main reasons for having functional defects

are damage to the central nervous system and musculoskeletal system. In pediatric patients with

multiple injuries, orthopedic treatment is crucial to minimize future disability.



94


2003 National Board of Medical Doctors

2008 Board of Orthopaedic Surgery

2011 Department of Orthopaedic Surgery Clinical Fellow

Gangnam Severance Hospital Division of Traumatology

(Prof, Kyu Hyun, Yang)

Education

Professional

Training



95


Painful Memory Case I


A 85-year-old woman had an open pelvic fracture as a result of a high energy pedestrian traffic

accident with direct trauma against the bus bumper. She arrived at our trauma bay in a state of

shock (blood pressure 70/30mmHg and heart rate of 120 beats/min). She was managed according

to the ATLS protocol with aggressive resuscitation. Chest radiograph and FAST were unremarkable,

while the pelvic radiograph showed an unstable open book pelvic fracture. Initial surgical manage-

ment included irrigation and debridement of the pelvic and vaginal wound, ligation of Right obtu-

rator artery and branch of internal iliac artery, pelvic packing, external fixation of pelvis. She was

admitted to intensive care department in a hemodynamically stable condition with blood pressure

of 110/69 mm. Other injuries sustained included a left ankle bimalleolar fracture, right ankle medial

malleolar fracture and Left acetabular transverse fracture. The ISS was calculated to be 36. After

two days, definitive stabilization of pelvic fracture was performed with anterior plate fixation of the

symphysis and pubic fractures and external fixator was removed. After 2 weeks, we found that the

anterior pelvic plate and screw was loosening and her wound was infected.



96


1999. 03 - Pusan National University of Medicine

2014. 3 ~ 2015. 2: Orthopedist, Professor of Trauma Center at Pusan National

University Hospital (Traumatology)

2015. 3 ~ present: Clinic Assistant Professor of Orthopedic and Trauma Center at

Pusan National University Hospital (Traumatology)

Education

Experience



97


Painful Memory Case II


Objective

To review the case which was challenging to manage and gave a painful memory to surgeon.

Methods

Eldery patient who had polytrauma including pelvic ring injury. (ISS=29)

ORIF for pelvic ring injury was performed.

Results

During followup, fixation failure and reduction loss was occurred.

Furthermore, neglected fracture was observed.

Conclusion

When treating eldery patients, it needs more cautious approaches and choices of treamtnet.



98


Medical doctor of Medical School, graduated February, 2005

- Inje University, Busan, Korea

Interns : March, 2005 ~ February, 2006

- Inje University Seoul Paik Hospital, Seoul, Korea

Resident : March, 2006 ~ February, 2010

- Department of Orthopedic Surgery, Seoul, Korea

- Inje University Seoul Paik Hospital

Army doctor (Captain) : March, 2010 ~ April, 2013

- Armed Forces Capital Hospital

Fellowship : May, 2013 ~ February, 2016

- Korea University Guro Hospital (May, 2013 ~ April, 2014)

- Inje University Ilsan Paik Hospital (May, 2014 ~ February, 2015)

- Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea

(March, 2015 ~ February, 2016)

Clinical Assitant Professor : March, 2016 ~ Now

- Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea

Medical License, Ministry of Health and Welfare, Korea - February, 2005

Board of Orthopedic Surgery, Ministry of Health and Welfare, Korea - March, 2010

Subspecial board of Trauma Surgery, The Korean Society of Traumatology - February, 2015

2nd AOT AP Scientific Congress & TK Experts' Symposium - May, 2014

- Awarded The Young Investigator

Education

Experience

Certificate

Achievement



99


Painful Memory Case III


I tried to look into the management for orthopedic trauma patients with pregnancy through my

painful memory cases.



100


Mar. 2005-Feb. 2011 Kosin University School of Medicine (M.D)

Sep. 2014-Jul.2016 Korea University School of Medicine (Master)

Mar. 2012-Feb. 2016 Resident, Department of Orthopaedic Surgery, VHS

Medical center, Seoul, Korea

Mar. 2016- present Clinical Instructor, Trauma Division, Department of

Orthopaedic Surgery, Korea University College of Medicine

2017.3 - ESPIT

2017.3 - AO Trauma Symposium - Foot & Ankle

2017.4. - AO Trauma Europe Masters Course - Osteotomy in Posttraumatic Deformity

- Lower Extremity

2017.5 - Korean-Japanese Combined Orthopaedic Symposium

Education

Professional

Training and

Employment

Lisensure and

Certification



101


Painful Memory Case IV


Fracture of Osteoporotic Bone like a sponge, How to reduce it?

Fractures in the elderly are still increasing and are almost always associated with osteoporosis.

Osteoporotic bone, structurally altered because of reduction of bone mineral density and quality

deterioration, can easily head for fracture after minimum mechanical stress. Treatment of fracture

with severe osteoporotic bone is one of the toughest problems we can stuck with. Because the

bone quality is too poor to maintain reduction of fracture. Osteoporosis at the site of fractures may

lead to unsatisfactory results due to inadequate operation. Today I’d like to talk about my painful

memory of osteoporotic bone fracture. And we will discuss about reduction technique of osteopo-

rotic bone.




Director


Moderator

Kun Hwang (Inha Univ. Hospital)

Seogki Lee (Chosun Univ. Hospital)

1F. Seminar 1

Symposium 3

Trauma in Special Population

06-23 (Fri.), 2017

103


1985-1992: School of Medicine, Seoul National University

2012: Ph.D Depart. of Surgery, School of Medicine, Seoul National University

1995-1996: Intern, Seoul National University Hospital

1996-2000: Resident, Depart. of Surgery, Seoul National University Hospital

2000-2001: Fellowship Division of HepatobiliaryPancreas Surgery and Liver

Transplantation, Depart. of Surgery, Seoul National University Hospital

- 2015 : Associate Prof. Department of Surgery Eulji University

Present : Director of Regional Trauma Center, Cheju Halla General Hospital Jeju

Member of Korean Surgical Society

Member of Korean Association of HBP Surgery

Member of The Korean Society of Traumatology

Director, External Affair Coordination Committee, The Korean Society of Traumatology

Education &

Training

Employment

Professional

Association



104


Pediatric Trauma


I. intrududction

Trauma leading cause of death > 1 year

65% of deaths due to unintentional injury

II. Unique Problems in the Pediatric Population

- High Surface Area/Body Volume = Greater Heat Loss

- Less calcified therefore more flexible ->Greater incidence of abdominal, chest and spinal cord

injury without fracture

III. Specific injury

1. CNS

- CNS injury is the leading cause of death among injured children

- Physiologic reserve of the child: recover more frequently and more fully than similarly injured

adults

- Children tend to sustain injuries that produce diffuse edema rather than those that cause focal

space-occupying lesions



105



2. Spinal Cord Injury

- Spinal cord injury without radiologic abnormality (SCIWORA) syndrome is a problem unique

to the pediatric population

- Radiologic evaluation should consider normal variants, such as C2-C3 pseudosubluxation oc-

curring in 9% of children up to age 7 years

3. Thoracic Injuries

- Thoracic injury occurs in about 5% of children

- Isolated thoracic injuries seen commonly in adults are relatively uncommon in children

- Due to the pliability of the pediatric rib cage and mediastinal mobility, significant intrathoracic

injury may exist in the absence of external signs of trauma

- Over half of rib fractures in children younger than 3 years may be due to child abuse

- Traumatic diaphragmatic rupture occurs in about 1% of children with blunt chest trauma, with

left-sided rupture being more common

4. Small Intestinal Injury

- The most common intra-abdominal organs injured in restrained children involved in MVAs are

hollow viscus type

- The most common site of the intestinal tract to be injured is the jejunum in the area of the Tre-

itz ligament. Such injury occurs in association with lap seat belt use or rapid deceleration. Up

to 50% of children with lap seat belt injuries have associated retroperitoneal injuries

5. Spleen injury

- Because of the risk of overwhelming sepsis following splenectomy (OPSS), the current philos-

ophy is to manage splenic injuries conservatively unless the spleen is hemodynamically com-

promised

6. Hepatic Injury

- The success rate for nonoperative management of blunt hepatic injury is about 85-90%.

- Hemodynamic instability should prompt surgical treatment; however, a role for angiographic

embolization may exist

106



7. Pancreatic Injury

- A frequently mechanism involves falling into bicycle handlebars

- Timely diagnosis of major pancreatic injuries and prompt surgical treatment are essential to de-

crease mortality and morbidity rates in pediatric patients

8. Vascular Injuries

- Most vascular injury is associated with orthopedic injuries, such as supracondylar fracture or

long-bone fracture

- The most important differential diagnosis in pediatric vascular trauma is between thrombosis

and spasm of the injured vessel. Spasm usually lasts less than 3 hours. When the pulses re-

main absent longer than 6 hours, thrombosis or transection of the vessel must be excluded

IV. Unique injury in pediatric population

1. Air Bag Injuries

- Most pediatric injuries are a result of proximity to air bag deployment and unused or improp-

erly used seat belts

- Can cause decapitation in young children, severe face, chest and abdominal injuries

- The safest place for a child is in the middle of the back seat, either in a safety seat or in a

3-point restraint

2.Child Abuse

- physical abuse, sexual abuse, emotional abuse, and child neglect

- maintain a high level of clinical awareness when evaluating these children

V. Initial management

1. Airway

- oral airway: DO NOT INSERT AND ROTATE 180 degrees

107



- Endotracheal Intubation: Broeslow Tape,Tube diameter should be the size of the child’s 5th

finger

- Failure of Intubation: Needle Cricothyroidotomy is best

2. Breathing

- Pneumothorax without fractures common

- 12-16 chest tube in a baby, 28-32 chest tube in a small teenager

- Pulmonary Contusion: Common in children after blunt chest injury, Often no associated rib

fractures

3. Circulation

- Estimated Blood Volume = 80cc/kg

- Fluid Bolus = 20cc/kg of crystalloid x 3

- Colloid/Blood Bolus = 10cc/kg

- Vascular Access: 2 attempts at percutaneous venous access, Interosseous infusion,. Saphenous

vein cutdown above the medial malleolus, Percutaneous femoral vein catheter, Internal Jugu-

lar catheter, Subclavian catheter

4. Disability

- Pediatric Glascow Coma Scale

5. Exposure

- Keep the child WARM!!!!

Baer Hugger

Heating Lamps (be careful of burning the skin!)

Wrap the extremities in wool cast padding

Each child should wear a hat to prevent heat loss from the scalp

108




109


Management of Trauma in Pregnant Women


Trauma in pregnancy differ in some aspects from trauma of the general public. The first, there

are two patients. The fetus can become a patient depending on the gestational age. Therefore, an

obstetrical evaluation is indispensable even in case of trauma, and emergency delivery may be

necessary in some cases. The second, anatomical change due to pregnancy occur. As the pregnan-

cy week passes, the position of the uterus gradually rises to the upper abdomen, so the position of

the fetus changes, and the position of the abdominal organs also changes. The third, physiologic

changes occur during pregnanacy, too. The amount of fluid is continuously increased until 34

weeks, and the hemoglobin is not increased by the increase of body fluid volume, so there may

be physiological anemia during pregnancy. As a result, cardiac output is increased and heart rate

increases about 10-15 times per minute over the pregnancy period.

The mechanism of trauma in pregnancy is mostly caused by blunt trauma that traffic accidents,

falls, and direct impact of the abdomen, and the penetration is rare. The degree of maternal dam-

age is most important in determining the prognosis of the mother and the fetus. Therefore, The

most important way to treat the fetus is to treat the mother. However, the fetus should be exam-

ined after primary survey of mother because the fetus may be accompanied by severe damage

even if the mother is mildly injured.



110


Clinical Assistant Professor, Department of Thoracic and Cardiovascular Surgery

Wonju Severance Christian Hospital, Yonsei University, Wonju College of Medicine

Medical License, Korea - 2005

Korean Board of Thoracic and Cardiovascular Surgery - 2010

Subspecialty Certification for Traumatology - February 2015

Subspecialty Certification for Critical Care Medicine - August 2015

Internship - Gangnam Severance Hospital, Yonsei University, 3. 2005 - 2. 2006

Residency - Severance Hospital, Yonsei University, 3. 2006 - 2. 2010

Fellowship - Severance Hospital, Yonsei University, 3. 2010 - 2. 2012

Assistant Professor - Eulji University , Eulji University Hospital, 3. 2012 - 1. 2013

Clinical Assistant Professor - Yonsei University Wonju College of Medicine, 2. 2013 -

Present

Present title &

Affiliation

Licensure

Specialty Board

Subspecialty

Certification

Professional

Training



111


Management of Trauma in Geriatric Patients:

Rib Fracture in Octogenerian




112


2007-2011 College of Medicine, Seuoul National University

2011-2012 Internship, Armed Forces Capital Hospital

2012-2016 Resident, Department of Radiology, Seoul National University Hospital

2016-2017 Director of Healthcare Center, Armed Forces Daejeon Hospital

2017- Clinical fellow of interventional radiology, Department of Radiology,

Seoul National University Hospital

Education

Employment



113


Endovascular Treatment of Vascular Injury in

the Military Soldiers


Gunshot in the military troop could cause a high energy wound combined with multiple inju-

ries through adjacent bone, soft tissue and vessel. Among these, vascular injury is the most import-

ant factor that determined the survival rate of gunshot patients. Because of these reasons, rapid and

accurate detection and treatment is cruciate to prevent unintended death in the gunshot patient.

Recently, CT angiography has been developed with multiple detectors and it provides prompt

whole-body scan in the patient with severe trauma. Moreover it has a powerful detection ability

using dynamic phase images with contrast administration when the vascular injury is suggested.

Recently, endovascular treatment, such as transcatheter arterial embolization(TAE) is a alternative

treatment option in the patient with vascular injury. Recently TAE for the vascular injury with se-

vere trauma shows high technical successful rate.

In this lecture, we should recognize the characteristics of military casualties and prepare the

alternative treatment of vascular injury such as TAE, because sometimes military trauma is accom-

panied by mass casualties.

Key Words: Gunshot, Embolization, Trauma




Director

Jun-Dong Moon (Kongju National Univ.)

Moderator

Sun Joo Wang (Hallym Univ. Hospital)


1F. Seminar 2

Training Course 3 (KR)

Traumatic Cardiopulmonary Arrest (TCPA)

06-23 (Fri.), 2017

115


Ph.D in Emergency Medicine, College of Medicine, Korea University

Emergency Medicine, Medical Education, Emergency Medical Service

Clinical Professor, Department of Emergency Medicine, Anam Hospital, Korea

University

EMS Physician, Seoul Metropolitan Fire Academy

Education

Area of Expertise

Professional

Experience

Training Course 3 (KR) - Traumatic Cardiopulmonary Arrest (TCPA)


116


Traumatic Cardiac Arrest - Similar but

Different




117


1994 - 2000 Korea University College of Medicine Seoul, Republic of Korea



2000 - 2001 Korea University College of Medicine

Education

Training



118


Airway Matters in Maxillofacial Injury


Airway management outside hospital has been a highly controversial topic. Cancellation of air-

way management in a difficulty situation may not be an option in the acute trauma setting as well

as pre-hospital setting.

Development of the ‘airway-breathing-circulation’ approach for the management of severely

ill and injured patients, initiated by Advanced Life Support and Advanced Trauma Life Support

courses remains worldwide clinical practice. While airway management in pre-hospital setting con-

tributes to patient’s good outcome, available evidence for pre-hospital airway management is still

controversy.

However, there are small but significant proportion of pre-hospital trauma patients require early

advanced airway intervention. This intervention should be done delaying time to arrival at hos-

pital. The procedure is performed whenever patient need it even if the system cannot provide it

comfortably or safely.

When you start to manage the airway of trauma patient, you should always consider patient

evaluation, intervention using various techniques and devices, recognition of any trauma to the

airway or surrounding tissues, anticipation of their respiratory consequences, and planning and ap-

plication of management, the potential for exacerbation of existing airway or other injuries by the

contemplated strategies.

In this session, the evidence surrounding early emergency airway management after injury is ex-

amined, and the use of various airway device in many different situation is introduced.



119


Graduated from Chonnam National University of Medicine

Internship at Chonnam National University Hospital

Complete a Course of Resident in Thoracic surgery

ESPIT Instructor

Member of KARPET (Korean Association for Research, Procedures and Education on

Trauma)

(Present) Team of Trauma Center in Mokpo Hankook Hospital

Experience



120


Cardiac Arrest Associated with Chest Injury


The cardiac arrest following chest injury involves a high mortality rate. In most cases, it reflects a

cardiac tamponade, tension pneumothorax, or hemorrhagic shock resulting from injury to the heart

or large vessels nearly. Therefore, immediate decompression of tension pneumothorax, tamponade

and adequate volume restoration are important in resuscitation of cardiac arrest following chest in-

jury. Rapid resuscitative thoracotomy to allow direct cardiac massage, decompression of hemoperi-

cardium, and bleeding control is important as well. However the probability of survival described

in the literature is very low for severe chest trauma with cardiac arrest. But some guidelines recom-

mend that all patient in cardiac arrest with suspected chest trauma who are not responding to air

way opening and restoration of circulating blood volume should have their chest decompressed.



121


1998-2004 Yonsei University Wonju College of Medicine - Medicine

2007-2015 Yonsei University of Graduate School - Emergency Medicine

2014- Present Wonju Severance Chrstian Hospital Emergency Medicine,

Trauma Surgery

2009- Present Korean Society of Echocardiogaraphy

2007- Present The Korean Society Tramatology

2009-2015, Present The Korean Society of Emergency Medicine Emergency Medicine

2009- Present

2015 National Education of Rescue Training Institute

2015 The Korean Society of Emergency Medicine (Triage)

2016 - Korean Association of Aero Emergency Medical Service

Education

Experience

Society



122


Prehospital eFAST : Evidence-Based

Recommendations


Ultrasonography examination of trauma patients is increasingly performed in prehospital era in

developed countries. But it is obscure that if prehospital sonography have a postivie effect in trau-

ma patients. While there is moderate evidence to support the use of prehostpial ultrasonography

in physician-staffed emergency medical services, the evidence is lacking of the utility of ultrasonog-

raphy with a non-physician-saffed EMS.




Director


Moderator


1F. Seminar 2

Special Lecture

REBOA

06-23 (Fri.), 2017

124


1989-1995 Medical School, St. Marianna University School of Medicine

Assistant Professor, Department of Emergency and Critical Care Medicine, St Marianna

University School of Medicine, Kawasaki, Kanagawa, Japan: 2007-Present

Chief, Division of Emergency and Trauma Radiology, Department of Emergency

and Critical Care Medicine, St Marianna University School of Medicine, Kawasaki,

Kanagawa, Japan: 2006-Present

Director, Department of Radiology, National Disaster Medical Center: 2007-Present

Secretary General, Japanese Society of Emergency Radiology: 2005-2016

President, International Society for Diagnostic and Interventional Radiology in

Emergency, Critical Care and Trauma (DIRECT): 2016-Present

Attending Staff Radiologist: Division of Emergency and Trauma Radiology, Department

of Emergency and Critical Care Medicine, St Marianna University School of Medicine,

Kawasaki, Kanagawa, Japan: 2005-2007

Research Fellow, Division of Emergency and Trauma Radiology, Shock Trauma Center,

University of Maryland, Baltimore, Maryland, US: 2004-2005

Attending Staff Radiologist: Department of Radiology, St Marianna University School

of Medicine, Kawasaki, Kanagawa, Japan: 2001-2004

2013-Present General Member, Radiological society of North America

Education

Current Affiliation

Past Affiliation

Society

Memberships



125


REBOA; Resuscitative Endovascular Balloon

Occlusion of the Aorta


REBOA; Resuscitative Endovascular Balloon Occlusion of the Aorta has been getting its position

in trauma care. Although the concept of this procedure looks very simple, you have to learn a lot

before you do it. The goal of this lecture is to learn; 1) the concept, 2) indication, 3) the technique,

4) the complications, and 5) further application of REBOA.

