Introduction
Türkiye is located on a highly seismically active Anatolian plate where major earthquakes have occurred throughout history. 1 On February 6, 2023, two earthquakes with magnitudes of 7.8 and 7.5 near Kahramanmaraş heavily affected 11 provinces in Southern and Southeastern Türkiye. 1,2 These devastating earthquakes were followed by several aftershocks, killing thousands and injuring many more in the region. The affected region represents a large area inhabited by 14 million people, which corresponds to 16.4% of country’s population. 1,2 Among these, 4.6 million were children. According to data from April 16, 2023, nearly 50,000 people died 2 and 108,000 were seriously injured. 3 It has been the largest earthquake in this region since the 1900s. 1
The effects of the disaster were felt, especially in emergency departments (EDs), minutes after the earthquake, and the emergency systems quickly became overwhelmed. In mass-casualty events, particularly significant ones such as this particular disaster, coping with patients in the ED, which are usually the most capable of providing care for critical patients regardless of prior notification, can be challenging.
The literature on the management of children affected by earthquakes is scarce and mostly adopted from adults. Children are inherently different from adults and experience much more of the impact of earthquakes because of their unique needs and vulnerabilities, such as smaller body portions, different physiology, and developing organ systems. 4 Therefore, it is important for children to be evaluated by a physician experienced in their special needs, even in the midst of disasters and emergencies.
The most common type of injury in children affected by earthquakes is fracture, followed by soft tissue injuries. Reference Sarisözen and Durak5 Crush injuries and crush syndromes are common patterns of earthquake injuries. Reference Jacquet, Hansoti, Vu and Bayram6
The institution used for study, located 600km from the epicenter of the earthquake, is a tertiary university hospital and Level 1 trauma center, one of the out-field hospitals where earthquake victims were referred for further treatment. This study aimed to determine the characteristics and outcomes of children who presented to the pediatric emergency department (PED) after an earthquake and to evaluate children who had crush injuries at a referral tertiary university hospital away from the earthquake area. In addition, another objective of the study was to guide disaster management and planning for children for possible earthquakes in the future.
Material and Methods
Study Design
The medical records of all children who presented to the PED by self-presentation or transportation from the earthquake area from February 6 through March 7, 2023 were retrospectively reviewed. Approximately 75,000 children are evaluated annually in the PED. The hospital is located in the capital city of Türkiye and is a 272-bed tertiary-care pediatric hospital. It is also a Level I trauma center for children. This study was approved by the Clinical Research Ethics Board of Hacettepe University Faculty of Medicine (Ankara, Türkiye; GO 23/376).
Disaster Action Plan
In the early morning after the earthquake, a “Disaster Action Plan” was implemented. All elective operations and admissions to the pediatric wards were canceled. Pediatric emergency physicians and residents, pediatric intensive care physicians, pediatric nephrology physicians, and other trauma-related departments, including pediatric surgery, orthopedics, plastic and reconstructive surgery, and cardiovascular surgery, were prepared for possible future cases of PED. Additionally, on the first day of the earthquake, three pediatric emergency specialists and two pediatric intensive care specialists who worked in the hospital voluntarily visited the earthquake area. The following days, volunteers from pediatric residents and specialists went to the region as teams.
Patient Population and Referral System
Following extraction, victims were transferred to the frontline hospitals in the region that were not damaged and to secondary referral hospitals in the region or nearby. Many of these hospitals were located in Adana and Mersin. After stabilization and initial treatment in these referral centers, the patients were referred to the study center or other tertiary hospitals, especially Ankara (Figure 1). Additionally, many children presented to the PED through their own means with their families.
Figure 1. Patient Transportation Network to Hospital.
All children who applied from the earthquake region were included in this study period. There were no exclusion criteria.
All patients were evaluated in three categories according to the complaint at admission to PED. The first group of patients (Group 1) were those rescued from rubble. Patients in this group were transferred from a field hospital or referral center in the earthquake area, and some were admitted by their own means. The second group of patients (Group 2) were in the earthquake zone and presented with complaints of clinical symptoms, such as simple injuries, infectious diseases, gastroenteritis, or health issues that arose from inadequate nutrition and living conditions in the next period. The third group (Group 3) included the children whose caregivers had to migrate while living in the earthquake area, presented to the PED due to any health problem not related to the earthquake but to chronic diseases that needed follow-up, and had problems accessing their medication.
