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COMPREHENSIVE REVIEW

Earthquakes and Trauma: Review of Triage and Injury-Specific, Immediate Care

Oliver P. Gautschi;1,2 Dieter Cadosch;2 Gunesh Rajan;3 Ren Zellweger2

1. Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland 2. Department of Orthopaedic and Trauma Surgery, Royal Perth Hospital, Perth, Western Australia 3. Department of Otorhinolaryngology, Head and Neck Surgery, Fremantle Hospital, Western Australia Correspondence: Oliver P. Gautschi, MD Department of Neurosurgery Cantonal Hospital St. Gallen Rorschacher Strasse 95 9007 St. Gallen, Switzerland E-mail: ogautschi@datacomm.ch Keywords: crisis management; disaster relief; earthquake; immediate care; mass casualty; mass fatality; trauma; triage Abbreviations: ABC = airway, breathing, circulation CASTA = Combined Australian Surgical Team-Aceh ICRC = International Committee of the Red Cross ICU = intensive care unit NT = needle thoracostomy PTSD = post-traumatic stress disorder TT = tube thoracostomy WHO = World Health Organization Received: 26 July 2007 Accepted: 25 September 2007 Revised: 29 October 2007 Web publication: 18 April 2008

Abstract Earthquakes present a major threat to mankind. Increasing knowledge about geophysical interactions, progressing architectural technology, and improved disaster management algorithms have rendered modern populations less susceptible to earthquakes. Nevertheless, the mass casualties resulting from earthquakes in Great Kanto ( Japan), Ancash (Peru), Tangshan (China), Guatemala, Armenia, and Izmit (Turkey) or the recent earthquakes in Bhuj (India), Bam (Iran), Sumatra (Indonesia) and Kashmir (Pakistan) indicate the devastating effect earthquakes can have on both individual and population health. Appropriate preparation and implementation of crisis management algorithms are of utmost importance to ensure a large-scale medical-aid response is readily available following a devastating event. In particular, efficient triage is vital to optimize the use of limited medical resources and to effectively mobilize these resources so as to maximize patient salvage. However, the main priorities of disaster rescue teams are the rescue and provision of emergency care for physical trauma. Furthermore, the establishment of transport evacuation corridors, a feature often neglected, is essential in order to provide the casualties with a chance for survival. The optimal management of victims under such settings is discussed, addressing injuries of the body and psyche by means of simple diagnostic and therapeutic procedures globally applicable and available. Gautschi OP, Cadosch D, Rajan G, Zellweger R: Earthquakes and trauma: Review of triage and injury-specific, immediate care. Prehospital Disast Med 2008;23(2):195201. Introduction Earthquakes have the potential to be one of the most catastrophic disasters that affect mankind. At the earths surface, earthquakes manifest themselves by shaking or displacing the ground, which if severe, may lead to the loss of life and destruction of property.1 Increasing knowledge about geophysical interactions and tectonic movements allow scientists to designate earthquakeprone areas and regions. Additionally, technological advancements in architecture, improved catastrophe management algorithms, and the adaptation of local infrastructures have rendered modern populations less susceptible to the impact of earthquakes.2,3 Despite all of these measures, seismic activity and earthquakes continue to cause immense loss of life and destruction of property (Table 1). Recent earthquakes in Bhuj (India), Bam (Iran), Sumatra (Indonesia), and Kashmir (Pakistan) show the devastating effects earthquakes have on both population and individual health (Table 2). The first priority of a disaster rescue team is the rescue and provision of emergency care for victims who have sustained physical trauma. However, achieving this remains a significant challenge due to the lack of access to basic necessities such as shelter, water, food, and sanitation facilities. In this paper, the management of trauma patients in such settings is discussed, adding our experiences with the Swiss Disaster Rescue Team during the earthquakes in Kobe ( Japan, 1995) and Bhuj (India, 2001), and with the Combined Australian Surgical Team-Aceh (CASTA) in Banda Aceh (Indonesia, 2004). These
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Location Valparaiso (Chile) Messina (Italy) Avezzano (Italy) Ningxia-Gansu (China) Great Kanto (Japan) Xining (China) Gansu (China) Quetta (Pakistan) Chillan (Chile) Erzincan (Turkey) Ashgabat (Turkmenistan, Soviet Union) Ancash (Peru) Tangshan (China) Guatemala Tabas (Iran) Great Mexican (Mexico) Spitak (Armenia, Soviet Union) Manjil-Rudbar (Iran) Great Hanshin (Kobe, Japan) Izmit (Turkey)