Strong evidences for this technique has not come up and its usefulness, effectiveness and harm-

fulness has been under discussion. It is essential to master basic skills of this procedure to apply it

safely and properly in critically injured patients. It is also very important to understand this proce-

dure is not the definitive solution but just a bridging technique for definitive hemostatic therapy by

surgical or radiological intervention with adequate transfusion. You have to have the right team to

work under the right concept, otherwise you cannot save your patients with REBOA.




Director


Moderator

Jeong Ho Kim (Gachon Univ. Gil Hospital)


1F. Seminar 2

Symposium 2

Bleeding Control in Pelvic Fracture

06-23 (Fri.), 2017

127


1999-2005: Bachelor’s Degree, Kosin University College of Medicine

2009-2015: Master’s Degree, Graduate School, Yonsei University College of Science

(Graduate Program of Nano Science and Technology)

2012.03-2014.02

Clinical and Research Fellow in Division of Surgical Critical Care and Trauma,

Department of Surgery, Severance Hospital, Yonsei University Health System, Seoul,

Korea

2014.03-

Clinical Assistant Professor in Department of Surgery, Wonju Severance Christian

Hospital, Yonsei University Wonju College of Medicine

2013 Board of Critical Care Medicine (The Korean Society of Critical Care Medicine)

2014 Board of Traumatology (The Korean Society of Traumatology)

Education

Training and

Fellowship Course

Professional

Experiences

Qualification



128


Preperitoneal Pelvic Packing in Patients with

Hemodynamic Instability Due to

Pelvic Fracture


The mortality rate of patients with hemodynamic instability due to severe pelvic fracture is re-

ported to be 40-60% despite a multi-disciplinary treatment approach. Angioembolization and exter-

nal fixation of the pelvis are the main procedures used to control bleeding in these patients. Sever-

al studies have shown that preperitoneal pelvic packing (PPP) is effective for hemorrhage control,

despite being small and observational in nature. In this lecture, author will explain physiologic and

anatomic concepts of PPP application in patients with pelvic fracture and shock, and will present a

regional trauma center’s early experience about this topic.



129


2011: Master. Ulsan University of Graduate School (Medicine)

2014: Doctor. Catholic Kwandong University of Graduate School (Medicine)

2011~ 2012: Clinic Assistant Professor at Gangneng Asan Medical Center

2013 ~ 2016: Clinic Assistant Professor of Trauma Surgery at The Catholic University

of Korea, Yeouido St. Mary’s Hospital

2017 ~ Present: Assistant Professor at Ulsan University Hospital

Member of The Korean Society for Vascular Surgery

Member of Korean Surgical Society

Education

Experiences

Society



130


Internal Iliac Artery Ligation


General Considerations

Either a midline or a transverse abdominal incision may be used. In most situations, bilateral

ligation is preferable to unilateral ligation. Not only is hemostasis more secure, but also any doubt

about a possible return to the operating room is removed. Although it is possible to perform the

operation by the extraperitoneal approach, the intra-abdominal approach is preferable except in

cases of extreme obesity. Some surgeons advocate complete transection of the hypogastric vessel

between two ligatures. This has no practical or physiologic advantage. On the contrary, its prac-

tice may lead to injury of the underlying veins. If such an injury should occur in the course of the

operation, applying pressure with a gauze sponge or suturing with an atraumatic needle and fine

suture material usually suffices to repair the defect. If this should fail, however, the vein itself can

be ligated above and below the defect. Incorporation of the previously tied artery into the suture

in the vein adds strength and security as well as a splinting effect. Two ties should be placed firmly

but gently in continuity approximately 0.5 cm apart and 0.5-1 cm below the bifurcation.

Transabdominal Approach

The abdomen is opened and the viscera packed away in the usual manner. Identification of the

bifurcation of the common iliac artery is made by the two bony landmarks: the sacral promontory

and an imaginary line drawn through both anterosuperior iliac spines. A longitudinal incision into

the posterior parietal peritoneum is made. Another method is to incise into the peritoneum directly



131



over the bifurcation. The incision then is carried distally a few inches. All these incisions have one

feature in common: They result in the formation of a medial and lateral peritoneal flap. The ureter

is always on the medial flap and may be visualized, reflected, and protected with ease. The ureter

normally crosses the common iliac artery from lateral to medial at a point just proximal to the bifur-

cation.

Extraperitoneal Approach

The skin incision in the inguinal area parallels the course of the external oblique muscle. It runs

6-8 cm in length in a line 3-5 cm medial to the anterosuperior iliac spine. After the fat and subcu-

taneous tissues are dissected away, a muscle-splitting incision bares the peritoneum. This is gently

reflected medially, exposing the posterior surface; the ureter is reflected medially and the vessels

laterally. Ligation is performed as previously described. Closure is the same as for a herniorrhaphy

Midline Extraperitoneal Approach

A midline extraperitoneal approach to the aorta is advocated by some. One authority extended

its use to bilateral ligation of the hypogastric arteries. A midline abdominal incision is made. After

the anterior sheath of the rectus muscle is exposed and opened below the level of the umbilicus,

dissection caudal to the semilunar line of Douglas is performed, and the peritoneal and preperito-

neal fat are separated. The peritoneum and its contents are reflected to the right (or left), thus ex-

posing the retroperitoneal structures

Summarized of Surgical Management of intractable pelvic hemorrhage Keith, L, Lynch, C, Glob. libr. women’s

med. 2008

132


Ulsan University, Seoul, Korea / Master of Medicine

Orthopedic Surgery, Medicine , February 2009

Orthopedic Surgery, Medicine , February 2005

Ulsan University, Seoul, Korea / Doctor of Medicine

Medicine, February 2000

3/2000 - 2/2001 Asan Medical center, Internship

3/2001 - 2/2005 Asan Medical center, Residency

3/2005 - 4/2008 Army Hospital, Army Surgeon

5/2008 - 2/2009 Asan Medical center, Fellowship

3/2009 - 2/2010 Asan Medical center, Fellowship

10/2013 - 12/2014 Denver Health Medical Center / Visiting Scholar & Research Fellow

3/2010 - 10/2016 Inje University, Haeundae Paik Hospital / Assistant Professor,

Associate Professor

Education

Experiences



133


Bleeding Control in Pelvic Fracture;

Bony Stabilization


1. Classification of pelvic fractures

Among the various categories of pelvic fractures, the tile classification and is widely used be-

cause the stability of the pelvis can be determined. Type A is a stable type fracture that does not

involve the posterior ring of the pelvis, Type B is a type of fracture involving rotational unstable

fracture, and type C is complete disruption of the posterior ring resulting vertical instability.

In open book type, type B1 fracture and type C fracture are accompanied by massive bleeding

and immediate treatment is needed. According to Cryer et al., Open book type showed 56% to 10

pint Transfusion of more than 10 pints was required in 33.3% of B2,3 type transitional cases with

a transposition of 0.5 cm or more and 47% of C type with transposition of 0.5 cm or more. The

anterior and posterior radiographs should be taken and the injury of the anterior ring, including the

symphysis pubis, may be more easily detected than the injury of the posterior ring. According to

Mears and Rubash, diastasis of 3 cm of symphysis pubis increases the pelvic volume by 1.5 L.

2. Hemodynamic instability and bony fixation

Hemorrhage in pelvis fracture is caused by pelvic artery injury, fracture site hemorrhage, and

pelvic venous plexus injury. Hewtenen and Slatis reported that 85% of hemorrhages were due to

venous injury and fracture sites. There are various methods for hemostasis, which are performed

according to the patient’s condition, availability of medical resources, and manpower. In general,

methods such as pelvic binder (sling), external fixation, internal fixation, direct surgical vascular



134



ligation, pelvic packing.

Although pelvic sheets or pelvic binders can be easily performed in emergency or emergency

rooms, caution is advised because lateral compression of the pelvic fracture can make the fracture

worse. Pelvic binder may be helpful in reducing the enlarged pelvic volume in the open book

type, but there is controversy over whether the tamponade effect is effective due to the damage of

the posterior ring.

External fixations are effective methods of hemostasis through the reduction and stabilization of

fracture, tamponade effect that reduces the volume of the retroperitoneal space, and the hemosta-

sis of the venous plexus due to the formation of retroperitoneal hematoma.

Anterior ring fixation can be accomplished with external fixation, but posterior ring fixation can

be achieved by C-clamp. In hemodynamically unstable patients, it is preferable to reduce the oper-

ation time as much as possible using an external bone fixation device. However, iliosacral screw or

internal fixation with plate are sometimes useful to manage bleeding.

135


1985-1991, Pusan National University College of Medicine, M.D.

1992-1997, Pusan National University Postgraduate School, Master Degree of

Medicine

2000-2005, Pusan National University Postgraduate School, Doctor Degree of

Medicine

March 2001- Feb. 2008, Professor by fund, Department of Radiology, Pusan National

University

March 2005 - May 2005, Visiting Professor in Kurume University Hospital, Fukuoka,

Japan

March 2008 - Feb. 2009, Assistant Professor, Department of Radiology, Pusan

National University

March 2009 - Feb. 2014, Associate Professor, Department of Radiology, Pusan

National University

Feb. 2010 - Feb. 2011, Visiting Professor in Auckland City Hospital, Auckland, New

Zealand

March 2014 - Professor, Department of Radiology, Pusan National University

March 2016 - Director of Department of Radiology, Pusan National University Hospital

Interventional Radiology

Cardiovascular Imaging

Education

Professional

Training and

Employment

Specialty



136


Interventional Radiology for Pelvic Trauma


Hemorrhage from pelvic trauma is a significant source of mortality and necessitates a multidisci-

plinary, algorithm-directed protocol. Embolization is an established endovascular technique useful

in the emergency treatment of many traumatic injuries. Embolization is a lifesaving procedure that

can control bleeding in an expeditious and minimally invasive manner by the intentional and con-

trolled occlusion of vessels to stop hemorrhage. MDCT images are invaluable to guide the angiog-

raphy when searching for areas of suspected injuries with selective angiograms. In the majority of

cases, selective or superselective angiograms are always required to rule out any injuries and active

contrast extravasation.

Multidisciplinary trauma teams with established protocols that help to decide when emboliza-

tion and/or surgery are required are a critical part of the modern management of arterial injuries.

Embolization should be performed early in the control of arterial bleeding before severe coagulop-

athy develops. For these reasons, interventional radiologist should be an active member of trauma

team. Familiarity with clinical presentation, pretreatment imaging, angiographic findings, and en-

dovascular techniques are all essential components to effective diagnosis and treatment of trauma

patients with embolotherapy.



137


1995.2: Graduate Seoul National University College of Medicine

1995.2: M.D. Certified, Seoul, Korea

2000.2: Radiology Board Certified by Korean Radiological Society, Seoul, Korea

2007.2: Seoul National University, Ph.D., Seoul, Korea

2012.4-2017.2: Associate Professor in Radiology & Emergency Medicine, Seoul

National University Hospital, Seoul National University College of Medicine, Seoul,

Korea

2017.3-Present: Professor in Radiology & Emergency Medicine, Seoul National

University Hospital, Seoul National University College of Medicine, Seoul, Korea

Since 2000: Member, Korean Radiological Society

Since 2003: Member, Koran Society of Interventional Radiology

Since 2005: Member, ASER (American Society of Emergency Radiology)

Since 2006: Member, SIR (Society of Interventional Radiology)

Since 2010: Member, CIRSE (Cardiovascular and Interventional Radiological Society of

Europe)

Since 2012: President, KSER (Korean Society of Emergency Radiology)

Education

Professional

Appointments

Other Professional

Positions



138


Panel Discussion





Director

Bo-Ra Seo (Mokpo Hankook Hospital)

Moderator

In Ho Park (Mokpo Hankook Hospital)

Seong-Keun Moon (Wonkwang Univ. Hospital)

1F. Seminar 2

Symposium 4

Common Questions about Neurotrauma : Non-Neurosurgeon's View

06-23 (Fri.), 2017

140


Graduated from Pusan University of Medicine

Manager at Changwon Hospital

Neurosurgeon at Pusan National University Hospital

Trained at Osaka Prefectural Acute and General Medical Center

(Present) Clinic Assistant Professor of Neurosurgery at Pusan National University

Hospital (in Full Charge of Trauma Center)

Member of Korean Board of Neurosurgery

Life-Member of Korean Spinal of Neurosurgery Society

Life-Member of Korean Neurotraumatology Society

Education

Experience

Society

Symposium 4 - Common Questions about Neurotrauma : Non-Neurosurgeon's View


141


Optimal BP & ICP & CPP in TBI Patients


Intracranial pressure (ICP) is the pressure inside the cranial vault and is affected by intracranial

contents, primarily brain, blood, and cerebrospinal fluid. The intracranial volume is constant. Since

the intracranial vault is a fixed space, ICP increases with an increase in brain volume and cerebral

blood volume, increased cerebrospinal fluid production, and or decreased cerebrospinal fluid

clearance. Mass lesions such as tumors, hemorrhagic lesions, cerebral edema, or obstruction of ve-

nous and or CSF return can increase ICP. As mass lesions (such as traumatic brain swelling) occu-

py more volume, intracranial compliance decreases, and elasticity increases. A critical threshold is

reached when space-occupying lesions can no longer expand without neuronal injury, herniation,

and brain death. It is important to remember that the idea of ICP, while important in itself, must

also be considered in the context of its inverse relationship with cerebral perfusion pressure, which

is discussed elsewhere.

The level of systolic blood pressure (SBP) has long been felt to play a critical role in the second-

ary injury cascade after severe traumatic brain injury (TBI). In 1989, Klauber reported a mortality of

35% in patients admitted with a SBP <85 mm Hg, compared with only 6% in patients with a higher

SBP. The traditional definition of hypotension has been a SBP <90 mm Hg, and this was the target

recommended. As will be noted, the literature now supports a higher level that may vary by age.



142


1997.3.~2003.2. Dankook University College of Medicine B.S. (Medicine)

2009.3.~2011.2. Dankook University Graduate School of Medicine M.S. (Medicine)

2003.3.~2004.2. Intern in Dankook University Hospital

2007.5.~2011.2 Resident in the Department of Neurosurgery, Dankook University

Hospital

2010.8.~2010.9. Visiting Scholar, Nagoya University Hospital (Cerebrovascular

Surgery-SUGITA scholarship)

2011.3.~2013.2. Clinical Instructor (fellowship), Asan Medical Center, Department of

Neurosurgery (Vascular and Brain Tumor Section)

2013.3.~2016.2. Clinical Assistant Professor (Neurotrauma and Neurovascular

Surgery), Dankook University Hospital, Trauma Center and Department of Neurosurgery

2016.3~Present. Assistant Professor (Neurotrauma and Neurovascular Surgery),

Dankook University, College of Medicine, Trauma Center and Department of

Neurosurgery

Education

Postgraduate

Training

Hospital

Appointment



143


Multimodality Monitoring in TBI Patients


One of the most important goals of neurologic critical care is to detect secondary brain injury

at a time when permanent damage can still be prevented. The clinical examination remains the

gold standard for the assessment of patients with neurologic disease despite great advances in

neuroimaging and other diagnostic tools. The main purpose of invasive neuromonitoring is to

create this window of opportunity between the onset of functional disarray and neuronal injury.

It is therefore, of fundamental importance for any unit that engages in invasive brain monitoring

to have the infrastructure in place to react to detected changes in a timely fashion. Partial pressure

of brain tissue oxygen (Pbto2) is a measure of cerebral oxygen tension reflecting oxygen delivery,

diffusion, and consumption in the brain tissue. Optimizing Pbto2 may potentially improve aerobic

metabolism. Cerebral microdialysis is a technique through which the concentrations of lactate, glu-

cose, pyruvate, glycerol, and glutamate can be monitored in the brain tissue. Alternations in these

metabolites may be early indications of metabolic disarray, such as anaerobic metabolism. Jugular

venous oxygen saturation (Svjo2) and the arterial-jugular difference of oxygen content (AJDo2)

are measures of global oxygen extraction by the brain. High Svjo2 may reflect hyperemia and low

Svjo2 may reflect inadequate cerebral perfusion and possibly ischemia. Reginal cerebral blood flow

(rCBF) is a direct assessment of local brain tissue perfusion, and a surrogate of this can be obtained

with a thermal diffusion probe inserted into the brain parenchyma.



144


1992-1994 Yonsei University Graduate School, M.M.Sc.

1997-1999 Korea University Graduate School, D.M.Sc.

2003-2005 Department of Neurosurgery, Research professor, University of Utah

2008-Present Professor , Neurosurgery, Wonju college of Medicine, Yonsei University,

Wonju, Korea

2013-2017 Director, Office of Planning and Coordination, Yonsei University, Wonju

Health System, Wonju, Korea

The Korean Neurosurgery Society (1994- Present)

The Korean Neurotrauma Society, Chairman (2012-2013)

The Korean Cerebrovascular Society(1997- Present)

The Korean Brain Tumor Society (1997- Present)

Asian Congress of Neurological Surgery (1998- Present)

Korean Society of Critical Care Medicine (2009- Present)

Education &

Training

Experience

Society



145


Indications & Timing of Decompressive

Craniectomy


After traumatic brain injury (TBI), intracranial pressure can be elevated owing to a mass effect

from intracranial hematomas, contusions, diffuse brain swelling. Intracranial hypertension can lead

to brain ischemia by reducing the cerebral perfusion pressure and is associated with an increased

risk of death.

Decompressive craniectomy (DC) is a surgical method for immediate reduction of intracranial

pressure (ICP).

The rationale of DC is based in the Monro-Kellie Doctrine. If pathologic conditions that increase

ICP is happened, compensatory mechanisms operate to keep ICP constantly. There is exponential

relationship between intracranial volume and ICP. A CPP less than 60 to 70 mmHg is associated

with diminished oxygenation and altered metabolism in brain parenchyme. It is clear that patients

with untreated ICP (ICP ≥20 mmHg) after TBI will result poor outcomes, and improved ICP cor-

relates with functional outcome. Current Brain Trauma Foundation guidelines suggested the ICP

lower than 20 to 25 mmHg after TBI. Patients with well-controlled ICP under the threshold appear

to have improved outcomes. The treatment of increased ICP is very important for the prognosis of

patients. Initial managements used such as analgesia, sedation, elevation of the head, CSF drainage

through a ventricular cathe ter (if present), and optimization of ventilation to maintain normal arte-

rial partial pressure of carbon dioxide. Tier therapies are followed as intravenous administration of

hyperosmolar solutions, neuromuscular blocking agents, hypothermia, and barbiturate coma thera-

py.

At recent RESCUEicp study, this is secondary DC. At 6 months, DC in patients with TBI and



146



refractory intracranial hypertension resulted in lower mortality and higher rates of vegetative state,

lower severe disability, and upper severe disability than medical care. The rates of moderate dis-

ability and good recovery were similar in the two groups.

147


2011-2012 Severance Hospital Clinical Spine Surgery Seoul, South Korea Fellow

2009-2011 Yonsei University M.S. Neurosurgery Seoul, South Korea

2003 Korean National Board of Medical Examiners

2008 Korean Board of Neurosurgery

7/1/2012 - Present Ajou University Hospital, School of Medicine

Department of Neurosurgery Neurotrauma and Spinal

Neurosurgery Division Clinical Assistant Professor

3/1/2014 - Present Ajou University Hospital, School of Medicine

Regional Trauma Center Neurotrauma Division

Education

License,

Certification

Principal

Position Held



148


Neurologic Sign and Neuroimaging

Suggesting Poor Prognosis


The prognosis of Traumatic Brain Injury (TBI) has been improved with establishment of several

treatment strategies. The basis is consisted with development of imaging modalities, neurointensive

care, invasive intracranial monitoring and aggressive control of intracranial pressure. However, the

prognosis of severe traumatic brain injury remains still poor.