The information about medical and surgical procedures performed and time period under the ruble (TPR) was obtained from the medical records sent over from the first center along with the patients. For patients who arrived without medical records, their information was recorded based on the verbal statements they provided. The information after their arrival at the PED was retrieved from the hospital’s electronic medical recording system.
Patients’ demographic data, complaints, Pediatric Trauma Score (PTS), Injury Severity Score (ISS), TPR, diagnoses, injury types, number of affected extremities, laboratory findings, prognoses, presence of crush syndrome and/or acute kidney injury (AKI), dialysis need, and surgical procedures undertaken, such as fasciotomy and amputation, were recorded.
Therapeutic Strategy
Triage acuity levels of all patients were determined using the Emergency Severity Index (ESI version 4th). The first group of patients and all unstable patients were immediately evaluated in the trauma room. All children who had been rescued from the rubble were initially evaluated by a trauma team consisting of a pediatric emergency physician, pediatric intensive care unit (PICU) physician, chief of the pediatric resident, and pediatric resident. After the initial assessment and stabilization, oligo-anuric children were hydrated with 1,200cc/m 2 alkalinized solutions (50mEq bicarbonate in 1L D5 0.45% NaCl); any children with suspicion of crush syndrome were hydrated with 3000cc/m2 - 4000cc/m2 alkalinized solutions (50mEq bicarbonate in 1L D5 0.45% NaCl) in PED. The patients were referred to the departments of orthopedics, pediatric surgery, pediatric nephrology, plastic surgery, and cardiovascular surgery according to their needs. The need for antibiotics and tetanus prophylaxis was also determined.
Definitions
Crush injuries with direct injury due to collapsing material and debris were considered crush injuries. Reference Sever and Vanholder7 Swelling, pain, paresthesia, paresis or paralysis, and/or absent peripheral pulses, pallor, and reduced capillary return in the extremities were considered symptoms and signs of acute compartment syndrome. Reference Sever and Vanholder7,Reference Duckworth and McQueen8 Patients with systemic symptoms, including local tissue injury, organ dysfunction (reduced urinary output), and metabolic abnormalities (acidosis, hyperkalemia, and hypocalcemia) were considered to have crush syndrome. Reference Sever and Vanholder7 The presence of oligo/anuria (<0.5ml/kg/h x6-12h) and the need for hemodialysis were accepted as AKI due to crush syndrome. Reference Sever and Vanholder7 Indications for renal replacement therapy were defined by pediatric nephrology and/or PICU specialists.
The PTS, Abbreviated Injury Scale (AIS), and ISS were used to determine injury severity. Reference Baker, O’Neill, Haddon and Long9,Reference Tepas, Mollitt, Talbert and Bryant10
Outcomes
The primary outcome was to define the characteristics of earthquake victims in a PED which is located distant from the epicenter of the disaster. The secondary outcome was the evaluation of children with crush injuries.
Statistical Analysis
Descriptive statistics of all numeric variables, including mean, standard deviation (SD), minimum and maximum values, median (interquartile range [IQR]), and proportions of all categorical variables, were calculated. Two independent group means were compared using Student’s t-test for independent groups. Non-parametric results are presented as medians (IQR) and were compared using the Mann-Whitney U test. A P value significance was set at P < .05. SPSS for Mac (version 23.0; IBM Corp.; Armonk, New York USA) was used for all the statistical analyses.
Results
From February 6, 2023 through March 7, 2023, 252 children affected by the earthquake were admitted to the Hacettepe University Ihsan Doğramacı Childrens Hospital PED (Ankara, Türkiye). The distribution of patients according to group and days after the earthquake is shown in Figure 2. The patients consisted of 128 (50.8%) girls and 124 (49.2%) boys with a median age of six (IQR = 1.7-12.1) years, ranging from zero to 17.9 years.
Figure 2. Distribution of Patients Admitted to the PED According to the Groups and Days After Earthquake (Group 1: Children Rescued from the Rubble; Group 2: Children Affected by Environmental Conditions of Disaster; and Group 3: Children with Chronic Illnesses).