Initial neurologic assessment should be taken after airway maintenance, breathing and circula-

tion. Glasgow coma scale is widely used neurologic assessment examination. It is consisted with

Eye opening, Verbal response and Motor response. Motor response was more predictable compo-

nent than others. In intubated patients, Verbal response may be calculated using equation.

Pupil Light Reflex (PLR) is simple and important in TBI patient. An abnormal finding in PLR

represents brain stem dysfunction. Optic nerve and third cranial nerve injury should be ruled out.

Anisocoria means herniation and compression of brain stem and it usually means immediate surgi-

cal decompression is required.

Other detectable reflexes are coughing reflex, corneal reflex and gag reflex. The absence of

these reflexes means severe brain stem dysfunctions which may progress to brain death. Drug in-

toxication and alcohol ingestion may cause underestimation of neurologic status.

Computed tomography is most rapid and valuable imaging protocol in acute trauma patient.



149



Plain radiography is very inadequate. Contrast enhancement is useful in neurologically deteriora-

tion but trauma history is uncertain. Ultra-early examination is not a guarantee for better outcome.

TBI patient may deteriorate rapidly in several hours. Short term follow up is recommended in risky

patient. Dangerous traumatic mechanism or patients on anticoagulation should be considered for

short term imaging follow up.

Swirl sign in hematoma on CT means that there is active bleeding. It usually predicts rapid de-

terioration requiring surgical treatment.

Diffuse injury may not be detected on CT scan. Diffuse axonal injury defines persistent coma-

tose mentality with no causable intracranial lesion on CT scan. In this situation, MRI scan will help

to find out the cause. Multiple microbleedings, injury of axial structures - corpus callosum, mid-

brain and brain stem - may be seen in MRI scan. Without stem injury, patients with diffuse axonal

injury will recover their mentality but may be with cognitive dysfunction. Brain stem injury causes

delayed mental recovery and severe autonomic dysfunction.

Signs and findings predicting poor outcome is important to decide management modality and

give consent to patients and their family. And appropriate work up and treatment to these signs

and findings will reduce mortality and morbidity of TBI patients.

150


2004.09-2006.08: Postgraduate Master Course, Graduate School of SNU (Degree of M.S.)

2007.03-2009.02: Postgraduate Doctoral Course, Graduate School of SNU (Completed)

2011.12- Present: Public Servant, Department of Neurosurgery, The Armed Forces

Capital Hospital, South Korea

2012.08-Present: Chief of Spine center, The Armed Forces Capital Hospital, South

Korea

2014.02-2016.01: Chief of Planning and Coordination Bureau, The Armed Forces


2014.02-Present: President, Korean Military Society for Quality in Health Care,

South Korea

2016.02-Present: President of Department of Neurosurgery, The Armed Forces


2016.06-Present: Director of Military Neurotraumatology, The Korean

Neurotraumatology Society, South Korea

2016.12-Present: Chief of Task Force Team of Construction and Establishment of

Korean Armed Forces Trauma Center

The Koran Medical Association

The Korean Neurosurgical Society

The Korean Neurotraumatology Society

Education

Professional

Career

Membership in

Societies



151


Experiences of Spinal Trauma in Military

Hospital


Objectives: This study analyzed and reviewed to know the clinical result and characteristics of

spinal cord injury (below ASIA grade D) and vertebral fractures managed with surgical treatment in

the Armed Forces Capital Hospital for 6 years experiences.

Materials and Methods: Korean military personnel who sustained a spine injury that result-

ed in neurological deterioration (below ASIA grade D) and vertebral fractures which should be

managed with surgery from November 2011 to June 2017. Demographic and injury-specific char-

acteristics were abstracted for each individual identified. The raw incidence of spinal injuries was

calculated and correlations were drawn between the presence of spinal trauma and military spe-

cialty, mechanism and manner of injury. Significant associations were also sought for specific injury

patterns, including low thoracic and upper lumbar vertebral fractures. Clinical result was checked

by ASIA scaling and radiological data.

Results: Among 155,220 patients who visited Neurosurgical department in the Armed Forces

Capital Hospital for 6 years, total 60 patients who suffered from traumatic spinal injury and ver-

tebral fractures with or without neurological deterioration underwent surgery. 33.3 percent of all

casualties under the surgical management with spinal injury were suffered from neurological de-

terioration and 10 caused by suicide attempt, 5 by fall down during military training, 5 caused by

parachute descents. Spinal burst fracture was the most common type of injury (n = 31), while spi-

nal dislocations occurred in 2. Two sustained cervical spine injury. Spinal cord injuries(N=13) were

more likely to occur as ASIA grade A in 1, B in 3, C in 6, and D in 10. Significant improvement

after operation was shown in 13 by ASIA scale. Most common remnant neurological deterioration



152



was lower extremity weakness with or without paraparesis and bladder bowel symptoms. Most

common involved levels of vertebral fractures was the thoracolumbar junction (n=25). About Half

of thoracolumbar injury cases (n=13) were performed by anterior reconstruction of vertebral body

and fixation only and all of them achieved good clinical outcomes about restroration of kyphotic

deformity and neurological improvement.

Conclusion: Most of spinal cord injury achieved good improvement after early surgical inter-

vention. Thoracolumbar fracture were restored to good neurological status and stability only by

anterior corpectomy and fusion. But ASIA A was poor prognostic factor after surgery. Early decom-

pression will promise clinical better outcome and improvement.


Director

Jongbouk Lee (National Medical Center)

Moderator

Jongbouk Lee (National Medical Center)


1F. Main Auditorium

Plenary Session 3

Step by Step 2017

06-24 (Sat.), 2017

154




1999-2008 Research Fellow in Nagoya University Graduate School of Medicine

2010 The Degree of “Doctor of Medical Science (PhD)” was Awarded

from Teikyo University

2011-Present Associate Professor in Trauma and Resuscitation Center


2009-2011 Assistant Professor in Trauma and Resuscitation Center


2000 Board Certificate Member of the Japanese Association of Acute

Medicine (Present; Senior Fellow of he Japanese Association of

Acute Medicine)

2008 Board Certification Member in the Japanese Organization of Cancer

Therapy

2013-Present Active Member - International Surgical Society ( ISS/SIC)

2013-Present General Secretariat of in International Association of Trauma and

Intensive Care(IATSIC) - Japan chapter in International Surgical

Society ( ISS/SIC)

Course Coordinator International Association of Trauma and

Intensive Care(IATSIC)

Education

Professional

Training and

Employment

Licensure and

Certification

Profesessional

Activity

155


Management of Traumatic Patients in Japan




156


Dr Kenneth Mak is a general surgeon with subspecialty clinical interests in hepatobiliary and pancreatic

surgery, surgical critical care as well as in trauma surgery. He maintains his clinical practice as a Senior

Consultant in the Department of Surgery, at Khoo Teck Puat Hospital, Singapore.

Dr Mak co-chairs the National Trauma Committee in Singapore and is a member of the National Pre-Hospital

Emergency Care Steering Committee. He is also member of the IATSIC International Training Faculty for the

Definitive Surgical Trauma Course (DSTC) and a Course Director for the National Advanced Trauma Life Support

Course in Singapore.

Dr Mak is a Clinical Associate Professor with the Yong Loo Lin School of Medicine, National University of

Singapore. He is a member of the Specialist Accreditation Board and an Executive Council member of the Joint

Committee for Specialist Training. He further heads the General Surgery Residency Advisory Committee, which

oversees General Surgery specialty training in Singapore.

Dr Mak is also the Deputy Director of Medical Services, Health Services Group in the Ministry of Health,

Singapore. He is responsible for the provision of health services by all public acute and community hospitals,

as well as primary care clinics in Singapore.

Dr Mak serves in the Singapore Armed Forces and holds the rank of Colonel. He has held command and staff

appointments at Battalion, Brigade and Divisional levels.



157


Management of Pancreatoduodenal Injuries


Injuries to the pancreas and duodenum pose diagnostic and therapeutic challenges to the sur-

geon. A high index of suspicion, sound clinical judgement and adherence of damage control prin-

ciples can allow for good clinical outcomes in the treatment of such injuries. Complex pancreato-

duodenal injuries, with associated vascular injuries, may require more challenging surgical repair.

This presentation outlines the main principles that guide resuscitation and treatment of patients

with pancreatoduodenal trauma. The evolving role of surgery is discussed, both in the treatment of

pancreatoduodenal injury, but also in the management of complications.



158


Chief of Trauma and Surgical Critical Care-San Antonio Military Medical Center

2015 to Present

Chief of General Surgery-San Antonio Military Medical Center 2015

Co-Director Surgical and Trauma ICU - San Antonio Military Medical Center

2014-2015

Trauma Fellowship, University of Hawaii, Honolulu, HI / 2007-2008

Program Director: Dr. Hao Chih Ho

Surgical Critical Care Fellowship, University of Hawaii, Honolulu, HI / 2006-2007

Program Director: Dr. Mihae Yu

General Surgery Residency, Eisenhower Army Medical Center, Fort Gordon, GA

2001-2005

1983-1988

Examiner-2012, 2011, 2009

Postoperative Fluid and Electrolytes- Tripler Army Medical Center Cardiac

Nurse Course Dec 2009, Jul 2012

Member American Association of Trauma Since 2013

Fellow American Board of Surgeons Since 2010

Member Society of Critical Care Medicine 2007

Board Certified Surgical Critical Care October 1, 2007 Expires July 2018

Board Certified General Surgery March 21, 2006 Expires 2028

Positions

Academic

Education

Licensure/

Certification



159


The Trauma System as San Antonio Military

Medical Center: A Paradigm for a

National Trauma System


Background: The San Antonio Military Medical Center (SAMMC) is completely run, organized

and funded by the United States Military. The Medical Center has been caring for civilian trauma

patients since organized trauma has been present within the city of San Antonio. In 1977, three

years after the end of Vietnam War, SAMMC embarked on an official relationship with the city to

care for civilian trauma patients. Over the past 40 years the Medical Center has been recognized

as a center for innovation in the care of the trauma patient. This bidirectional flow of information

between the civilian and military has resulted in national attention in the recently published, feder-

ally funded, document: “A National Trauma Care System: Integrating Military and Civilian Trauma

Systems to Achieve Zero Preventable Deaths After Injury”

Learning Objentives:

1. Overview of the military and civilian successes that have been contributed to include

a. Defining preventable trauma deaths

b. Joint Trauma Theater System/Regional Trauma Center

c. Whole blood transfusions and 1:1:1 Massive transfusions

d. Clinical Practice Guidelines

e. Critical Care Air Transport

f. Tourniquets

g. Damage Control Resuscitation and Surgery



160



2. Overview of the challenges of military hospital caring for civilian trauma patients to include

a. Using military funds to care for civilian trauma patients

b. Staffing a busy trauma center with military personnel during war

3. Brief overview of the National Trauma Care system as it applies to SAMMC

Conclusion: SAMMC’s military organization and unified structure along with its clarity of mis-

sion when caring for a combat casualties partnered with the civilian communities constant and de-

manding need for trauma care provides a symbiotic relationship that has been successful enough

to contribute to the model for a national trauma care system.


Director


Moderator

Jung Nam Lee (Gachon Univ. Gil Hospital)

Jungchul Kim (Chonnam National Univ. Hospital)

1F. Main Auditorium

Symposium 5

Trauma Management Update

06-24 (Sat.), 2017

162


1991. 3 ~ 1999. 2: B.D., College of Medicine, Pusan National University, Busan, Korea

2002. 3 ~ 2004. 2: M.D., Postgraduate School of Medicine, Pusan National University,

Busan, Korea

2010. 3 ~ 2012. 2: Doctor's Course, Postgraduate School of Medicine, Pusan National

University, Busan, Korea

2000. 3 ~ 2001. 2: Internship, Pusan National University Hospital, Busan, Korea

2001. 3 ~ 2005. 2: Residency, Department of Surgery, Pusan National University

Hospital, Busan, Korea

2008. 5 ~ 2009. 2: Fellowship, Department of Surgery, Pusan National University

Hospital, Busan, Korea

2009. 3 ~ Present: Assistant Professor, Pusan National University Hospital, Busan,

Korea

2012. 3 ~ 2016. 3: Divisional Director of Trauma Program, Trauma Center, Pusan

National University Hospital, Busan, Korea

2014. 6 ~ Present: Chief, Department of Trauma and Durgical Critical Care, Pusan

National University Hospital, Busan, Korea

Member, Korean Surgical Society

Executive member, Korean Society of Acute Care Surgery

Member, Korean Society of Critical Care Medicine

Member, Korean Society of Traumatology

Educational

Background

Post-Doctoral

Training Including

Residency/

Fellowship

Hospital

Positions

Membership



163


Should TEG/ROTEM be a Standard of

Trauma Care?




Models of coagulation and limitations of standard coagulation tests

Coagulation is a complex, dynamic, highly regulated and interwoven process involving a myriad

of cells, molecules and structures. The model of coagulation that was conventionally taught was

the cascade model of a series of proteolytic reactions that act as a biological amplifier.

By Dr Graham Beards

164



However, the limitations of this model of the hemostatic process become clear in clinical

situations. The intrinsic and extrinsic pathways cannot be operating as independent, redundant

pathways in vivo and it was also recognized that cells are important participants in this process,

and that normal hemostasis requires cell associated tissue factor (TF) and platelets, in addition to

the proteins of the coagulation cascade.

So, new model of coagulation was proposed in 2001 by Hoffman and Munroe, and has become

the accepted description of how hemostasis takes place in vivo. The cell base model proposes that

hemostasis occurs in three distinct, but overlapping steps - initiation, amplification and propagation.

BSAVA Manual of Canine and Feline Clinical Pathology, 3rd edition

The activated partial thromboplastin time (aPTT) and prothrombin time (PT) are the most

commonly used tests of coagulation. The aPTT is used to assess the contact activation and the

integrity of the intrinsic coagulation pathway (factors XII, XI, IX and VIII) and final common

pathway (factor II(prothrombin), V,X and fibrinogen). The PT is used to assess the integrity of the

extrinsic pathway, which consists of TF and VIIa, and coagulation factors of the common pathway.

As mentioned before, in vivo the coagulation reactions occur on specific cell surfaces, rather

than on phospholipid surfaces as they do in the PT and aPTT assays. So, in many studies, standard

coagulation tests cannot reflect the coagulopathy.

Coagulopathy in trauma

Recently, the unique changes in coagulation caused by trauma are starting to be understood, but

165



it is very complex and remains mostly unknown.

By Hess et al.

Trauma patients with coagulopathy are the largest consumers of blood and blood products and

the decision of what, when and how much blood and blood product to transfuse is often empiric

or based on traditional coagulation lab tests such as INR/PT, PTT and platelet count. Any delay in

obtaining the lab results can lead to inadequate transfusion and increased morbidity and mortality.

Thus in trauma, global, functional and immediately available laboratorial evaluation of hemostasis

can improve both patient management and outcome.

Viscoelastic tests of coagulation (TEG/ROTEM)

Viscoelastic coagulation tests have a chance to overcome many of the limitations of conventional

coagulation tests, as they measure the entire coagulation process, from fibrin formation through

to final clot strengthening and fibrinolysis. It provides a global and functional assessment of

coagulation. In addition, the faster availability of results may assist clinical decisions of what, when

and how much blood and products to transfuse.

The two tests have the same foundational principles and share many similarities, from hardware

(equipment) and procedures (technique) to tracing (graph) and parameters, equivalent with

interchangeable results and interpretations.

166



By Sankarankutty et al.

The studies on TEG- or ROTEM-based transfusion algorithms suggested that while both tests can

be used to construct transfusion guidelines, the blood products transfused differ according to the

algorithm selected. Therefore, a standardized guideline for this is needed.

Conclusion

TEG and ROTEM have many of the characteristics of ideal tests for use in trauma including

global evaluation of coagulation, both quantitative and functional assessment. TEG and ROTEM

could have important roles in trauma in 3 ways: by promptly diagnosing early trauma coagulopathy

(diagnostic tools); guiding blood transfusion and revealing patients’ prognosis. But, their potential

clinical utility must be balanced against limitations particularly the considerable heterogeneity in

methods, reagents and parameters evaluated.

167


Dr. Lee entered the School of Medicine, Ajou University, in March 1988 and graduated from the same with a

BA degree in medicine in February, 1995. He entered Graduate School of medicine, Ajou University, in March,

1997, was awarded a Master degree in Medicine, 1999, and a Ph.D. degree in Medicine, 2002. He completed

a 1-year internship course on Ajou University Hospital, 1995 and 4-year residency course in Department

of General Surgery, Ajou University Hospital, 1996 - 2000. He received special training from the San Diego

Microsurgical institute & Training Center at Mercy Hospital La Jolla, California, U.S.A., in October, 1997 and

Trauma Center of UC San Diego Medical Center, Hillcrest San Diego, California, U.S.A., in January, 2003.

He did his Fellowship Training in General Surgery in 2001 and Trauma Surgery in 2002. Dr. Lee enlisted in

the Republic of Korea Navy in March, 1992 and was discharged from service and placed on the reserve list

afterwards.

He was employed as a faculty member of Ajou University Medical Center & School of Medicine as an

instructor in September, 2002 and promoted to be an Assistant Professor of Ajou University Medical Center

& School of Medicine in September, 2004. He worked at the Royal London Hospital in the United Kingdom as

an Honoary Consultant Trauma Surgeon from 2007 to 2008.

Dr. Lee has received numerous awards, including the 2010 Recognition in National Emergency Medical

System by Ministry of Health and Welfare, and Civil Merit Medal in 2011 for his devotion to a Trauma Care

System in South Korea.

Dr. Lee was awarded certificate of appreciation two times from White House Medical Unit of the United

States in 2009 and 2010 due his outstanding support for the US troops stationed in South Korea and lots of

American Citizens.


John Cook-Jong Lee (Ajou Univ. Hospital)

168


Retrohepatic Vena Cava Injury

John Cook-Jong Lee (Ajou Univ. Hospital)



Traumatic injury to the retrohepatic veins continues to carry high mortality rates. In the last few

decades various management strategies have been proposed. However, treatment of such injuries

still remains highly variable and technically challenging due to the surgically inaccessible location

of these vessels and the consequent difficulty controlling bleeding.[1] Massive hemorrhage on the

vena cava is a major obstacle to repair. Also, damage to the hepatic veins can be extraparenchymal

or intraparenchymal.[2] Life-threatening bleeding from these injuries occurs if the supporting struc-

tures, mainly the suspensory ligaments, diaphragm, or liver parenchyma, are disrupted. Therefore,

the exposure of a major venous injury may release the tamponade and result in free bleeding and

exsanguination. As Buckman et al. outlined, there are three main strategies described to deal with

these mortal injuries. The first is to directly repair te venous injury with or without vascular isola-

tion. The second is with a lobar resection. The third is by using a strategy of tamponade and con-

tainment of the venous bleeding.

Direct venous repair

Schrock et al. first introduced the atriocaval shunt in 1968. The goal is to shunt the blood from

the infrahepatic vena cava, bypassing the retrohepatic cava, and directing flow into the artia. This

along with the Pringle maneuver, is theoretically used to creat a bloodless field. Unfortunately, of

the approximately 200 cases published using atriocaval shunting, only at best 10-30% survive their

injury. Shunting a patient cannot be successfully accomplished if the patient has already had major

blood loss, becomes coagulopathic, and has inadequate operative incisional exposure.

169



In our case, 42 years old, male with penetrating injury on the junction of retrohepatic IVC and

hepatic vein injury was successully treated with direct venous repair. We use venovenous bypass

from Rt fimoral vein to Rt. Artria with Pringle maneuver.