Abbreviation: PED, pediatric emergency department.
Evaluation of Children Rescued from the Rubble (Group 1)
Fifty-four patients rescued from the rubble were evaluated. The primary characteristics of children in the first group are presented in Table 1. At the presentation time, 55.6% (n = 30) of children had no guardian. Thirty-seven children (68.5%) presented to PED through ambulance, 78.3% (n = 29) of them were transferred from a secondary referral hospital in the region, and the rest of the children were transferred from the frontline hospitals in the region. Nine children (16.7%) presented to PED by their own means following admission to the frontline hospitals in the region. Eight children (14.8%) presented directly to PED without previous admission to any health institution after the earthquake.
Table 1. Clinical characteristics of children rescued from the rubble (Group 1)
Abbreviations: PTS, Pediatric Trauma Score; ISS, Injury Severity Score; ESI, Emergency Severity Index; TPR, time period under the rubble; AKI, acute kidney injury; PED, pediatric emergency department; PICU, pediatric intensive care unit.
a Median [IQR].
b Mean (SD).
c Hospitalization longer than 24 hours is defined as inpatient unit.
Thirty-four children (64.2%) were administered intravenous fluid in the field hospitals; seven children (13.7%) had no medical records of fluid management in the previous hospital. Eight children (14.8%) had undergone hemodialysis, two children (3.8%) had plasma exchange, and seven children (13.2%) had been transfused before being transferred.
Extremity injuries were the leading physical examination finding (n = 48; 88.9%). Neurological (n = 17; 31.5%) and abdominal findings (tenderness was accepted as a positive sign; n = 13; 24.1%) were the other common abnormalities.
Ten children (18.5%) had extremity fractures and 14 (25.9%) children had vertebral and/or pelvic fractures. Compartment syndrome findings were detected in 34 children referred (64.2%); six (11.1%) of them had limb amputation and 19 (35.2%) had fasciotomy on admission to PED.
The most common consultations in the PED were as follows: orthopedics and traumatology (n = 45; 83.3%), pediatric surgery (n = 33; 61.1%), plastic surgery (n = 29; 53.7%), pediatric nephrology (n = 22; 40.7%), cardiovascular surgery (n = 17; 31.5%), and neurosurgery (n = 9; 16.7%).
The most frequently observed cause of hospital admission was crush injury (62.2%; n = 33); the remaining reasons are provided in Table 2.
Table 2. Reasons for Hospitalization in Children Rescued from the Rubble
Abbreviation: AKI, acute kidney injury.
a No guardian.
Forty-six children (85.2%) had crush injuries, 11 of them (24.4%) had injuries in more than one limb. In the first/field center, fasciotomy was performed in 19 patients (35.2%), and limb amputation was performed in six patients (11.1%). Of the 19 patients who underwent fasciotomy in the first center, nine underwent repeated fasciotomy after admission, and eight patients required amputation. Two patients who were transferred without fasciotomy or amputation at the first center required extremity amputation. The total number of children who had at least one extremity amputated was 13 (24%). The median TPR was longer in patients who required amputation (48 hours [IQR = 24-68] versus six hours [IQR = 2-12]; P < .001).
Crush syndrome developed in 46.3% (n = 25) of the children rescued from the rubble. Fifty-two percent of them (n = 13) were girls, mean age of 14.3 (IQR = 10.7-16.6) years and TPR of 10 hours (IQR = 6-48) and there were no statistically significant differences in the group who had no crush syndrome (62% of them [n = 18] were girls a median age of 11 [IQR = 7.3-11.8]; P >.05). The average PTS and ISS at presentation were 8.4 (SD = 1.9) and 19.4 (SD = 7.7), respectively, in children with crush syndrome, and this was statistically significant compared to children who had no crush syndrome (10.2 [SD = 1.9] and 6 [SD = 5.9]; P = .001 and P < .001). Nineteen children with crush syndrome (19/25; 76%) had developed AKI, and 14 of them (14/25; 56%) had needed dialysis due to the AKI. The characteristics of patients who required dialysis (RRT) and those who did not are shown in Table 3.