However, in two more cases, we were failed with direct venous repair. They were blunt trauma

patients. All of them already had severe exsanguination and coagulopathy with massive tearing of

vena cava with other organ injury including liver.

Anatomic resection

Anatomic resection has resulted in a high mortality when carried out for traumatic bleeding. In

certain circumstances when the dissection has already been done by the injury itself, resection for

debridement may be indicated. However, current data do not promote anatomic resection for ma-

jor venous injury unless direct repair is necessary.

Tamponade with containment

The focus on severe vascular injury management has shift to methods of tamponading and con-

taining venous injury in addition to embolization of arterial bleeding. At this time it seems that the

most successul method of managing severe retrohepatic or hepatic venous injury is by using tam-

ponade and containment. Direct repair of damaged vessels continues to have a very high morbidi-

ty even in the most experienced hands. Overall, the best approach to severe liver injury includes

(a) Expedient recongnition and operative intervention of unstable hemorrhaging patients,

(b) Mibilization of the liver ligaments not directly involved with hematoma to better visual-

ize the injury

(c) Placement of a viable omental tongue into parenchymal defect

(d) Rapid determination of the need for gauze packing when direct surgical maneuvers fail

(e) Angiographic embolization of hepatic arterial injured branches when ongoing hemor-

rhage or CT blush is seen[3]

170



1. Kaoutzanis, C., et al., Successful repair of injured hepatic veins and inferior vena cava following

blunt traumatic injury, by using cardiopulmonary bypass and hypothermic circulatory arrest.

Interact Cardiovasc Thorac Surg, 2011. 12(1): p. 84-6.

2. Biffl, Walter L. MD; Moore, Ernest E. MD; Franciose, Reginald J. MD, Venovenous Bypass and

Hepatic Vascular Isolation as Adjuncts in the Repair of Destructive Wounds to the Retrohepatic

Inferior Vena Cava

3. Kenneth L. Mattox, Ernest E. Moore, David V. Feliciano, Trauma, 7th Edition, Mcgraw

hill:p.552-554

171


1993 - 1999 Graduate from Catholic University College of Medicine, Bachelor

2001 - 2003 Graduate school of Medical Science, Catholic University College of

Medicine (Master Degree)


Medicine (Ph.D)

1999 Internship, Holy Family Hospital, The Catholic University of Korea

2000-2004 Residentship in General Surgery, Catholic Medical Center, Korea

2004-2007 Captain, Republic of Korea(ROK) Army

2006-2007 Chief of Medical Staff, Zaytun Hospital, Iraq, ROK army

2007-2010 Fellowship in General Surgery, Uijeongbu St. Mary Hospital

2010-2012 Clinical Assistant Professor in Trauma Surgery, Uijeongbu St.

Mary’s Hospital

2011-Now Subspecialist, Critical Care Medicine

2012-Now Subspecialist, Trauma Surgery

2013-Now Assistant Professor in Division of Trauma Surgery, Uijeongbu St.

Mary’s Hospital

2013-Now Director, Committee on information, The Korean Society of

Traumatology

2013-Now Director, Committee on information, The Korean Society of Acute

Care Surgery

2015-Now Assistant Administrator, The Korean Surgical Ultrasound Society

2015-Now Director, Department of Trauma Surgery

2015-Now Director, Regional Trauma Center, North Kyunggi Province

Education

Professional

Experience


Hang Joo Cho ( The Catholic Univ. Hospital)

172


Open or Closed? The MIS Applied to Trauma




Minimally invasive surgery(MIS) is now widely used in all surgical field except for trauma sur-

gery. This is because MIS have several disadvantage including increased possibility of missed injury

& bowel injury, increased IICP, more time consuming, greater chance of gas embolism. If missed

injuries were occurred or time to bleeding control is delayed, the patient’s survival was threatened.

However,MIS have extinguished benefits including improved cosmesis, low tissue desiccation,

lower chance of post-operative paralytic ileus and so on.

Laparoscopic trauma surgery(LTS) is devided into two classes, diagnostic & therapeutic.

Diagnostic laparoscopy

Diagnostic laparoscopy is used for sparing non therapeutic laparotomy. Especially in cases with

abdominal stab wound with proven or equivocal penetration of fascia, suspected intraabdominal

injury after blunt trauma, diagnosis of diaphragmatic injury from penetrating trauma to the thora-

coabdominal area. Sensitivity, specificity, diagnostic accuracy of diagnostic laparoscopy range from

75% to 100%.

Therapeutic laparoscopy

Laparoscopic repairs of injuries to every organ have been described. Injuries to diaphragm,

parenchyma organ and gastro-intestinal tract have been successfully repaired laparoscopically.

173



Patients who continue to bleed following embolization can be treated with laparoscopy by topical

hemostatic agent or even splenectomy. Small laceration of stomach, duodenum, small bowel, co-

lon can be repaired laparoscopically. Sometimes an anastomosis or a long repair are usually per-

formed extracorporeally through a small focused celiotomy. Diaphragmatic hernia(esp. Lt.) can be

repaired successfully by various laparoscopic suture techniques.

Contraindication

Hemodynamic instability is currently the absolute contraindication for laparoscopy. Concomitant

severe traumatic brain injury also exclude laparoscopy because of increased intracranial pressure

Conclusion

Position of laparoscopic surgery in trauma field is between laparotomy and observation. Be-

cause of innovative development of laparoscopic instruments, almost all surgery can be conducted

by laparoscopic method. Role of laparoscopy in trauma will be increased also in trauma surgery. If

the patient’s vital sign is stable, laparoscopic methods can be applied, however we should be care-

ful about missed injury.

174




2002.2 : Master, Korea University of Graduate School (Medicine)

2005.2 : Doctor, Korea University of Graduate School (Medicine)

2016.2 ~ : Head of Critical Care Department at Korea University Guro Hospital

2016.7 ~ : Board Member of Korean Surgical Infection Society

2014.4 ~ 2014.5 : Trauma Surgeon, Agok MSF Trauma Hospital, South Sudan

2014.3 ~ : Manager of Trauma Surgery at Korea University Guro Hospital

2014.3 ~ : Board Member of MEDICINS SANS FRONTIERES KOREA

2013.6 ~ : Director, Korea Disaster Surgical Response Team

2014.3 ~ 2016.3 : Board Member of MEDICINS SANS FRONTIERES JAPAN

2013.3 ~ : Associate Professor of General Surgery at Korea University Guro Hospital

2011.10 ~ 2012.11 : Manager of Trauma surgery at Cheju Halla General Hospital

2011.1 ~ 2011.5 : Field Medical Doctor / Medical Consultant in MSF-CH Yanbian

2010.10 ~ 2010.11 : Trauma Surgeon, Hangu MSF Trauma Hospital, Pakistan

Education

Qualification &

Experience

175


Damage Control Surgery.

Light and Dark Side





Director


Moderator

Il Ung Hwang (Former Commanding General, Armed Forces Medical Command, ROK)


1F. Main Auditorium

Symposium 8

Trauma US

06-24 (Sat.), 2017

177




1993 - 1999 Graduate from Catholic University College of Medicine, Bachelor


Medicine (Master Degree)


Medicine (Ph.D)

1999 Internship, Holy Family Hospital, The Catholic University of Korea

2000-2004 Residentship in General Surgery, Catholic Medical Center, Korea

2004-2007 Captain, Republic of Korea(ROK) Army

2006-2007 Chief of Medical Staff, Zaytun Hospital, Iraq, ROK army

2007-2010 Fellowship in General Surgery, Uijeongbu St. Mary Hospital

2010-2012 Clinical Assistant Professor in Trauma Surgery, Uijeongbu St.

Mary’s Hospital

2011-Now Subspecialist, Critical Care Medicine

2012-Now Subspecialist, Trauma Surgery

2013-Now Assistant Professor in Division of Trauma Surgery, Uijeongbu St.

Mary’s Hospital

2013-Now Director, Committee on information, The Korean Society of

Traumatology

2013-Now Director, Committee on information, The Korean Society of Acute

Care Surgery

2015-Now Assistant Administrator, The Korean Surgical Ultrasound Society

2015-Now Director, Department of Trauma Surgery

2015-Now Director, Regional Trauma Center, North Kyunggi Province

Education

Professional

Experience

178


Recent Updates in FAST from the Perspective

of a Trauma Surgeon




FAST (Focused Assessment with Sonography for Trauma)란 외상환자에게 초음파 검사를 시행

하여 흉복부 손상을 빠르게 진단하는 초음파 진단법이다. 초창기에는 복강 내 저류액의 유무를 확인

하기 위하여 시행하였다. 1996년 Focused Abdominal sonogram for trauma를 FAST로 기술하였다

가 1999년 국제합의회의를 통하여 복강 내 장기에만 국한되지 않는 것을 고려하여 Focused Assess-

ment with sonography for trauma로 이름을 바꾸었다. 복부와 심장검사에 기흉의 진단을 추가하여

eFAST(extended FAST)를 시행하기도 한다. FAST 검사는 ATLS(Advanced Trauma Life Support)중

에 주로 시행되며 중증외상환자의 치료에 선봉에 서 있는 외상외과 의사에게는 상당히 중요한 검사

법이다. FAST는 최소 4군데의 검사가 필요하다. 곡선형 탐촉자를 이용하여 1) 검상하, 2) 우상복부

3)좌상복부 4) 골반 의 순서로 검사를 시행하며 심장과 복강내에 혈액의 유무를 판단하게 된다.

먼저 심장막 구역에서는 검상하 영상으로 확인을 하게 되며, 심장에 있는 혈액을 기준으로 게인

을 조절한다. 만약 검상하 영상으로 심장이 잘 보이지 않는다면 부흉골 장축, 단축영상과 4 chamber

view를 통해서라도 심장은 반드시 확인한다.

두 번째로는 우상복부의 모리슨 궁의 혈액의 저류를 확인하는데 간이나 비장 손상시에 가장 먼저

혈액이 고이는 곳이 우상복부이기에 맨 처음 확인하게 된다. 우측 11-12번 늑간을 활용하여 탐촉자

를 위치시켜 간, 신장, 횡격막의 단면을 얻게 된다.

세 번째로는 좌상복부의 횡격막하 공간과 비장과 신장사이의 공간에 혈액의 저류를 확인한다. 중

요한 것은 우상복부보다 조금더 머리쪽으로 그리고 뒤쪽으로 탐촉자를 위치시켜야만 잘 관찰이 된

다는 것이다.

마지막으로 골반의 더글라스 궁을 관찰하는데 종축과 횡축 두 가지로 관찰하게 된다. 먼저 횡축

179



영상으로 치골결합의 머리 방향으로 약 4cm 떨어진 곳에서 시작하여 꼬리쪽으로 탐촉자를 내려오

게 하면서 골반강내 액체의 저류를 확인한다. 이 때 방광이 차 있으면 더 좋은 영상을 얻을 수 있기에

foley catheter 삽입 전에 시행하면 좋다. 다시 탐촉자를 90도로 돌려 종축영상을 확인한다.

FAST는 외상외과 의사가 직접 수행함으로서 초음파 검사의 장점을 극대화 할 수 있다. 외상환자

는 최종치료까지의 시간이 1시간 이내를 목표로 하기에 환자가 혈역학적으로 불안정하며 초음파에

서 복강내 출혈이 의심이 된다면 CT 등의 추가 검사 없이 바로 수술실로 향하게 된다.

단점으로는 어떠한 장기가 손상을 받았는지 정확히 모른다는 것이다. 기존의 다기관 연구에서 고

형장기의 손상을 진단할 수 있는가에 대하여 연구하였는데 장기가 얼마나 다쳤는지에 따라서 달라

지겠지만 민감도는 25-75% 정도이며, 시간이 훨씬 더 소요되므로 아직까지 효용성은 떨어지는 것으

로 판단한다.

최근에는 E-FAST에서 더 나아가 흉부에서 pneumothorax뿐아니라 hemothorax, lung contusion

을 진단할 수도 있으며 primary resuscitation인 ABCDE에서 초음파가 모두 유용하며 사용되어야 한

다고도 보고되고 있다.

결론적으로 외상환자의 최종치료까지의 시간을 줄이는 데 없어서는 안될 가장 중요한 검사 수단

으로서 처음에는 복부의 free fluid의 저류를 진단하는 것에서 더 나아가 일차 소생에서의 모든 응급

질환을 감별하는 수단 및 특히 shock인 환자에서 원인을 진단하는데 까지 점점 더 확대되고 있다.

180




Emergency physician, M.D., Ph.D.

Associate Professor in Dongguk University College of Medicine

Executive Director of Society of Emergency and Critical Care Imaging

Member of the Korean Society of Emergency Medicine

International Ultrasound Instructor of Winfocus

181


Ultrasound Guided Procedure of Central

Venous Catheterization (CVC)




1. Pre-procedure ultrasound (US) scan

A. Pre-scan of central vein

- Vessel patency, thrombosis

B. Pre-scan of Lung

- Confirming proper pleural attachment in the ipsilateral anterior chest wall

- Lung sliding sign or lung pulse

2. Ultrasound guided procedure

A. USG venous puncture

- dynamic scan, longitudinal view

B. USG guidewire confirmation

- Scan distal IJV just above clavicle

3. Post-procedure US confirm

A. Lung scan for pneumothorax

- Check for no lung sliding, lung point

B. Right heart scan with contrast

- Microbubble appearance within 1 second (proper tip position)

182



Table 1. Checklist of SECURE protocol

Checklist

1st STEP

Pre-scan of

internal jugular vein

Scan the internal jugular vein □ Completed □ Not

Vein sit on artery anteriorly

Narrowing or thrombus inside

□ Head rotation

□ Quit protocol

2nd STEP

Pre-scan of pleura

Scan ipsilateral anterior pleura □ Completed □ Not

Lung sliding sign

Lung pulse

□ Attached pleura

□ Attached pleura

3rd STEP

Ultrasound guided

internal jugular vein

puncture

Scan the needle tip penetrating □ Completed □ Not

Needle tip in jugular vein

Arterial puncture

Arterial hematoma

Vessel injury

□ Insert guidewire

□ Compression

□ Quit protocol

□ Quit protocol

4th STEP

Guidewire scan

Scan jugular vein above clavicle □ Completed □ Not

Guidewire inside the jugular vein

Arterial inserted guidewire

Invisible guidewire

Vessel injury

□ Insert expander

□ Remove guidewire

□ Neck vessel scan

□ Quit protocol

5th STEP

Post-scan of pleura

Scan anterior pleura, again □ Completed □ Not

Preserved lung sliding or pulse

Loss of lung sliding

Loss of lung pulse

□ No pneumothorax

□ Pneumothorax

□ Pneumothorax

6th STEP

Post-scan of heart

Scan right side heart □ Completed □ Not

Push-to-bubble time > 1 second □ Catheter malposition

183



Fig. 1 (A) Pre-scan of internal jugular vein. (B) Pre-scan of pleura, (C) Ultrasound guided vein puncture, (D) Guide-

wire scan, (E) Post-scan of pleura, (F) Post-scan of heart with agitated saline.

184




B.A. Hanyang University, 1996 (Medical school)

Board certification of Emergency Medicine, Samsung Seoul Hospital, 2001

2013-Current, Associate Professor of Medical School, Hanyang University

2007-2012, Assistant Professor of Medical School, Hanyang University

2011-2015, President of Korean Academy of Emergency Cardiovascular Care

2013-Current, Educational Chair, Society of Emergency Critical Care Imaging

Moderate Alcohol Consumption & Health Beneficial Effect

Aldehyde Dehydrogenase 2 & Related Genetic Polymorphism

Emergency Ultrasound,Telemedicine and Telecare

Emergency Cardiovascular Care

Education

Professional

Experience

Academic Service

Research Interest

185


The Role of POCUS in Cardiovascular

Trauma




The Role of POCUS in Cardiovascular Trauma

Bossng Kang Emergency Medicine

Hanyang University Guri Hosp Gyunggi, Korea

Diagnosis & USG Procedure• Thoracic Aorta Trauma (isthmus)• Pericardial effusion (bleeding)• Cardiac Tamponade

• early diastolic RV collapse

• USG Pericardiocentesis• apical/ parasternal approach

Diagnosis• Injury of Myocardial Walls

• RV(>>LV) non-Coronary RWMA• Dilatation of Chamber (RV)• Thrombus within Dysfunctional Chamber• Atrial Rupture (>> Ventricular)

• Stress induced CMP• Tricuspid Valve Trauma (chordae rupture)

first, pericardial effusion confirmed ?

Patient selection using Echo

186



5

early diastolic RV collapse

Pericardiocentesis required ?

7

Blind subcostal approachtraditional method

Less frequently used, depending on the 2D Echo finding

- Trauma: liver, heart(CA), lung - High complication rate - long pathway

Tamponade finding detection not easy w fast HR

Who needs

emergency pericardiocentesis ? - appropriate patient selection –

• Obvious tamponade finding w severe symptom or low B.P.

or Cardiac arrest

Ideal site for needle entry

Mark

187



Mark Ideal site for needle entry Apical approach



Certified Emergency Physician (KSEM)

Certified Critical Care Physician (KSCCM)

Certified Physician for Echocardiography (KSECHO)

Adjunct Professor of Dept of EMT in Dongnam Health College

Adjunct Professor of Dept of EM in Yosei University Medical College

President, Society of Emergency and Critical Care Imaging (SECCI)

Board of Director, Korean Society of Critical Care Medicine (KSCCM)

Faculty and Instructor, Essential Surgical Procedures in Trauma (ESPIT) in Korea

Board of Director, WINFOCUS (World Interactive Network of Focused on Critical Ultrasound)

Faculty and Instructor, USLS BL1P, USLS AL1P, WBE, WMTBE and WBLUS of WINFOUCS

International Faulty of AACES in Singapore

Director of SEARCH 9Es Course in Korea

US Chapter Author of the Korean Text Books of Trauma and Critical care medicine

189


The Role of Lung US in Trauma




POC LUNG ULTRASOUND IN TRAUMA

Dr. YOUNG-ROCK HA. Dept. EM. BUNDANG JESAENG HOSPITALPRESIDENT, Society of Emergency and Critical Care Imaging (SECCI)

ABC OF LUNG ULTRASOUND

OUTLINE

ABC of lung ultrasound

Traumatic pneumothorax

Traumatic hemothorax

Traumatic lung contusion

PROBE FOR A LUNG US

Equipment• Microconvex Probe 4-7 MHz• Curvilinear Probe 2-6 MHz• Any probe depending on the focus.

Settings• Marker to left of screen• No harmonics

Technique• Patient in supine position• Longitudinal plane• Probe perpendicular to chest wall

4-7 MHz

2-6 MHz

190



How to scan the lung

Longitudinally and perpendicularly

HOW TO INTERPRET IT IN A SINGLE SCAN?

Pleural line

Chest wall

Sub-pleural space

Lung sliding, lung point, lung pulse, pleural abnormality

A-lines, B-lines, Consolidation, Effusion

Sternum

Anterior Axillary

12

34

Posterior

Axillary

56

Complete evaluation of both lungs• Locate the diaphragm• Divided 6 regions in each chest• Every intercostal spaces

COMPREHENSIVE LUS

Crit Care Med 2010;38:84 –92

FIND THE “BAT SIGN’ IN STEP 1.

• Visible only in longitudinal scan• Mandatory first sign to acquire• Permanent landmark of the lung surface

Lower ribUpper rib

＊＊

HOW MANY POINTS?6 points: BLUE 10 points 14 points

Kristensen Insights Imaging 2014Lichtenstein Chest 2008 Segikuchi Chest 2015

Normal lung pattern: APleural line and lung sliding

A-pattern

191



NORMAL LUNG2D & M-MODE

2D• Lung sliding• A lines

M-mode• Seashore sign

Transducer

Multiple US Beam Reflections

NORMAL INTERLOBULAR

SEPTAHOMOGENEOUS

TISSUE-AIR INTERFACE

REVERBERATIONS

NORMAL ARTIFACTS (A lines)

B-pattern

Abnormal lung pattern: B

Interstitial syndrome in trauma =lung contusion

C-pattern

Abnormal lung pattern: C

Alveolar consolidation in trauma = lung contusion

A’-pattern

Abnormal lung pattern: A’

pneumothorax

Transducer


NORMAL INTERLOBULAR

SEPTAHOMOGENEOUS


Transducer

THICKENED INTERLOBULAR

SEPTA


INHOMOGENEOUS TISSUE-AIR INTERFACE

REVERBERATIONS

COMET TAILS (B lines)

REVERBERATIONS

NORMAL ARTIFACTS (A lines)

LUNG US ACCORDING TO THE AIR-TO-FLUID RATIO

Traumatic PNX Lung contusion HPX

192



LUNG

DIAGNOSTIC POWER OF LUNG US IN TRAUMA

VISCERAL PLEURA

PARIETAL PLEURA

PLEURAL CAVITY

EVLWVariable Air/fluid

Lung contusion

Pure Air in pleural cavity

pneumothorax

Pure Fluid in pleural cavity

Hemothorax

J Trauma. 2004;57:288–295.

TRAUMATIC PNEUMOTHORAX

abdo

menlung

Normal Lung

Collapsed lung

PNEUMOTHORAX

abdo

men


Absence of lung sliding

Absence of pathological artifacts arising from pleural line =

No B-lines/ No consolidation/ No lung pulse

ABSENCE OF THE LUNG BENEATH THE PLEURA (in the explored area)

PNEUMOTHORAX

193



A’-pattern

Abnormal lung pattern: A’

pneumothorax

LUNG POINT

OCCULT PNEUMOTHORAX

Anatomical distribution of traumatic occult pneumothoraces

Mennicke et al. Am J Emerg Med 2012

Normal PatternPNEUMOTHORAX

Seashore sign

TENSION PNEUMOTHORAX

Can’t and need not to find out the lung point!

Needle thoracotomy!

F/50 Fall down Occult pneumothorax

194



AACES.SG

Pitfall: Subcutaneous emphysema

SUBCUTANEOUS EMPHYSEMA

USSEN 83%SPE 98%

CXRSEN 25.5%SPE 95%

THE SINUSOID SIGN

HEMOTHORAX

THE QUAD SIGN

AACES.SG

THE SPINE SIGN

195



AACES.SG

HOMOGENOUSLY ECHOGENIC

abdo

menlung

Pleural Effusion Pleural Effusion

lung

90°

DETECTION

LUNG CONTUSION

M/39 FELL DOWN FROM 30 M HIGH. 80/60, 115/M

Vignon P, CRIT CARE 2005.

Roch A, CHEST 2005

End Expiratory IP Distance 5th intercostal space > 50 mm

> 500 ml

End Expiratory Basal IP Distance > 45 mm (Rt)

> 50 mm (Lt)> 800 ml

INTERPLEURAL DISTANCE

lung

SEMI-QUANTITATIVE ASSESSMENT

LUNG CONTUSION

Sonographic definition of lung contusion(a) consolidation: a moderately hypoechoic blurred lesion whose dimensions remained unchanged during the inspiration phase.(b) B lines: multiple (at least three) vertical hyperechogenic lines arising from pleural line.• B lines are a early sign of lung contusion which is not visible on

chest X-ray.

196



FOCAL (LOCALIZED) INTERSTITIAL SYNDROME

Pneumonia and pneumonitisAtelectasisPulmonary contusionPulmonary infarctionPleural diseaseNeoplasia

Intensive Care Med. 2012;38(4):577–91.

CAUSES OF LUNG CONSOLIDATIONS

• Infection• Pulmonary embolism• Lung cancer and metastasis• Compression atelectasis• Obstructive atelectasis• Lung contusion

Intensive Care Med. 2012;38(4):577–91.

The shred line: irregular border connected with aerated lung

SHRED SIGN

Irregularly spaced B lines Closely spaced B lines

Coalescent B lines Consolidation

Lung contusion along to the severity of aeration loss

Yang PC. AM REV RESPIR DIS 1992; Lichtenstein DA. INT CARE MED 2004

• Alveolar consolidation: echo-poor or tissue- like pattern• Located at thoracic level• Anatomic boundaries: regular upper border (pleural line or PE),

irregular (shred sign, aerated lung) or regular (lobar pneumonia) lower border

• ± Air broncograms (true consolidation / atelectasis)

‘HEPATIZATION’ OF LUNG PARENCHYMA

12 studies were included in this meta-analysis (1681 chest trauma patients, 76% male).

US: SEN 0.92 (95% CI: 0.81-0.96)SPE 0.89 (95% CI: 0.85-0.93)

Chest radiography: SEN 0.44 (95% CI: 0.32-0.58) SPE 0.98 (95% CI: 0.88-1.0)

Emergency. 2015;3(4):127-34.

197



THE ANATOMOPATHOLOGICEVOLUTION OF THE LUNG CONTUSION: 3 PHASES1. The trauma itself, which determines a hemorrhagic or

lacerated core by direct energy transfer to the lung parenchyma

2. An edematous phase, with a progressive infiltrate of the interstice within 1 to 2 h after the primary injury

3. A Consolidation phase: Flooding of air spaces with blood, inflammatory cells, and tissue debris. This consolidation is maximal at 24 to 48 h after the primary injury.

• The conventional CXR can only detect contusion in the third phase, when a confluent consolidation is established.

LUS score in each area:0 = no contusion in the area, 1 = contusion in a part of the area, 2 = contusion in the whole area.

LUNG US IN TRAUMA

FAST

E-FAST

CA-FAST

PNEUMOTHORAX

HEMOTHORAXLUNG CONTUSION

Eur J Trauma Emerg Surg (2015)

A LUS score of 6 was identified as the best threshold value

Cumulative categories of ARDS: severe (PaO2/FiO2 ≤ 100 mmHg), severe to moderate (PaO2/FiO2 ≤ 200 mmHg), severe to mild (PaO2/FiO2 ≤ 300 mmHg)

TAKE HOME MESSAGE• In the setting of acute injury, ultrasound enhances the basic

trauma evaluation, influences bedside decision-making, and helps determine whether or not an unstable patient requires emergent procedural intervention.

• Lung ultrasound allows better diagnostic performance in detection of pneumothorax, hemothorax, and lung contusions compared to bedside chest radiography.

• Lung contusion extent assessed by LUS on admission identifies patients at risk of developing ARDS within 72 h after a severe blunt trauma.

• Chest-Abdominal FAST should be used as initial investigation during the primary survey and management.


Director

Kang-Hyun Lee (Yonsei Univ. Wonju College of Medicine)

Moderator


Keum Seok Bae (Yonsei Univ. Wonju College of Medicine)

1F. Main Auditorium

Symposium 10 (KR)

Current of Trauma Center :Still Much to be Improved

06-24 (Sat.), 2017

199




Medical College, Yonsei University (MB)

Graduate school of Medicine, Seoul National University (ABD)

Life Member of The Korean Society of Traumatology

Life Member of The Korean Society for Thoracic & Cardiovascular Surgery

2003.03 - 2011.02 : Assistant Professor, Department of Thoracic & Cardiovascular


2011.03 - 2013.11 : Associate Professor, Department of Thoracic & Cardiovascular


2013.12 - 2014.04 : Associate Professor

2014.04 - Present : Fund Professor

2015.03 - Present : Director of Trauma Center, Pusan National University Hospital,

Busan, Korea

2013.06 - Present : Secretary General, The 2nd & 3rd PPTC

2014.03 - Present : Councilor of KARPET(Korean Association of Research, Procedure

and Education on Trauma) Faculty of ESPIT(Essential Surgical

Procedures In Trauma)

2014.09 - Present : Director of BESPIT

Academic

Background

Work

Experience

200


Proposal for Improvement of the System for

Dedicated Trauma Specialis




201




1992-1998 M.D., Chungnam National University College of Medicine, Daejon, Korea

2006-2008 M.S., Graduate school, Ajou University School of Medicine, Suwon, Korea

1998-2003 Intern & Resident, Department of Surgery, Ajou University Hospital,

Suwon, Korea

2003-2006 Public health doctor, Jeju, Korea

2006-2007 Fellow in Upper gastrointestinal division, Department of Surgery, Ajou

University Hospital, Suwon, Korea

2003- Member, Korean Surgical Society

2006- Member, Korean Gastric Cancer Association

2007- Member, Korean Society of Endoscopic & Laparoscopic Surgeons

2007- Member, Korean Society of Clinical Oncology

2012- Member, Korean Society of Traumatology

Education

Postdoctoral

Training

Societies

202


Outcomes of the Supporting Services for

Installation of Regional Level 1 Trauma

Centers




In Korea, injury is the third most common cause of death after cancer and cerebrovascular dis-

ease but is the major cause of death for working age population under age of 40 years old. Also,

the preventable trauma death rate is still higher than developed country. This result increased the

awareness of the need for establishing the trauma system. For this reason, the supporting services

for installation of regional level 1 trauma centers was started in 2012 by the Ministry of Health and

Welfare. The purpose of this service is to designate 17 regional level 1 trauma centers evenly across

the country and to provide adequate care for seriously injured patients 24 hours a day, 7 days a

week. As a result, the preventable trauma death rate will be lower to level of developed countries

by 2020. As of November 2016, 16 regional level 1 trauma centers were selected and 9 of them

were officially opened. If the project is completed as planned, quality of all phases of trauma care

(prehospital, transport, and hospital) is high, and lives of seriously injured patients can be saved

and disabilities can be minimized.

Key Words: Wounds and injuries, trauma, death, hospitals, transportation

203



서론

국내에서 운수사고, 추락, 익사, 화상, 중독, 자살, 타살 등 손상으로 인한 사망은 전체 사망 원인

중 암, 뇌혈관질환에 이어 3위를 차지하고 있으며[1], 국내외적으로 40세 이하의 생산 가능 활동인구

에서 주요한 사망원인으로 높은 사망률뿐만 아니라 심각한 후유 장애로 인한 일상 복귀의 지연으로

막대한 사회 경제적 비용 손실을 초래하는 질환으로 인식되고 있다. 2012년 우리나라에서 질병으로

인한 장재 손실 연수 중 추락은 7위, 교통 사고는 9위, 자살은 10위에 해당한다[2,3].

지역 사회 또는 한 국가의 외상 의료의 질 평가를 위해 사용되는 대표적인 지표로 외상 환자의 예

방가능사망률이 있다. 적절한 치료가 이루어졌다면 예방할 수 있었을 사망의 비율을 구하는 것으로

부적절한 치료가 환자의 사망에 직간접적으로 영향을 끼쳤을 때 예방 가능하다고 판정하는 것을 원

칙으로 하며[4-6], 적절한 외상진료체계를 갖추고 적시에 적절한 치료를 제공 받았을 때 예방 가능한

외상 사망률 또한 미국, 영국, 독일, 일본 등 선진국의 10-20%에 비하여 2배 이상 높은 수치를 보여주

고 있어 시급히 개선이 필요한 질환이다[7-16].

이에 우리나라에서는 3대 중증 응급질환으로 대표되는 급성 뇌혈관 질환, 급성 심혈관 질환, 중증

외상에 대한 응급진료가 발생 지역 내에서 24시간 상시 해당 질환에 대한 치료가 적시에 최종 제공

되도록 질환에 따른 응급의료 전달체계를 구축하고 응급환자의 사망과 후유 장애를 줄이고자 2008

년부터 중증응급질환 특성화 사업을 시작하였다. 전국에 응급의료 기관 중 평가를 통하여 중증외상

특성화 센터로 지정된 기관의 경우 전문의 당직비, 보조인력 (응급구조사, 코디네이터, 정보입력 담

당자 등) 인건비, 운영비 등의 금전적 지원이 일부 이루어졌다. 그러나, 외상 전담 전문의 및 전담 인

력은 극소수에 불과하였고 전담 인력 및 전용 시설을 갖추더라도 진료수익 대비 대기비용이 과다하

여 기관의 자발적인 투자 유인이 없었고, 의료인에게도 위험부담과 높은 근무 강도로 인해 인력 유인

및 양성에 한계가 노출되었다.

특히, 3대 중증 응급질환 중에서 중증외상은 전용 소생실, 수술실, 중환자실, 혈관조영실 등 고도

의 독립적인 전용시설이 필요하며, 다발성 손상이 빈번하여 여러 전문 진료 과목(외과, 흉부외과, 신

경외과, 정형외과, 응급의학과 등)의 즉각적인 협진이 가능한 진료체계가 필요하여 전문 의료진들에

대한 높은 대기비용으로 병원의 자발적인 투자와 참여 유도를 위한 국가의 정책적 지원이 절대적으

로 필요한 상황이었다.

본문

권역외상센터 설치지원 사업의 배경 및 목적

2011년 1월 삼호 주얼리호 석해균 선장 사건으로 인해 중증외상센터의 필요성이 시급히 대두되

204



었으며 2012년 권역외상센터 설치 지원 사업을 시행하는 계기가 되었다. 권역외상센터 설치 지원 사

업은 응급의료에 관한 법률 제 30조의 2[17]를 근거로 하고 있으며, 365일 24시간 중증외상환자에게

병원도착 즉시 응급수술 등 최적의 치료를 제공할 수 있는 시설, 장비, 인력을 갖춘 외상전용 치료기

관인 권역외상센터를 설치하는 것으로 전국 어디서나 1시간 이내에 중증외상환자의 진료가 가능하

도록 권역외상센터를 균형배치 하는 것이다. 이를 중심으로 지역 내 외상환자 진료 및 신속이송체계

구축, 전문 인력 양성 등 지역사회 중증외상 관리체계의 중추기관으로서의 역할 수행을 통해 우리나

라의 예방 가능한 외상 사망률을 전국 17개 권역외상센터 선정 및 개소완료가 예상되는 2020년까지

선진국 수준인 20% 미만으로 낮추는 것을 목표로 하고 있다(2016년 권역외상센터 설치지원 사업 안

내, 보건복지부).

권역외상센터 설치지원 사업의 개요

1차적으로 2017년까지 지리적 접근성과 인구수를 고려하여 전국 5개 대권역에 17개 권역외상센

터를 균형 배치하는 것을 목표로 하고 있으며, 2016년 11월 현재까지 별도 선정된 서울의 국립중앙

의료원을 포함하여 전국에 16개 기관이 선정되었고, 시설, 장비, 인력 등에 대한 2년여의 준비 과정

을 거쳐 9개 기관이 공식 지정 받아 개소를 하였다.(Table 1).

응급의료에 관한 법률 시행규칙 제 17조의 2, 별표 7의 2 권역외상센터의 요건과 지정기준[18]에

따라 법정 지정 필수 요건으로 2개의 외상 소생실, 2개의 수술실, 20개의 중환자실, 40개의 외상병실,

1개의 혈관 조영실 및 각 실에 따른 필수 장비와 인력을 외상 전용, 전담으로 운영하도록 하고 있다.

권역외상센터는 전문의 중심으로 운영하도록 하고 있으며 외상 팀에 외과, 흉부외과, 신경외과, 정형

외과 전담 전문의를 반드시 배치하도록 하고 있다. 이에, 개소당 시설, 장비 비용으로 80억원, 운영비

로 매년 연차 별 인력 충원에 따라 전담 전문의 1인당 연간 1억 2천만원 이내, 2명 이내의 외상코디네

이터 인건비, 3억 6천만원 이내에서 비 전담 전문의의 당직비 지원 및 운영비의 10% 이내에서 외상

전담인력에 대한 교육, 훈련비 등을 국비로 지원토록 하고 있다. 국비지원 항목 외에 법정 지정요건

확보는 자부담 원칙으로 하고 있으며 국비 전담 전문의 5인당 1명의 자비 전담전문의를 총원 하도록

하고 있고, 운영비 일부는 2016년부터 인력 충원과 운영실적 등을 평가하여 지원규모를 차등하여 지

원하고 있다.

권역외상센터 현황

2016년 11월 현재 전국에 16개 권역외상센터가 선정 되었고, 이중 9개 기관이 공식 지정을 받아

개소를 하였다. 나머지 기관들도 개소를 위한 준비에 박차를 가하고 있으며, 개소한 권역외상센터들

의 경우 법적 기준에 필요한 시설과 장비들은 대부분 보유하고 있으며, 개소한 기관들의 병상 현황은

205



Table 2 에 있다.

별도 선정된 국립중앙의료원을 제외하고, 부산대병원의 경우 시설, 장비비로 339억여원이 지원

되었으며, 나머지 기관들은 80억원씩 지원되었다. 운영비는 각 권역외상센터마다 매년 인력 충원을

감안하여 지급되고 있으며, 2015년 기준 15개 권역외상센터에 190여억원이 지원되었고 개소 기관이

늘고 인력 충원이 확대되면서 운영비 지원 규모는 매년 큰 폭으로 증가하고 있다(Table 3).

각 권역외상센터 별로 차이는 있으나 일부 기관과, 일부 특정 전문 과목의 전담 전문의 충원은 사

업 안내서 상의 연차 별 전담 전문의 충원 권고에 미치지 못하고 있어, 권역외상센터 본연의 업무를

충실히 이행하기 위해서는 이에 대한 대책이 필요한 상황이다(Table 4). 또한, 국립중앙의료원 중앙

응급의료센터는 2012년에 권역외상센터 외상등록체계를 개발하여 기 선정된 권역외상센터와 서울

지역 외상 공백을 해소하고 양질의 외상 전문의 양성을 위해 선정된 외상 전담 전문의 수련기관인

고대구로병원과 신촌세브란스 병원에서 전송되는 외상환자의 진료 관련 정보를 실시간으로 수집하

여 외상진료체계의 기반을 마련하고, 외상 진료의 질 향상을 위한 평가 자료 및 외상관련 연구와 정

책수립의 기초 자료를 제공하기 위해 순차적으로 구축을 하여 운영하고 있다(Table 5).

권역외상센터 설치지원 사업 시행의 결과

2012년 권역외상센터의 외상등록체계가 개발되고 2013년부터 순차적으로 외상등록체계가 구축

되면서 데이터의 안정화 단계를 거치고 2014년부터 기 구축된 권역외상센터의 외상 진료 정보가 수

집되면서 2014년과 2015년의 외상 환자 등록 현황을 비교하였다(Table 6). 2014년에 비해 2015년의

ISS 15점 초과의 중증 외상환자수와 전체 외상환자수가 증가하는 양상을 보이나, 2014년 이후 정식

개소하는 기관이 늘어나고 외상등록체계 기관이 2개 추가된 것을 고려하면 권역외상센터로의 외상

환자 집중이 충분히 이루어졌다고는 볼 수는 없을 것이다. 하지만 2015년 MERS로 인한 전체 외상 환

자 감소의 영향을 고려해야 할 것이다.