Table 3. Comparison of Clinical and Laboratory Characteristics in Children Needing Hemodialysis
Abbreviations: RRT, patients who required dialysis; TPR, time period under rubble; PTS, Pediatric Trauma Score; ISS Injury Severity Score; LOS, length of stay,
a Mean (SD).
b Median [IQR].
The relationship between the number of crushed extremities and complications is presented in Table 4. All children who had crush injuries or open wounds were administered antibiotics as a prophylaxis for secondary infections (n = 40; 74.1%). Ceftriaxone and clindamycin were used as the prophylactic antibiotics. Children who had undergone fasciotomy or amputation in the field hospitals (n = 22) had more infectious complications than the children (n = 29) who underwent surgery at the study center (68% versus 40%; P = .009).
Table 4. Number of Crushed Extremities and Complications
Abbreviation: AKI, acute kidney injury.
The tetanus vaccine was administered to 36 children who were unvaccinated or whose information could not be accessed according to the scarce information obtained from the available medical records.
Twenty-eight (51.9%) children in this group lost their first-degree relatives, and 33 children (61.1%) had issues with sheltering and guardian problems after discharge.
Children Affected by Environmental Conditions of Disaster (Group 2)
In this group, 182 children were presented to the PED. The median age was four (IQR = 1.2-9.2) years; 50% were girls (n = 91). Twelve (6.7%) children were brought to ambulances, one of them had poor general condition. One-hundred-sixty-four (90.1%) children were discharged directly from the PED; 28 of them had short diagnostic tests and simple treatments (eg, urine analysis and/or wound care), five children were hospitalized in pediatric wards, and two children needed PICU care. The mean length of hospitalization was 3.3 (SD = 61.8) days (Table 5). Six (3.2%) children had been hospitalized before the earthquake and were transferred to the PED because of a damaged hospital.
Table 5. Reasons for Admission to the Hospital for the Second Group of Patients
Abbreviation: ICU, intensive care unit.
Accommodation problems (eg, sheltering and poor sanitation; n = 49; 26.9%) and cold weather conditions (n = 29; 15.9%) related diseases were the most common PED presentations. The most common diagnoses were upper respiratory tract infections (n = 69; 37.9%), acute gastroenteritis (n = 23; 12.6%), simple physical trauma that occurred while running from the earthquake (n = 16; 8.8%), and lower respiratory tract infections (n = 13; 7.1%).
Children with Chronic Illnesses (Group 3)
Sixteen children with chronic illnesses presented to the PED with non-urgent causes because the hospitals in the field were dealing with disaster victims or were damaged. Mean age was 6.4 (IQR = 1.8-13.8) years, 62.5% of whom were the boys (n = 10). The children were referred to pediatric neurology (33.3%; n = 5), pediatric oncology (25%; n = 4), pediatric nephrology (18.8%; n = 3), pediatric gastroenterology (12.5%; n = 2), pediatric allergy (6.3%; n = 1), or pediatric cardiology (6.3%; n = 1).
Discussion
Emergency departments are a critical component of the health care system because they provide care for patients who have life-threatening or other conditions that require emergency medical treatment. Access to emergency care is more important than ever in the event of natural or man-made disasters, because the world has witnessed an increase in the number of disasters in recent years. 11 Unfortunately, children are most affected by natural and man-made disasters because of their physical and psychosocial vulnerability, the disruption of services essential for their development, high dependency on parents and other caregivers, and limited voice and representation. Therefore, pediatric needs should be considered in all the disaster plans.
This study reports the PED presentations of 252 children affected by the earthquake during the first 30 days following this devastating event. A total of 70.3% of the first group and 37.6% of all victims were admitted to the PED in the first seven days after the disaster. This disaster once again showed that PEDs should be prepared for earthquake victims, especially within the first week after the disaster, and that academic centers have important responsibilities before, after, and during disasters, even if they are far from the disaster area.
The wide-reaching impact of a major disaster had resulted in inadequate search and rescue operations, transportation for those affected, and limited capacity for hospitals and medical staff. Moreover, reaching victims within the first golden hours proved extremely challenging because of several factors, including health care workers in the region being earthquake victims themselves, extensive damage to access roads, and the destruction of certain hospitals within the area.