2015년 이후 매년 권역외상센터에 대한 평가가 진행 중으로 최근의 자료는 공개가 어려워 2014

년 외상등록체계가 구축된 별도 선정 기관인 국립중앙의료원, 10개의 권역외상센터, 2개의 외상 전

담 전문의 수련기관의 외상 환자 등록 자료를 분석해 보면 다음과 같다. 2014년 외상등록체계에 등

록된 전체 외상환자수는 22,172명으로 중증도 점수 ISS(Injury Severity Score) 1-8점이 12,073명으

로 54.5%, 9-15점이 5,671명으로 25.6%, 15점 초과가 4,192명으로 18.9%였다. 남성이 여성에 비하

여 1.91배가 많았으며, 연령대는 50대가 19.1%로 제일 많았으나 20대에서 70대까지 고르게 분포하

였다. 손상 유형은 둔상 90.1%, 관통상 6.1%, 화상 1.1%, 사고 종류는 미끄러짐이 25%, 교통사고

21.3%, 추락 15.3% 순이었다 내원 경로는 직접내원이 60.7%, 전원이 38.4%, 내원 수단은 119 구급차

38%, 자동차 35.1%, 기타 구급차 24.1% 순이었다. 각종 지표에 대한 빈도는 Table 7. 에 있다. 2015

206



년에는 2014년에 선정된 의정부성모병원과 안동병원의 자료가 추가되어 등록된 전체 외상환자수

는 31032명이며 중증도, 성비, 연령대, 손상 유형, 내원 경로, 내원 수단과 각종 지표 값의 구성비는

2014년에 비하여 유의한 변동은 없었다.

결론

2012년 권역외상센터 설치 지원 사업이 시행된 이후 2016년 11월 현재까지 권역외상센터로 선정

된 16개 기관 중 정상적인 본연의 업무를 수행할 수 있는 정식 개소한 권역외상센터는 9개에 불과하

며, 이마저도 대부분 2014년 이후에 개소를 하여 아직 사업 시행 초기에 해당된다고 할 수 있다. 개

소 기관들이 늘면서 중증외상 환자들은 최종 치료 기관인 권역외상센터로의 빠른 이송과 집중이 필

요하다는 것에 동의하고 있으나 현장에서 적절한 병원으로의 이송을 위한 환자 분류 체계, 이송 인

력에 대한 체계적인 교육뿐만 아니라 책임소재에 대한 법적, 제도적 정비는 미진한 상태이며, 개소를

준비하는 여러 기관들에서 사업 시행의 지연이 나타나고 있다. 이러한 이유 중 대표적인 예로 경제

적인 논리만을 내세워 사업 초기의 초심을 잃은 병원 경영진들의 철학의 부재, 전용 시설 확보를 위

한 공사의 지연과 위에서 언급한 전담 인력 채용의 어려움이다. 심지어 정식 지정을 받아 개소한 권

역외상센터들의 경우에도 일부 전문 과목의 경우 수급 불균형으로 필수 전담 전문의 채용에 어려움

을 호소하는 기관이 많은 실정이지만 높은 업무 강도에 비하여 충분한 대우를 받지 못해 이직을 하

거나 외상 진료를 포기하는 경우도 자주 접하게 된다.

정부는 권역외상센터의 안정적인 조기 안착을 위해 충분한 외상 전담 인력의 양성과 전담 인력에

대한 적극적인 처우 개선을 위해 노력해야 하며, 수가 합리화와 같은 지원을 통해 권역외상센터가 진

료만으로도 재정 자립을 할 수 있도록 경영 수지 개선을 위한 법적, 제도적 개선이 필요하다.

선정된 권역외상센터는 사명을 갖고 빠른 개소를 위해 노력해야 하며, 개소한 기관들의 경우 지

역 외상체계의 리더십을 갖고 양적 확장뿐 만 아니라 질적 향상을 위한 다음과 같은 활동에 적극 노

력하여 초기의 구축, 성장 단계를 벗어나 중장기의 안정화, 성숙 단계의 권역외상센터가 이루어질 것

이다.

● 병원 전 단계: 적절한 이송체계 확립을 위한 법적, 제도적 정비 및 부처간 협의, 병원 전 이송

인력에 대한 적절한 현장 분류 체계 확립, 이송 시 소생 및 활력 징후 유지를 위한 이송 인력

의 교육, 현장 이송 인력과의 의사 소통 강화 방안 등

● 병원 단계: 최종 치료 제공 기관으로서의 역할 강화 및 기능 정립, 충분한 전담 인력의 확보 및

양성, 표준 진료 지침의 확립, 진료 시 발생 가능한 오류의 최소화, 전담 전문의 외에 기관 내

207



전문 인력과의 포괄적 협력 방안 강구, 배제적 외상센터가 아니라 포괄적 협력 시스템을 갖춘

외상센터의 확립 등

● 지역 사회 외상체계의 확립: 특수 외상 분야(중증 화상, 소아외상, 미세수술 등)의 인력 확보

또는 지역 내 질환별 네트워크 강화 방안, 지역 외상체계에서 리더십을 같고 중증 외상환자

진료에 있어서 지역 응급의료기관과의 역할 조정 및 적절한 병원간 이송에 대한 협력 방안 논

의 등

ACKNOWLEDGMENTS

데이터 수집과 분석을 위해 도움을 주신 국립중앙의료원 중앙응급의료센터 외상사업관리단 이진

석 부단장, 김소라 연구원, 나선경 연구원, 이윤희 연구원, 임보라미 연구원, 채하나 연구원에게 감사

드립니다.

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15. Yoon Kim, Koo Young Jung, Kwang Hyun Cho, Hyun Kim, Hee Cheol Ahn, Se Hyun Oh,

Jae Baek Lee, Su Jin Yu, Dong Ik Lee, Tai Ho Im, Sung Eun Kim, Jae Hyun Park. Preventable

Trauma Deaths Rates and Management Errors in Emergency Medical System in Korea. J Kore-

an Soc Emerg Med. 2006; 17(5): 385-394.

16. Hyun Kim, Koo Young Jung, Sun Pyo Kim, Sun Hyu Kim, Hyun Noh, Hye Young Jang,

209



Han Deok Yoon, Yun Jung Heo, Hyun Ho Ryu, Tae oh Jeong, Yong Hwang, Jung Min Ju,

Myeong Don Joo, Sang Kyoon Han, Kwang Won Cho, Ki Hoon Choi, Joon Min Park, Hyun

Min Jung, Soo Bock Lee, Yeon Young Kyong, Ji Yeong Ryu, Woo Chan Jeon, Ji Yun Ahn,

Jang Young Lee, Ho Jin Ji, Tae Hun Lee, Oh Hyun Kim, Youg Sung Cha, Kyung Chul Cha,

Kang Hyun Lee, Sung Oh Hwang. Changes in Preventable Death Rates and Traumatic Care

Systems in Korea. J Korean Soc Emerg Med. 2012; 23(2): 189-197.

17. National Law Information Center, Emergency Medical Service Act, Article 30-2(Des-

ignation of Regional Trauma Center). Sejong, Korea Ministry of Government Legislation,

Available from http://www.law.go.kr/lsSc.do?menuId=0&p1=&subMenu=1&nwYn=1&sec-

tion=&tabNo=&query=%EC%9D%91%EA%B8%89%EC%9D%98%EB%A3%8C%EC%97%90%20

%EA%B4%80%ED%95%9C%20%EB%B2%95%EB%A5%A0#undefined.

18. National Law Information Center, Emergency Medical Service Act, Ordinance of the

Ministry of Health and Welfare, Article 17-2(Designation Criteria and Requirements of Re-

gional Trauma Center). Sejong, Korea Ministry of Government Legislation, Available from

http://www.law.go.kr/lsSc.do?menuId=0&p1=&subMenu=1&nwYn=1&section=&tab-

No=&query=%EC%9D%91%EA%B8%89%EC%9D%98%EB%A3%8C%EC%97%90%20

%EA%B4%80%ED%95%9C%20%EB%B2%95%EB%A5%A0%20%EC%8B%9C%ED%96%89%EA

%B7%9C%EC%B9%99#undefined.

210



Table 1. Current state of the supporting services for installation of regional trauma centers.

Large region Special selection(2)

Selected regional trauma center(14)

*Official opening, Designated regional trauma center(9)

Additional selection(1)

ICapital area

Kangwon

National Medical Cen-ter(Seoul)

*Gachon University Gil Medical Cen-ter(2012, Incheon)

*Wonju Severance Christian Hosp.(2012, Gangwon)

*Ajou University Hosp.(2013, South Gyeonggi)

Uijeongbu St. Mary’s Hosp.(2014, North Gyeonggi)

II Chungcheong

*Dankook University Hosp.(2012, Chun-gnam)

*Eulji University Hosp.(2013, Daejeon)

Chungbuk National University Hosp.(2015, Chungbuk)

IIIJeolla

Jeju

*Mokpo Hankook Hosp.(2012, Jeon-nam)

*Chonnam National University Hosp.(2013, Gwangju)

Wonkwang University Hosp.(2015, Jeon-buk)

Cheju Halla General Hosp.(2016, Jeju)

IV Gyeongbuk

Kyungpook National Hosp.(2012, Dae-gu)

Andong Hosp.(2014, Gyeongbuk)

V Gyeongnam *Pusan National Uni-versity Hosp.(Busan) *Ulsan University Hosp.(2013, Ulsan) Gyeongnam

*9 out of 15 selected hospitals were officially opened and designated as regional trauma center.

211



Table 2. Current situation of hospitals facilities(bed number) in 9 designated regional trauma cen-

ters as of June 2016.

Region Selec-tion Year

Designa-tion Date

Hosp. Name Space Scale(beds)

Oper-ation Room

ER

Resus-citation Room

ER obser-vation area

ICU Ward Total

Incheon `12.11 `14.07.21 Gachon University Gil Medical Center

2 2 6 20 52 80

Chungnam `12.11 `14.11.13 Dankook Uni-versity Hosp.

2 2 6 20 40 68

Jeonnam `12.11 `14.02.21 Mokpo Han-kook Hosp.

2 2 6 20 40 68

Gangwon `12.11 `15.02.12 Wonju Sever-ance Christian Hosp.

2 2 6 20 52 80

Busan `08.03 `15.11.09 Pusan Nation-al University Hosp.

6 2 12 50 80 144

South Gyeo-nggi

`13.07 `16.06.13 Ajou Universi-ty Hosp.

3 2 6 40 60 111

Ulsan `13.07 `15`09`17 Ulsan Univer-sity Hosp.

2 2 6 20 40 68

Daejeon `13.07 `15.11.24 Eulji Universi-ty Hosp.

2 2 9 20 40 71

Gwangju `13.07 `15.09.22 Chonnam National Uni-versity Hosp.

2 2 6 20 41 69

212



Table 3. Current state of supporting for the operating expense in regional trauma centers.

Selection Year

Designa-tion Date

Hosp. Name Support for the operating Expense

(1 million won)

‘12 ‘13 ‘14 ‘15

Special selection

- National Medical Center 574 454 480 540

‘12 ‘14.7.21 Gachon University Gil Medi-cal Center

86 1,440 1,920 1,753

-- Kyungpook National Hosp. 38 1,440 1,920 1,590

‘’14.11.13 Dankook University Hosp. 60 1,440 1,920 1,620

‘14.2.21 Mokpo Hankook Hosp. 146 1,440 1,920 2,040

‘15.2.12 Wonju Severance Christian Hosp.

150 1,440 1,920 1,740

‘13 ‘15.11.9 Pusan National University Hosp.

364 720 1,440 1,900

‘16.6.13 Ajou University Hosp. 60 1,440 1,490

‘15.9.17 Ulsan University Hosp. 86 1,440 1,470

‘15.11.24 Eulji University Hosp. 529 1,440 1,350

‘15.9.22. Chonnam National University Hosp.

300 1,440 1,440

‘14 - Andong Hosp. 60 780

- Uijeongbu St. Mary’s Hosp. 60 1,200

‘15 Chungbuk National Universi-ty Hosp.

180

Wonkwang University Hosp. 60

‘16.11 - Cheju Halla General Hosp.

213



Table 4. Human resource(specialty) status in regional trauma centers as of June 2016.

Selec-tion Year

Designa-tion Date

Hosp. Name Dedicated Specialty Supporting Specialty Total

GS CS OS NS ANES RAD EM

Special selec-tion

- National Medical Center

2 0 1 1 0 1 1 6

‘12 ‘14.7.21 Gachon Univer-sity Gil Medical Center

9 4 1 2 1 1 1 19

-- Kyungpook Na-tional Hosp.

1 1 4 0 1 0 0 7

‘’14.11.13 Dankook Univer-sity Hosp.

6 1 1 2 2 3 0 15

‘14.2.21 Mokpo Hankook Hosp.

3 4 3 5 1 2 4 22


5 2 3 2 2 0 1 15


8 6 4 3 2 1 0 24

‘16.6.13 Ajou University Hosp.

6 1 3 1 2 1 1 15

‘15.9.17 Ulsan University Hosp.

7 1 3 1 1 2 0 16

‘15.11.24 Eulji University Hosp.

1 0 3 0 1 1 1 7

‘15.9.22. Chonnam Na-tional University Hosp.

4 2 4 2 2 1 1 16

‘14 - Andong Hosp. 5 2 1 0 0 1 1 10

- Uijeongbu St. Mary’s Hosp.

4 1 2 1 1 0 1 10

‘15 Chungbuk Na-tional University Hosp.

3 0 1 2 1 2 0 9

Wonkwang Uni-versity Hosp.

3 1 2 3 1 0 0 10

‘16.11 - Cheju Halla Gen-eral Hosp.

3 0 0 0 0 0 0 3

214



Table 5. The operating status of the trauma registry in regional trauma centers and trauma training

centers.

Selection Year

Designa-tion Date

Hosp. Name Develop-ment of trauma registry

Operating status of trauma registry

‘12 ‘13 ‘14 ‘15 ‘16

Special selection

- National Medical Center - O O O O

Trauma training center

‘14 Korea University Guro Hosp. - - O O O

‘14 Yonsei University Severance Hosp. - - O O O

‘12 ‘14.7.21 Gachon University Gil Medical Center

- O O O O

-- Kyungpook National Hosp. - O O O O

‘’14.11.13 Dankook University Hosp. - O O O O

‘14.2.21 Mokpo Hankook Hosp. - O O O O

‘15.2.12 Wonju Severance Christian Hosp. - O O O O

‘13 ‘15.11.9 Pusan National University Hosp. - - O O O

‘16.6.13 Ajou University Hosp. - - O O O

‘15.9.17 Ulsan University Hosp. - - O O O

‘15.11.24 Eulji University Hosp. - - O O O

‘15.9.22. Chonnam National University Hosp.

- - O O O

‘14 - Andong Hosp. - - - O O

- Uijeongbu St. Mary’s Hosp. - - - O O

‘15 - Chungbuk National University Hosp.

- - - - O

- Wonkwang University Hosp. - - - - O

‘16.11 - Cheju Halla General Hosp. - - - - -

215



Table 6. Comparison of the registered number of patients in regional trauma centers between 2014

and 2015.

Selection Year

Desig-nation Date

Hosp. Name 2014 2015

ISS<15 ISS>15 Total ISS<15 ISS>15 Total

Special selection

- National Medical Center

46 13 59 394 24 418

‘12 ‘14.7.21 Gachon University Gil Medical Center

2588 509 3097 2656 499 3155

-- Kyungpook Na-tional Hosp.

1268 438 1701 1138 364 1502

‘’14.11.13 Dankook Universi-ty Hosp.

1985 353 2338 1702 402 2104

‘14.2.21 Mokpo Hankook Hosp.

1879 299 2178 1986 312 2298


2185 345 2530 2593 484 3077


1340 454 1794 1851 481 2332

‘16.6.13 Ajou University Hosp.

1725 540 2265 1626 483 2109

‘15.9.17 Ulsan University Hosp.

1002 281 1283 1304 388 1692

‘15.11.24 Eulji University Hosp.

1873 419 2292 1242 330 1572

‘15.9.22. Chonnam Nation-al University Hosp.

1305 450 1755 1371 491 1862

‘14 - Andong Hosp. - - 2556 300 2856

- Uijeongbu St. Mary’s Hosp.

- - 2108 387 2495

Mean

(±SD)

- 1563.3

(±682.4)

382.8

(±144.9)

1935.6

(±788.2)

1732.8

(±658.5)

380.4

(±128.8)

2113.2

(±740.2)

Total

(%)

17196

(80.7)

4101

(19.3)

21292

(100)

22527

(82)

4945

(18)

27472

(100)

Data extraction date: Jan 29, 2015 from regional trauma center trauma registryThere may be some fluctuation, according to the data extraction date.

216



Table 7. Each index for registered patients in regional trauma centers in 2014.

Index N(Valid number) Mean Median Standard Deviation

Scene-to-hosp. time(min) 6839 62.3 25.0 1639.4

Injury-to-hosp. time(min) 22081 1305.0 105.0 14621.9

Massive transfusion time(min) 243 51.6 41.0 36.5

ER stay time(min)

ISS 0-8

9-15

>15

22170(100)

11853(53.5)

5575(25.1)

4127(18.6)

361.5

346.1

456.2

283.1

237.0

247.0

272.0

176.0

559.3

346.1

888.4

369.0

ICU stay time(day) 4701 8.4 4.0 15.6

Result of leaving ER(%)

Admission

Transfer

Death

22172(100)

19610(88.4)

2207(10.0)

351(1.6)

Result after admission(%)

Normal discharge

Transfer

Death

19136(100)

15603(81.5)

2649(13.8)

608(3.1)


Director


Moderator

Seok Ho Choi (Dankook Univ. Hospital)


1F. Seminar 1

Symposium 6 (KR)

Medical Treatment Guideline Committee

06-24 (Sat.), 2017

218




2013.05 - Present: Pusan National Univ. Hospital (Assistant Professor)

2010.04 - 2013. 04: Daejeon Armed Force Military School of Medicine ( Instructor)

2006.03 - 2010.02: Pusan National Univ. Hospital (Residence)

219


CPR in Blunt Trauma Patients: Indication and

Contraindication, How Long?




220



Junsik Kwon (Ajou Univ. Hospital)

Graduated from Yonsei Univ. School of Medicine

Residence at Seoul National Univ. Hospital

Former Aju Univ. Hospital Assistant Professor

2011 - 2013 Aju Univ. Hospital (Instructor)

2016 - Aju Univ. Hospital (Assistant Professor)

Education

Career

221


Vascular Access in Shock Patients

Junsik Kwon (Ajou Univ. Hospital)



외상환자 처치의 질을 보다 높이기 위한 논의가 계속되고 있지만, 아직까지도 외상 분야에서 가장

큰 이슈는 예방 가능한 외상 사망률을 줄이는 것이다. 외상으로 인한 초기 사망 중 예방 가능한 원인

중 대부분은 출혈에 대한 대처를 실패했기 때문인데, 이를 막기 위해 출혈 부위에 대한 신속하고 적

절한 지혈이 가장 강조되는 것이 사실이지만, 동시에 선제적이고 균형 있는 Resuscitation의 시행 역

시 중요하다. 이를 위해 출혈이 예상 되는 모든 외상 환자에게 Resuscitation을 위한 신뢰도가 높은

복수의 큰 구경의 IV line을 확보하는 것이 필수적이다. ATLS에서는 이러한 환자들에게 양 상지에 큰

구경의 말초 IV line을 확보하는 것을 고려하도록 하며, 많은 연구에서 출혈양이 15 - 20%를 넘지 않

는 환자의 경우 내경의 size가 최소 2mm가 넘는 catheter를 두 개 이상 확보한 다면 충분하다는 보고

를 하고 있다. 현재 한국에는 여러가지 말초 및 중심 정맥용 catheter가 제품이 들어와 있으며, 그 구

경과 길이에 따라 목적이 다른데, 응급실 및 Trauma bay에서 환자를 처치하는 의사 및 간호사들이

이미 병원에 들어와 있는 catheter의 종류와 사용법에 익숙해지는 데에는 많은 노력이 필요하다. 특

히 쇼크에 빠진 중증 외상환자는 collapse된 혈관으로 인해 catheter 삽입에는 매우 숙련된 기술 및

정확한 decision making이 필요하다. 이런 상황을 마주하였을 때 실패하지 않기 위해 염두 해 두어

야 하는 몇 가지 원칙은 다음과 같다.