Previous studies have indicated significant differences in the characteristics of earthquake-related patient influx and types of injuries between areas near the epicenter and less affected regions. Wen, et al Reference Wen, Sun and Shi12 reported that the number of patients in frontline hospitals peaked on the first day, whereas referrals to second-line hospitals peaked on the second day, and remained constant throughout the month. In the Marmara earthquake in 1999, it was observed that 93.2% of patients were admitted within the first seven days. Reference Sever, Erek and Vanholder13 A similar trend was also observed in this study, where 72% (n = 37) of children in the first group and 37.6% (n = 93) of all victims were admitted to the PED within the first seven days after the disaster. This indicates a substantial increase in patient influx, particularly during the initial week after disasters, and highlights the importance of differentiating between hospital types as the PED must be adequately prepared to handle such a high volume of patients. It is possible that ambulances may fall short in transporting the large number of individuals requiring assistance to health care facilities or in transporting numerous patients over long distances. In this study, ambulance transportation was the most prevalent method, with 68.5% (n = 37) of patients rescued from the rubble were transported to the PED by ambulance. Similarly in the Wen, et al study, 56.0% of the patients were transported by ambulance, 13.8% by helicopters, and 11.9% by trucks. Reference Wen, Sun and Shi12
Damaged health facilities and the increasing need for health care professionals have given rise to a need for field hospitals and voluntary health workers. As noted in the Haiti earthquake, well-organized teams from different countries created differences in mass-casualty events. Reference Babcock, Theodosis and Bills14,Reference Burnweit and Stylianos15 A team consisting of pediatricians, orthopedics, plastics, pediatric surgeons, and experienced team leaders is crucial for medical/surgical management of pediatric mass-causality events. Reference Burnweit and Stylianos15 Many providers want to help where destruction is most severe, but it is important to keep in mind that there will also be significant medical needs in non-disaster areas where large numbers of people are transported or relocated by their own means or ambulances. Reference Merchant, Leigh and Lurie16
Trauma caused by collapsed buildings is the main cause of morbidity and mortality following earthquakes. The most common injury sites are the extremities and spine, Reference Sarisözen and Durak5 the most common of which is a long bone fracture in the lower extremities, as reported in previous studies after earthquakes. Peek-Asa, et al Reference Peek-Asa, Kraus, Bourque, Vimalachandra, Yu and Abrams17 reported that 53.6% of hospitalized patients had lower extremity injuries, and Bulut, et al Reference Bulut, Fedakar, Akkose, Akgoz, Ozguc and Tokyay18 reported extremity injuries in 66.6% of patients after the 1999 Marmara earthquake. In this series, for children who were rescued from the rubble, extremity injuries were the most common parts of the injured body (78.8%), which is consistent with previous reports. The most important reason for hospitalization was trauma to the extremities. Therefore, providing sufficient medical facilities, personnel, and equipment to manage acute injuries is important in future earthquakes.
The need for medical treatment and causes of hospitalization after a disaster can change depending on the days after the earthquake, the distance to field hospitals or hospitals located in remote unaffected regions, the mean age of the affected population, and the type of disaster. In the first two-to-three days after the earthquake, the victims presented with injuries due to the collapse of most buildings to the field hospital, while secondary medical problems, such as infectious diseases and exacerbation of chronic diseases, were the main reasons for admission in the following days, as shown in the Düzce and Adapazarı earthquakes in Türkiye. Reference Bar-Dayan, Leiba and Beard19
Early and large-volume administration of intravenous fluids is crucial for the prevention and treatment of acute renal failure in individuals with crush injuries. Reference Sever and Vanholder7 In this study, it is difficult to comment on the role of fluid management in the PED during the course of crush syndrome and AKI. The reasons for this include the fact that the patients had no medical records during transport/transfer to determine data for fluid administration.