1. Make sure you are familiar with the techniques for vascular access before the trauma case

arrives

2. Use the technique for vascular access in which you are most experienced

3. Do not hesitate to start simultaneous exposure of several different veins

4. Do not forget the cubital fossa as a possible site for vein exposure

222



원칙을 세워 대처 하였으나 항상 성공적인 것은 아니며, 만약 일반적인 방법으로는 실패가 예상

되는 상황이라면 다음 세 가지 대응책을 고려해 보는 것이 도움이 될 수도 있다.

1. Surgical exposure of veins in the cubital fossa or on the leg

2. Percutaneous catheterization of the femoral vein

3. Central venous catheterization in the subclavian vein or external and internal jugular vein

Vascular access의 일반 원칙을 준수하고, 어려운 Case에 대처할 수 있는 몇 가지 대안을 나름대로

준비하여, 이에 대한 기술적인 숙련도를 갖추기 위해 노력한다면 최소한 초기에 어의 없는 이유로 환

자를 잃는 경험은 줄일 수 있을 것이다.

223




Feb. 2005 Bachelor’s Degree, Chonnam National University College of Medicine, GJ, Korea

Feb. 2013 Chonnam National University College of Medicine, GJ, Korea

Mar. 2015 ~ Feb. 2017 Master’s Degree, A candidate for the Doctor’s Degree,

Chonnam National University College of Medicine, GJ, Korea

2015 Lee YK Academy Award of Korean Society for Thoracic and Cardiovascular

Surgery

2012 Korean Board of Thoracic and Cardiovascular Surgery

2015 Korean Board of Critical Care Medicine

2017 Korean Board of Trauma Surgery

Education

Academic Honors

Medical Licensure

224


Crystalloid Versus Colloid:

What is the Best Treatment for Shock

Patients?




Multiple injury continues to represent a global public health issue and mortality and morbidity

in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on

the management of trauma patients [1]. The administration of intravenous fluids for treatment is the

most common intervention

in acute phase state. There is increasing evidence that the type of fluid may directly affect pa-

tient centred outcomes. There is a lack of evidence that colloids confer clinical benefit over crystal-

loids and they may be associated with harm. Hydroxyethyl starch preparations are associated with

increased mortality and use of renal replacement therapy in critically ill patients, particularly those

with sepsis; albumin is associated with increased mortality in patients with severe traumatic brain

injury [2].

Classic concept of the traumatic hypovolemic state, intravenous large amounts of normal saline

injection. And massive bleeding can cause even greater impacts on homestatic function, because

the changes of coagulation factors occur earlier than those of PLT in functional disorders because

of surgical bleeding [3].

Goals and endpoints for resuscitation and a review of initial fluid choice are discussed, along

with the coagulopathy of trauma and its management, how to address hemorrhagic shock, and

new pharmacologic treatment for hemorrhagic shock. For many years, the gold standard of treat-

ment was the rapid restoration of circulating volume with crystalloid solutions to normal, or even

supraphysiologic levels.

225



Research over the past 30 years has yielded significant improvements in the treatment of various

etiologies of shock, including the treatment of shock, using on early goal-directed Therapy. How-

ever, all types of shock are not the same, and different etiologies require different approaches. In-

travascular losses that result from third spacing. Aggressively replacing these losses with crystalloid

before irreversible damage occurs makes perfect sense. However, losses from hemorrhage include

water, electrolytes, colloids, clotting factors, platelets, and blood cells [4].

Although classic resuscitation and strategies may show effective levels or patterns during recov-

ery state and wound healing, the pathological reaction of shock can be clearly distinguished from

physiological processes [5]. Damage control resuscitation (DCR), a strategy combining the tech-

niques of permissive hypotension, haemostatic resuscitation and damage control surgery has been

widely adopted as the preferred method of resuscitation in patients with haemorrhagic shock. The

over-riding goals of DCR are to mitigate metabolic acidosis, hypothermia and coagulopathy and

stabilise the patient as early as possible in a critical care setting. Diagnosing and treating the shock

with massive trauma protocols as well as newer fluid resuscitation [6].

An important parameter for clinical outcome is to succeed in stopping the shock preferentially

within initial event. Additional end organ damage in the early phase is induced by shock itself and

aggravated by consumption and dilution of clotting factors. Although different aspects have to be

taken into consideration when viewing at bleedings induced by severe trauma compared to those

caused by major surgery, the basic mechanism is similar [7].

Finally, massive bleeding does due to massive bleeding-induced hemorrhagic shock. To evalu-

ate the role of the important mechanism of bleeding and shock, such as distributive pattern acido-

sis, and hypothermia used separately and in various combinations, in impairment of clot formation

and platelet function. On the basis of these findings, it would be possible to better understand the

underlying mechanisms shock process [8].

In conclusion, mortality in patients with trauma shock is high, and the past years has seen a

significant shift in resuscitation used to manage severely shock patients. However, the evidence to

support such change is limited. In order to move forward large randomised controlled trials and

well conducted observational studies with pragmatic endpoints are needed to improve our under-

standing of the complex interplay between bleeding and resuscitation, traumatic coagulopathy and

mortality.

226



REFERENCES

1. Rossaint R. The European guideline on management of major bleeding and coagulopathy fol-

lowing trauma: fourth edition. Crit Care.2016 Apr 12; 20: 100

2. Myburgh JA. Fluid resuscitation in acute medicine: what is the current situation? J Intern Med

2015; 277: 58-68.

3. Eikelboom JW, Mehta SR, et al. Adverse impact of bleeding on prognosis in patients with

acute coronary syndromes. Circulation 2006; 114: 774-82.

4. Cherkas D. Traumatic hemorrhagic shock : advances in fluid management. Emerg Med Pract.

2011 Nov;13(11):1-19; quiz 19-20.

5. S Gando. Pathophysiology of Trauma-Induced Coagulopathy and Management of Critical

Bleeding Requiring Massive Transfusion. Semin Thromb Hemost. 2016 Mar; 42(2): 155-65.

6. Curry N. What’s new in resuscitation strategies for the patient with multiple trauma? Injury.

2012 Jul; 43(7): 1021-8.

7.A Meißner. Massive Bleeding and Massive Transfusion. Transfus Med Hemother. 2012 Apr;

39(2): 73-84

8. Yunos NM.Chloride-liberal vs. chloride-restrictive intravenous fluid administration and acute

kidney injury: an extended analysis. Intensive Care Med. 2015 Feb; 41(2): 257-64.

227




Clinical Assistant Professor, Department of Trauma Surgery, Regional Trauma Center, Uijeongbu St. Mary’s

Hospital, Catholic University of Korea

Educational Background & Professional Experience

2000.3~2006.2 Graduated from Catholic University of Korea,

2006.3~2011.2 Training at Catholic Medical Center

2013.5~2014.5 Armed Force Goyang Hospital

2014.5~2015.2 Fellowship at Uijeongbu St. Mary’s Hospital

2015.3~ Clinical assistant professor, Department of Trauma Surgery, Regional Trauma Center, Uijeongbu

St.Mary’s Hospital

228


Initial Response to Trauma Team Activation:

Which Specialists Should be Involved?




Treating major trauma patients is a complex process, therefore, no single physician can manage

the patient alone. Because major trauma patients are easy to have multiple injuries from brain,

chest, abdomen to extremity. To secure patients’ survivor, it requires close interactions between

multidisciplinary trauma team. In initial response, it also requires several specialists. In 2016

guideline of regional trauma center from Ministry of Health and Welfare, main trauma team is

recommended to include at least two trauma surgeons (thoracic and cardiovascular surgeon, sur-

geon), one emergency physician and one neurosurgeon. However there exist other many guide-

lines about trauma and they recommend to make initial response team variously. Putting the right

man in the right place is difficult. Too few specialists in initial response team might make improper

management in emergent situation. Too many specialists in the team might bring conflict between

the parts. Each trauma center could set initial response team according to individualized needs and

situation. With proper team member and harmonious control of trauma team leader, we can yield

better outcome of trauma patients.

229



Bachelor of Medicine, Kyunghee University (2004)

Master of Medicine, Gachon University of Graduate School (2008)

Doctor of Medicine, Gachon University of graduate School (2015)

Internship, Resident in Department of Surgery at Gachon University Gil Medicine

Center (2004~2009)

Army Surgeon (27th Division of Medical Corps, the Service Support Group) (2009~2012)

Trauma Surgeon at Gachon University Gil Medicine Center (2012~2013)

Clinic Assistant Professor of Trauma Surgeon at Gachon University Gil Medicine Center

(2014~2015)

Assistant Professor of Traumatology at Gachon University of Medicine (2016~ )

Medical Doctor's License (2004)

Surgery Specialist (2009)

Traumatic Surgical Specialist (2014)

Critical Care Specialist (2015)

Education

Experience

License


230


Trauma Team Leader: Emergency Physician

vs. Trauma Surgeon




The size and composition of the trauma team may vary with hospital size, the severity of injury,

and the corresponding level of trauma team activation. The leadership and teamwork structure for

trauma care is generally dictated by provider preference, institutional history, and local culture rath-

er than uniform standards.

Coordinating doctors, nurses, and ancillary staff to care for patients requires teamwork and lead-

ership. This is particularly true in emergency settings where providers from numerous specialties

converge to care for critically ill patients with limited data and under strict time constraints.

Trauma team leaders (TTL) may be emergency physicians, general surgeons, they may also be

anesthesiologists, intensivists, or with an interest in trauma and with relevant experience and train-

ing. Primary role of TTL is to lead the resuscitative care of the major trauma patient. Subsequent

inpatient care is managed by the staff of the appropriate clinical service.

Leadership styles are divided into two main categories: directive or empowering. Directive lead-

ership is typical of a military chain of command. This type of leadership is effective when tasks are

simple, straightforward, and/or the leader is the only team member with expertise.

In empowering leadership, leaders delegate responsibility, allowing colleagues to make deci-

sions while the leader focuses on team communication and coordination. Newer theories postulate

231



that empowering (shared) leadership is more effective when tasks are complex. These theories

suggest the more complex a task, the more necessary it is for team members to share the responsi-

bility of management of information, communication, and adaptability to achieve success.

Trauma resuscitation has elements that are simple/task-oriented and components that are high-

ly complex requiring team member coordination. As such, directive and empowering leadership

styles might both play a role.


Director

Duck Hyun Ryu (Armed Force Capital Hospital)

Moderator

Byung-Seop Choi (COL, Armed Forces Medical Command)

Beomman Ha (COL, Armed Forces Capital Hospital)

1F. Seminar 1

Symposium 9

The Future of Military Trauma Care, Patient First in Military Trauma

06-24 (Sat.), 2017

233




2000-2004 Korea Military Academy

2006-2010 Doctor of Medicine(M.D.) in Seoul National University Medical School

2010-2011 Internship at Armed Forces Capital Hospital

2011-2014 Residency(Orthopedic Surgery) in Seoul National University Hospital

2014-2016 Master’s degree in Orthoedic surgery at Seoul National University

Hospital

2015-2017 Trauma Fellow in Seoul National University Hospital

- General Trauma/Microsurgery/Reconstruction

Education

234


2016 Combat Orthopedic Trauma




Introduction

War has historically provided an opportunity for medical advancement and innovation. Military

medical personnel face the challenge of managing a high volume of severe multisystem injuries,

relative to what is encountered in civilian practice.

Korea is still exposed to North Korea’s threats. Military medicine in Korea always prepares for

treating patients who may arise in combat situations. Moreover, orthopedic surgeons are getting

important in combat injuries, because the effect of using advanced personal protective equipment

and enhanced armored vehicles decreased the injuries of thorax, abdomen and the incidence of

extremity injuries accounted for a higher percentage of all combat injuries. In same reasons, sol-

diers who in previous conflicts would have succumbed to injuries in the battlefield now are sur-

viving but have sustained devastating orthopedic injuries that require extensive treatment. Combat

orthopedic trauma patients in Korea on 2016 were two who treated at civilian hospitals. Now this

paper presents the cases who treated in 2016 and long-term follow-up results in 2015 combat or-

thopedic trauma.

Mechanisms of injury

During the major military conflicts of the 20th century, the incidence of gunshot-related combat

injuries declined, whereas the incidence of trauma resulting from blast mechanisms, such as artil-

235



lery shell, landmine, or grenade, increased. One study demonstrated that 81% of all combat-related

injuries and 73% of all musculoskeletal injuries were precipitated by explosive blasts.

There were 4 casualties in 3 blast injuries and 2 gunshot injuries in 2015. Three blast injuries

were all by landmine mechanisms which one was PMD series mine by North Korea, another was

M14 anti-personnel mine, and the other was M15 anti-tank mine. There were 2 casualties in 2 blast

injuries in 2016. One blast injury was by landmine (M14 anti-personnel mine) during the combat

training. The other blast injury was by an explosive bomb accident during the combat training.

Types of Musculoskeletal injury

Of all combat casualties, 77% sustained at least one orthopedic injury, and fractures represented

40% of all musculoskeletal injuries, and amputations comprised 6% of all such injuries (Figure 1).

236



In 2015 cases, we experienced 2 major traumatic amputations by PMD series mines, soft-tissue

injuries with subtalar joint dislocation by M14 anti-personnel mine and open distal femur fracture

with soft-tissue injuries in face, hand and knee by M15 anti-tank mine.

Fortunately, there were only 2 blast injuries in 2016. One case was below knee(BK) amputation

by M14 anti-personnel mine and the other was Chopart amputation with burns all over his body.

Primary (Completion) Amputation

In traumatic limb amputations, the nonviable distal portion is often attached to the proximal

portion by a small skin bridge or a few intact tendons that span a segment of lost tissue. Tran-

secting such bridging tissue is called a primary or completion amputation. Primary amputation is

indicated if the limb cannot be reconstructed or salvaged. This procedure is occasionally done in

the emergency department, but it is typically performed during the first visit to the operating room.

Other indications for primary (completion) amputation include: (1) ischemic limbs with irreparable

vascular injury; (2) hemorrhage control refractory to other means; and (3) enabling lifesaving resus-

citation in a patient whose injury physiologic burden (e.g., ongoing shock, hypothermia, acidosis,

coagulopathy, or infection) will not permit limb salvage. The latter exemplifies when limb-salvage

techniques are beyond the physiologic capacity of the patient.

Delayed Amputation

Indications for delayed limb amputation may include complications like refractory wound sepsis,

failed flap coverage or limb salvage (due to vascular or musculoskeletal causes), and selective am-

putation to optimize limb function (e.g., relieve pain or prosthetic fitting). Selective amputation is

performed when the distal salvaged limb function is less than that with a prosthetic. This decision

is typically deferred to the definitive treatment facility after discussion with the casualty. Standard,

conventional amputation levels were developed mostly from patients with diabetic vasculopathies.

These standard civilian-based practices do not apply to most combat casualties. Positive outcomes

have been documented for amputees undergoing delayed surgical amputations of atypical configu-

rations (level and flaps). Atypical surgical amputations do not employ standard or traditional levels

of bony cuts, standard (textbook) skin incisions, or typical musculofascial flaps to cover the cut

bone and conform to conventional prosthetic fittings.

237



Reference

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eds: Combat Orthopaedic Surgery: Lessons Learned in Iraq and Afghanistan. Thorofare, NJ,

SLACK Incorporated, 2011, pp3-12.

2. Schoenfeld AJ: Orthopedic surgery in the United States Army: A historical review. Mil Med

2011; 176(6): 689-695.

3. Defense Casualty Analysis System: Department of Defense. Available at: https://www.dmdc.

osd.mil/dcas/pages/ summary_data.xhtml. Accessed March 11, 2016.

4. Owens BD, Kragh JF Jr, Macaitis J, Svoboda SJ, Wenke JC: Characterization of extremity

wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma

2007;21(4): 254-257.

5. Belmont PJ Jr, McCriskin BJ, Hsiao MS, Burks R, Nelson KJ, Schoenfeld AJ: The nature and

incidence of musculoskeletal combat wounds in Iraq and Afghanistan (2005-2009). J Orthop

Trauma 2013; 27 (5): e107-e113.

6. Schoenfeld AJ, Laughlin MD, McCriskin BJ, Bader JO, Waterman BR, Belmont PJ Jr: Spinal in-

juries in United States military personnel deployed to Iraq and Afghanistan: An epidemiolog-

ical investigation involving 7877 combat casualties from 2005 to 2009. Spine (PhilaPa 1976)

2013; 38(20): 1770-1778.

7. Schoenfeld AJ, Dunn JC, Belmont PJ: Pelvic, spinal and extremity wounds among com-

bat-specific personnel serving in Iraq and Afghanistan (2003-2011): A new paradigm in mili-

tary musculoskeletal medicine. Injury 2013; 44(12): 1866-1870.

8. Schoenfeld AJ, Newcomb RL, Pallis MP, et al: Characterization of spinal injuries sustained by

American service members killed in Iraq and Afghanistan: A study of 2,089 instances of spine

trauma. J Trauma Acute Care Surg 2013; 74(4): 1112-1118.

9. Schoenfeld AJ, Dunn JC, Bader JO, Belmont PJ Jr: The nature and extent of war injuries sus-

tained by combat specialty personnel killed and wounded in Afghanistan and Iraq, 2003-

2011. J Trauma Acute Care Surg 2013; 75(2): 287-291.

10. Belmont PJ Jr, Goodman GP, Zacchilli M, Posner M, Evans C, Owens BD: Incidence and

epidemiology of combat injuries sustained during “the surge” portion of operation Iraqi Free-

dom by a U.S. Army brigade combat team. J Trauma 2010; 68(1): 204-210.

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11. Belmont PJ Jr, Thomas D, Goodman GP, et al: Combat musculoskeletal wounds in a US

Army Brigade Combat Team during operation Iraqi Freedom. J Trauma 2011; 71(1): E1-E7.

12. Schoenfeld AJ, Goodman GP, Burks R, Black MA, Nelson JH, Belmont PJ Jr: The influence

of musculoskeletal conditions, behavioral health diagnoses and demographic factors on inju-

ry-related outcome in a high-demand population. J Bone Joint Surg Am 2014; 96(13): e106.

13. Goodman GP, Schoenfeld AJ, Owens BD, Dutton JR, Burks R, Belmont PJ Jr: Nonemergen-

torthopaedic injuries sustained by soldiers in Operation Iraqi Freedom. J Bone Joint Surg Am

2012; 94(8): 728-735.

14. Masini BD, Owens BD, Hsu JR, Wenke JC: Rehospitalization after combat injury. J Trauma

2011; 71(1 suppl): S98-S102.

15. Masini BD, Waterman SM, Wenke JC, Owens BD, Hsu JR, Ficke JR: Resource utilization and

disability outcome assessment of combat casualties from Operation Iraqi Freedom and Oper-

ation Enduring Freedom. J Orthop Trauma 2009; 23(4): 261-266.

16. Owens BD, Kragh JF Jr, Wenke JC, Macaitis J, Wade CE, Holcomb JB: Combat wounds in

operation Iraqi Freedom and operation Enduring Freedom. J Trauma 2008; 64(2): 295-299.

239




2007.3~2011.2 Yonsei Univ. School of Medicine

2011.3~2012.2 The Armed Force Capital Hospital, 교육수련부

2012.3~2016.2 Seoul National Univ. Bundang Hospital Department of Surgery

2016.3~2017.2 Seoul National Univ. Bundang Hospital Department of Surgery

2017.3~ The Armed Force Capital Hospital Department of Surgery

Education

Career

240


Epidemiology of Burn in Military




Backgrounds: We investigated the burn epidemiology, clinical differences and degree of tissue

injury to burn types. Such data can propose proper educational program designs to suit the com-

munity.

Methods: We had a retrospective clinical analysis of 908 acute burns for 7 year period (2010∼

2016). These included patient demographics, causes, tools of injuries and result of treatment.

Results: The male was predominant(905;99.7%). The young soldiers(752;82.8%), mean age of

20.6 yo, were the common victims. The flame burns(FB: 325;35.8%) was the most common and

followed scald burns (SB: 305; 34.6%), contact burns(CB: 219;24.1%), electric burns(EB: 45; 5.0%)

and chemical burns(ChB): 14;1.5%). The episode showed no seasonal or annual differences. CB

was most common in winter and EB in autumn.

SB had average 3.9% TBSA . Most of them were superficial(251; 82.3%) by spillage of hot

water/liquid food on lower leg(138; 45.2%) or foot.(102; 33.4%). Most were treat by simple dress-

ing(283; 92.8%). The 16(5.2%) showed wound hypertrophy and 4(1.3%) received burn skin care.

FB had relatively large wound of 9.3%. The 209(64.3%) had superficial wound by catching fire

to flammable oils(105; 32.3%) such as gasoline, solvent or to bomb powders(95; 29.2%) on head

and neck(195; 60.0%) or hands(188; 57.8%). They underwent simple dressing(271;83.4%) and

allogtafts or flap surgery(53;163%). The 41(12.6%) showed wound hypertrophy and 25(7.7%) re-

ceived burn skin care. There were 12(3.7%) corneal erosion or burns. The mortality rate was 1.2%(4

patient).

241



CB had small(1.1% TBSA), deep wound(172;78.5%) by application of hotpacks(176;80.4%) to

nude skin of lower leg(176; 80.3%). The more(133;60.7%) were treat by allogtaft or flap surgery.

But they had rare sequelae.

ChB had 3.8% TBSA. The most of wounds were superficial(13; 92.9%) and treated well.

EB had 6.8% TBSA. They had serious wound by touch to high tension live line(32; 71.1%).

They had lots of complications; LOC(6:13.3%), nerve injuries(5;11.1%), major amputations(1; 2.2%).

The 2(4.4%) showed wound hypertrophy and received burn skin care.

Conclusions: The cook should put on protector below the boots at the dining room. The light-

er or smoking should be strictly prohibited during work by flammable liquids or bomb powders.

Teaching of not to apply the hotpack on nude skin is very important. The hight tension live line is

always very dangerous.

242




Ph.D. , Graduate School of Medicine (Emergency Medicine), Pusan National University

M.D. , Pusan National University College of Medicine

Fellowship, Department of Emergency Medicine, Pusan National University Yangsan

Hospital

Residency, Department of Emergency Medicine, Pusan National University Hospital

Korean Society of Emergency Medicine

Korean Society of Critical Care Medicine

Society of Emergency & Critical Care Imaging (SECCI)

Korean Society of Traumatology

Korean Society of Disaster Medicine

Korean Society of Echocardiography

Academic

Qualifications

Postgraduate

Ttaining

Academic

Membership

243


What’s New in Traumatic Hemorrhagic

Shock




What’s New in Traumatic Hemorrhagic ShockThe Armed Forces Capital HospitalDepartment of Emergency Medicine

Captain, Hohyung Jung (M.D. PhD)

Overview What’s New?

• “ Stop the bleed “ and Bleeding control (B-CON)• Tranexamic acid (TXA)• Hemostatic monitoring – VHA (TEG, ROTEM)• Massive transfusion ratios (1 : 1 : 1)• Prehospital blood and plasma• REBOA – aortic balloon occlusion

What’s on the horizon?• Freeze –dried plasma• Self-expending foam

Objectives Describe current best practices and future directions in resuscitation of traumatic hemorrhagic shock

Disclosures

• Some treatment not yet be approved

• Speaker has no financial disclosures

Hemorrhagic Shock : the problem Mortality from major trauma is a worldwide problem.

Massive hemorrhage (non-compressible) is the major cause of preventable death in both military and civilian trauma.

Development of coagulopathy further substantially increases mortality.

Early control of bleeding and coagulopathy reduce morbidity and mortality in trauma hemorrhage

244



Hemorrhagic Shock : classification

Coagulopathy in Trauma

Key target for diagnosis and aggressive treatment in the bleeding phase

Pathophysiology

• Acute traumatic coagulopathy (ATC)

• Coagulopathy in the lethal triad

• Consumptive coagulopathy

Acute Traumatic Coagulopathy (ATC)

Traumatic endotheliopathy-> endogenous anticoagulation

Endogenous anticoagulation

• Auto-heparinization

• Protein C activation

• Hyperfibrinolysis : important cause of severe hemorrhage

Hemorrhagic Shock Two forms of blood loss from trauma

1) Direct or anatomic bleeding from the site of injury

• Compressible

• Non-compressible

2) Early coagulopathic bleeding

Mageale et al, Dtsch Arztebl Int 2011

Dobson et al, J Trauma 2015

245



Coagulopathy in the Lethal Triad

Mageale et al, Dtsch Arztebl Int 2011

Damage Control Resuscitation

Consumptive Coagulopathy

Coagulation factors, platelet consumption

Prothrombotic state of the microvasculature

Inflammatory response

Sympatho-adrenal overactivation : catecholamine

Hemorrhagic Shock : the solution Mechanical hemorrhagic control

• External bleeding : tourniquet, hemostatic dressings

• Internal bleeding (non-compressible) : interventions

Damage control resuscitation (DCR)

• Hemostatic resuscitation

• Permissive hypotensive resuscitation

• Regaining homeostasis and avoid further coagulopathy

What’s New? “ Stop the bleed “ and Bleeding control (B-CON)

Tranexamic acid (TXA)

Hemostatic monitoring – VHA (TEG, ROTEM)

Massive transfusion ratios (1:1:1)

Prehospital blood and plasma

REBOA – aortic balloon occlusion

246



B-CON

Bleeding control course for non-EMS (bystander)

Bleeding control should be the CPR of 21th century

Bleeding Control Kit Pre-hospital Hemostatic Dressings

Granville-Chapman et al, Injury 2010

Tranexamic acid (TXA) Prevent fibrinolysis (clot

breakdown)

Promote appropriate

coagulation

Lysine analogue

Many, many studies in

different surgical populations

Mannucci et al, NEJM 2007

247



TXA in Trauma Landmark studies

• CRASH-2 (worldwide)

• MATTERS (military)

Up to 14% improvement in survival (MTP)

1 extra survivor every 8 patients

MATTERS : less coagulopathy after TXA

Viscoelastic hemostatic assays (VHA)

Hemostatic monitoring – whole blood

• Thromboelastography (TEG)

• Rotational Thromboelastometry (ROTEM)

Rapid identification(< 30min) of coagulopathy and individualized, goal-directed transfusion therapy

Early identification of patients who will require MT

CRASH-2 : improved survival with TXA

MATTERS : improved survival with TXA


248




Johansson et al, Blood 2014

ROTEM

Schöchl et al, SJTEM 2012

a. Normal test result b. Reduced MCF c. Delayed initiation of coagulation

d. Prolonged CT and reduced MCF e. Hyperfibrinolysis

Massive Transfusion Protocols (MTPs)

Improve survival in traumatic shock

Mortality absolute risk reduction 15 – 20%

Lower crystalloid and blood product requirement

But inherent risks of blood product transfusion

TEG

VHA impact on outcomes

Improved survival

Reduction in blood product transfusion and thromboembolic events

Earlier shift from empiric to goal-directed transfusion strategy

Massive Transfusion Protocols (MTPs)

Bogert et al, Journal of Intensive Care 2014

Transfusion package

249



Massive transfusion ratios 1:1:1 vs 1:1:2

FFP : PLT : PRBC

High FFP : PRBC associated with lower mortality

~20% improvement in survival

1 extra survivor in 5 patients

Newer concepts in hemostatic resuscitation

Pre-hospital TXA ?

Pre-hospital blood products?

Plasma or PLT first ?

Retrospective cohort study Improved 24hr survival Improved shock parameters Decreased in-hospital transfusion requirements Overall survival not improved

Massive transfusion ratios

PROMMTT study (Holcomb, JAMA Surg. 2013)• 1 : 1 : 1 = improved 6hr survival• No 24hr survival benefit

PROPPR trial (Holcomb, JAMA 2015)• 1 : 1 : 1 = less death from hemorrhage• No 24hr or 30 day survival benefit

Optimal ratio is probably between 1 : 1 : 1 ~ 1 : 1 : 2

Retrospective cohort study Improvement in Vital functions TCA : High ROSC rate, but no survivors

Pre-hospital Blood Product RCTsName Full Product Control Country N Stage

PUPTH Pre-hospital Use of Plasma in Traumatic Hemorrhage

Thawed FFP

Standard care (0.9% NS) USA(Virginia)

210 Recruiting

PAMPer Pre-hospital Air Medical Plasma

Thawed FFP

Standard care (0.9% NS) USA(Pittsburg)

600 Recruiting

COMBAT Control Of Major Bleeding After Trauma

Thawed FFP

Standard care (0.9% NS) USA(Denver)

150 Recruiting

RePHILL Resuscitation with Pre-hospItaL bLoodproducts

1:1 pRBCand LysoPlas N-w

Standard care (0.9% NS) UK(Birmingham)

490 Recruiting

250



REBOA Resuscitative Endovascular Balloon Occlusion of Aorta

Not new, first reported in the 1950s during the Korean War

But renewed, alternative to resuscitative thoracotomy

Abdominal or pelvic hemorrhage, not thoracic

Temporary control of arterial inflow

Bridge the gap between shock and definite care

REBOA : vs resuscitative thoracotomy

Hemostatic Resuscitation

Stensballe et al, Curr Opin Crit Care 2016

REBOA : devices

251



REBOA : techniques1. Arterial access and positioning of sheath

2. Selection and positioning of the balloon• Using surface anatomic land mark• Zone I : xiphoid process• Zone III : umbilicus

3. Inflation of the balloon

4. Deflation of the balloon

5. Sheath removal

REBOA : position confirmation

Zone I : T4~L1 Zone III : L2~L4

X-ray

REBOA : “Safe” occlusion time? Partial-REBOA (P-REBOA)

• permissive regional hypoperfusion

Unknown….

Zone I (supra-celiac) : 30 ~ 45 min

Zone III (infra-renal) : 60 ~ 90 min

REBOA : aortic zones Zone I : descending thoracic aorta,

origin of the left subclavian~ celiac arteries

Zone II : paravisceral aorta, celiac ~ the lowest renal artery

Zone III : infrarenal abdominal aorta,the lowest renal artery ~ the aortic bifurcation

Select zone of occlusion based on injury pattern

Zone I & III preferred, avoid occlusion in Zone II

REBOA : position confirmation

Fluoroscopy Ultrasound

REBOA : algorithm for arrest

252



REBOA : algorithm for shock

REBOA outcomes

Perkins et al , Curr Opin Crit Care 2016

60min

REBOA : does it work? Probably.…?

Which patients ?

Contraindications ?

Torso ischemia, reperfusion injury

Femoral puncture site morbidity, distal clot

Therapeutic effect ?

Risk of severe complications and iatrogenic harm

REBOA outcomes


38%

REBOA outcomes


Balloon inflation/deflation

REBOA : which patients? where?

Exsanguinating non-compressible torso hemorrhage

Sub-diaphragmatic

Pre-hospital

Emergency department

OR

ICU

253



REBOA : summary REBOA feasible ED and Pre-Hospital setting

Wide range clinicians can perform

Potentially life saving

Partial-REBOA important

Therapeutic effect ?

Risk of severe harm

Many unanswered questions….

Freeze-dried plasma

French Army experience

US Army pilot project

Longer shelf-life (2 yrs vs 1 yr)

No need for refrigeration

Appears to be effective

Freeze-dried plasma equivalence to FFP

Pig model of hemorrhagic shock

Shuja et al, J Trauma 2008

On the horizon

Freeze-dried plasma

Self-expanding foam

Freeze-dried plasma

Self-expanding foam

Polyol + isocyanate phases mixed during injection

Duggan et al, J Trauma 2013

254



Self-expanding foam : concept

Rapid expansion Conforms to abdominal structures Solidifies Then operate

Self-expanding foam : animal studies




Self-expanding foam : pig studies





Dose dependent survival benefit in an animal model

Peev et al, J Trauma 2014

255



Summary Hemorrhage remains a leading cause of death

Hemorrhage control and resuscitation begins in field and continues in Bay

• B-CON, TXA, prehospital FFP/PLT/PRBC. 1 : 1 : 1 massive transfusion, VHA (TEG, ROTEM), REBOA

Evolving techniques are promising

• Freeze-dried plasma

• Self-expanding foam

Thank you !

The sooner you stop bleeding,

the better your patient’s outcome

256




Chief of Trauma and Surgical Critical Care-San Antonio Military Medical Center

2015 to Present

Chief of General Surgery-San Antonio Military Medical Center 2015

Co-Director Surgical and Trauma ICU - San Antonio Military Medical Center

2014-2015

Trauma Fellowship, University of Hawaii, Honolulu, HI / 2007-2008

Program Director: Dr. Hao Chih Ho

Surgical Critical Care Fellowship, University of Hawaii, Honolulu, HI / 2006-2007

Program Director: Dr. Mihae Yu

General Surgery Residency, Eisenhower Army Medical Center, Fort Gordon, GA

2001-2005

1983-1988

Examiner-2012, 2011, 2009

Postoperative Fluid and Electrolytes- Tripler Army Medical Center Cardiac

Nurse Course Dec 2009, Jul 2012

Member American Association of Trauma Since 2013

Fellow American Board of Surgeons Since 2010

Member Society of Critical Care Medicine 2007

Board Certified Surgical Critical Care October 1, 2007 Expires July 2018

Board Certified General Surgery March 21, 2006 Expires 2028

Positions

Academic

Education

Licensure/

Certification

257


Sharing Experience of Forward Surgical

Team in Afghanistan




Background: The previous United States Secretary of Defense Robert Gates on finding casu-

alty fatality rates being higher in Afghanistan than Iraq in 2009 issued a requirement that military

units be within one hour of surgical care. This resulted in a flourishing of Forward Surgical Teams

throughout Afghanistan. Colonel Kurt D. Edwards has deployed five times with these small units

to Afghanistan. Colonel Edwards will attempt to give his perspective and lessons learned operat-

ing within these small unit surgical teams.

Learning Objectives:

1. Overview of the US Army Forward Surgical Team organization currently and in the future.

2. Review the challenges with the current organization and deployment of Forward Surgical

Teams.

3. Review, through film, and personal experienced the lessons learned operating in small surgi-

cal units in austere environments with such procedures as:

a. Resuscitation

b. Craniectomies

c. Blast injuries

d. Extremity vascular trauma

e. Pediatric trauma

258



Conclusion: The proof that forward surgical teams within one hour of casualties improve out-

come is equivocal their perceived success ensures their continued high utilization. This should

prompt improvements in organization, training, and equimpment.


Director


Moderator

Myung I Choi (Chonnam National Univ. Hospital)

Kyung Hag Lee (National Medical Center)

1F. Seminar 2

Symposium 7

Nursing Roles in Trauma Center

06-24 (Sat.), 2017

260




261


Trauma Bay




262




March 2011 Graduate School of Health and Welfare, Dankook Univ.

August 2013 Graduate School of Health and Welfare, Dankook Univ.(Master of

Nursing)

July 2014 Obtained Elderly Professional Nurse Qualification

September 2017 Graduate School of Health and Welfare, Dankook

University(Doctor of Nursing)

September 1999 Joined Dankook University Hospital

June 2017 Currently working in Dankook University

Education &

Job Experience

263


Trauma Intensive Care Unit




Intensive care nursing will threaten living things.

This fact was revealed in the 1950s and 1980s.

Since then, with the advancement of medical and medical technology, patients have become increasingly complex, and nurses have become increasingly specialized knowledge and skills

As the delivery system has been evolving to enable continuous surveillance and treatment for serious patients, critical care nursing, an essential element, continues to evolve.

The American Association of Critical-Care Nurses (AACN) defines critical care as “an area of nursing that addresses human response to life-threatening illnesses.” Intensive care unit (ICU) re-fers to patients whose actual or potential health problems are life-threatening.

The higher the severity, the more unstable and dangerous the patient will need, and the more intensive nursing you need to watch 24 hours a day.

Like other medical areas, ICU nursing is undergoing a rapid change process, and the challenges facing ICU nursing are much greater than ever in the 21st century.

There are many areas where ICU nursing care can contribute to revitalizing the health care de-livery system that is led by the patient and the family in critical situations.

264



Although patients in critical condition are the main target of ICU care, interest in helping the patient’s family to have the ability to help patients is increasingly increasing, and the degree of in-volvement of ICU families in ICU nursing is increasing.

The role and tasks that nurses should perform are presented

At the heart of critical care is the use of critical thinking to maintain careful balance of care.

In terms of the holistic framework, human beings can not be thought of as part of an integrated physiological, mental, spiritual, and social beings.

In order to provide holistic care, an intensive care nurse should understand the following key concepts needed to understand patients and their families and provide mediation to them.

265




Cheju Halla Univ. Department of Nursing Science (Professional Bachelor)

Korea National Open University (Bachelor)

Inha Univ. Hospital Department of Nursing Science (Master's Degree)

Gachon Univ. Gil Hospital (Dedicated Nurse)

Education

Career

266


Physician Assistant




267




Chonnam National University, College of Nursing, Gwangju - Master in Nursing (2016 ~ )

Lehman College, Bronx, New York - Bachelor of Science in Nursing, 2009

Dongkang College, Kwangju, Korea - Associate degree in Nursing, 2004

North Central Hospital, Bronx, New York ( RN-BSN Course, 2009 )

- Clinical Practice in Telemetry Unit , ER and OR

Jacobi Medical Center, Bronx, New York ( RN-BSN Course, 2009 )

- Clinical Practice in Telemetry Unit & CCU

Dong-A Hospital (Korea)

- Worked in Endoscopy Room & the Surgical Department (From 2005 to 2006)

Moa Hospital (Korea)

- Delivery Room (From 2004 to 2005, 2010 to 2012)

Chonnam National University Hospital (Korea)

- Worked at Trauma Center as Program Manager and Register (From 2012 to Present)

Education

Experience

268


Registry




269




1998-2004 Medical Doctor

Gachon Medical School, Inchoen, Korea

2004-2009 Resident Gachon University Gil Medical Center

2009-2012 Chief of General Surgery Department Armed Forced Wonju Hospital

2012-2014 Fellowship of Trauma Surgery Gachon University Gil Medical Center

2016- Assistant Professor Gachon University Gil Medical Center

Education

Professional

Positions

270


Performance Improvement




Symposium Abstract

Published on June 21st, 2017

Publisher │ Ho-Seong Han

Chief Editer │ Sung-Hyuk Choi

The Korean Society of Traumatology

Hyundai Venture-Vill #528, 10, Bamgogae-ro 1-gil,

Gangnam-gu, Seoul, Korea

TEL : +82-2-364-5119

FAX : +82-2-459-8256

E-mail : [email protected]


DERMABOND PRINEO® Skin Closure System Strength and protection for excellent wound closure

COPY-15003-ET

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274



나제아는 수술 후 오심·구토를 강력하고 지속적으로 억제합니다

AN

A-1

5-A

-01

•나제아 주사액은 다양한 종류의 수술 후 오심 및 구토에 효과적입니다.1)

•나제아 주사액은 1일 1앰플로서 24시간 제토효과가 유지됩니다.2)

(24시간 내 2앰플까지 증량 가능합니다.)

•나제아 주사액은 항 구토 작용이 강력한 R체만의 순수한 5-HT3 수용체 길항제 입니다.3)

1) Hahm TS et al, Anaesthesia 2010 May;65(5);500-4 / Kwak YL et al, Spine. 2008 Aug 1:33(17):E602-62) Nasea Package insert3) Miyata K et al, J pharmacol Exp Ther. 1991 Oct:259(1):15-21

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