Compartment syndromes and crush injuries are a spectrum of diseases that develop because of muscle compression. Reference Long, Liang and Gottlieb20 Reducing intracompartmental pressure is the most important mechanism for compartment syndrome, and early fasciotomy is recommended if it is certainly indicated and effective in reducing intracompartmental pressure. Reference Sever and Vanholder7 However, the higher risk of secondary infections is another controversial problem associated with fasciotomy. Reference Better and Stein21 It has been observed in this series, the risk of infection was higher in children who underwent procedures such as fasciotomy or amputation in the field (68% versus 31%; P = .009). The main problem for patients with crush injuries is the development of crush syndrome. Metabolic acidosis, hyperkalemia, myoglobinuria, and AKI are common metabolic complications. Reference Long, Liang and Gottlieb20 Hyperkalemia and acidosis were not detected in the patients. However, in another study, hyperkalemia was detected in four of 15 children with crush syndrome. Reference Iskit, Alpay and Tuğtepe22 This may be because most patients were transferred after their first intervention at a health institution.
In the present study, it was shown that longer TPRs were correlated with amputation and dialysis requirements. In the Marmara Earthquake, a longer extraction time was shown to be related to the number of extremities undergoing fasciotomy and requiring amputation. Reference Sever, Erek and Vanholder13
As a tertiary center away from the epicenter of disaster, the patients taken from the rubble had severe injuries (41.1% of patients had severe and profound injuries, ISS score more than 15). They did not have life-threatening injuries that had to be treated within hours, owing to the long transport time requirement, as reported in distant centers during other disasters. Reference Zhao, Shi, Hu and Li23 The absence of mortality is important, as it shows that the survival rate will be high when children, most of whom die in the field, reach a pediatric center where they can receive good care.
Children with respiratory infections, which are the most common cause of PED presentations, have replaced trauma presentations after the first few days. After the earthquake, the medical needs shifted from the physical effects of direct trauma to the effects of earthquake-related environmental hazards. Reference Farfel, Assa and Amir24 The fact that the children in the second group were mostly in their infancy (mean age 12.42 [SD = 6.3] months) supports the hypothesis that young children are more easily affected by environmental and hygienic conditions. As reported in other studies, respiratory and gastrointestinal infections are the leading causes in PED. Reference Zhao, Shi, Hu and Li23 Infections observed after disasters are usually caused by massive population displacement, environmental changes, disruption of the supply of safe drinking water and food, poor hygiene, and overcrowding. Reference Kouadio, Aljunid, Kamigaki, Hammad and Oshitani25,Reference Rathore26 Infection control measures should be implemented in disaster control plans, and rapid implementation of these measures may decrease the frequency of infectious diseases after disasters.
During this period, children with chronic illnesses were admitted to the PED for treatment and equipment. Children with disabilities are usually not involved in disaster planning, although they are at higher risk of disasters and have a lower chance of evacuation. Reference Ronoh, Gaillard and Marlowe27,28 Special action should be taken for these children.
Strengths
The strength of this study is that the experiences with children exposed to disasters are shared, which raises awareness about incorporating lessons learned into policies and practices to reduce the effects of future disasters on children. From this disaster, the following lessons were learned:
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– Children have better survival and morbidity rates when they receive appropriate care.
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– Electronic or written recording systems must be used.
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– Teams working in the field must be experienced with children from field triage to patient transport and communication.
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– The needs of the teams going to the region must be determined, and sufficient medical equipment and personnel support should be provided.
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– Pediatric emergency physicians and intensivists must play the role of leaders during such huge disasters. And,
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– The transportation of patients from the affected area must be carefully planned.
Limitations
This study has several limitations. The most significant limitations of the study were that it was conducted at a single center and the information was collected retrospectively. Additionally, the inclusion of only patients who came to the hospital from the disaster area resulted in selection bias. And some patients did not have sufficient medical records, including medical treatment at the field, field hospital, and during transportation. The lack of knowledge about intravenous fluid administered before transportation makes it difficult to interpret the effects of fluid administration on the development of AKI.
Conclusion
This study reveals that health centers should be prepared to respond to large numbers of critically ill children during a disaster, even if they are far from the affected area. In the early days, common problems were crush injuries, crush syndromes, and AKI. However, centers should also be prepared for patients affected by the environmental conditions created by the disaster, as well as patients in need of medical treatment due to chronic illnesses. The most crucial thing in the management of these patients was multi-disciplinary teamwork. And a comprehensive disaster plan specific to children that can serve all these patient groups is needed to ensure rapid response and appropriate coordination of disaster management.
Conflicts of interest
None declared.