Year 1906 1908 1915 1920 1923 1927 1932 1935 1939 1939 1948 1970 1976 1976 1978 1985 1988 1990 1995 1999

Richter scale 8.2 7.2 7.0 8.6 8.3 7.9 7.6 7.7 8.3 7.8 7.3 7.9 8.2 7.5 7.7 8.1 6.9 7.7 7.2 7.6

Deaths ~20,000 ~100,000 ~30,000 ~190,000 ~143,000 ~175,000 ~70,000 ~45,000 ~30,000 ~33,000 ~110,000 >66,000 ~255,000 ~23,000 ~25,000 >10,000 >25,000 >40,000 >6,400 >17,000

Injured NA NA NA NA NA NA NA NA NA NA NA >140,000 >165,000 ~77,000 NA >50,000 ~31,000 >60,000 ~35,000 ~44,000

Table 1Major earthquakes in the 20th century Source: http://en.wikipedia.org/wiki/Category:Earthquakes_in_the_20th_century

Location Bhuj (India) Bam (Iran) Indian Ocean (Sumatra, Indonesia) Kashmir (Pakistan) Java (Indonesia) Year 2001 2003 2004 2005 2006 Richter 7.9 6.6 9.19.3 7.6 6.3

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Deaths >20,000 ~43,000 >229,000 >79,000 ~6,000

Injured ~60,000 >30,000 >110,000 >106,000 >36,000

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Table 2Major earthquakes in the 21st century Source: http://en.wikipedia.org/wiki/Category:Earthquakes_in_the_21st_century

experiences highlight the necessary preparation that must be undertaken by governments and medical organizations located in seismic areas. Furthermore, experiences have demonstrated that triage is a continuous process and that, without functioning evacuation corridors, medical efforts are largely in vain. Pitfalls and Problems in Patient Retrieval, Triage, and Transport Patient Retrieval Retrieval and response times are critical for the patients survival in emergency settings. Past observations of earthquakes during the 1970s and 80s indicated that rapid extrication of people who were trapped is crucial for their survival.4 Victims
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who were retrieved within 24 hours had a survival rate of 8595%. Recent findings from China and Turkey indicate that the mortality of buried victims two to six hours after entrapment is >60%, and that 2550% of the injured could have been saved if retrieval and first aid had been rendered simultaneously.5 Victims with severe trauma only have a chance of survival if treatment in a trauma center is rapidly available, a condition that usually is not realistic in such settings. Several studies indicate that initial emergency treatment is performed best by local medical services, since external medical assistance usually arrives well after that of local healthcare personnel due to further proximity to the disaster site.6,7 Survival of trapped casualties depends on early medical interventions by emergency teams on-site.
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Category IPriority for Surgery Those patients for whom urgent surgery is required and for whom there is a good chance of recovery. In practice many of these patients will have abdominal injuries. Category IINo Surgery Those patients who do not require surgery either because their wounds are so slight that they can be managed non-operatively or because their injuries are so severe that they are likely to die or have a poor quality of survival. Category IIICan Wait for Surgery Those patients who require surgery but not on an urgent basis.
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Table 3Triage categories of the International Committee of the Red Cross

Patient Triage Triage in a disaster management setting starts with a clear, established, operational, disaster plan that defines the roles and automated algorithms of the multidisciplinary rescue teams and medical squads involved. Rapid evacuation of areas for the establishment of treatment sites and first-aid camps must be included in these plans. They also must include potential difficulties that may arise, such as specific regional and geographical conditions. Early establishment of local medical centers can alleviate the burden from local, existing health institutions.8 Triage should evolve at three locations: (1) at the scene; (2) in the treatment resuscitation area; and (3) in the hospital. A disaster scenario, such as a mass-casualty incident, requires a various array of triage tools to manage individual trauma. Mass casualties necessitate triage where the principal aim is to provide medical care to all injured people who have a reasonable chance of survival. Subsequently, the aim of triage is to get the right patient at the right time to the right treatment facility.9 The International Committee of the Red Cross (ICRC) has established several triage categories in order to provide a basic algorithm for decision-making in a disaster scenario (Table 3).3,5,6 It is recommended that at the scene, the most experienced healthcare provider should be responsible for triage management. Severely injured patients with a chance of survival are transported first. Marking the patients with different methods like ink marks or special tags, according to the triage ICRC category, is vital to organizing and assessing the triage priorities in mass-casualty incidents. Disaster triage and management of mass-casualty incidents represent a tactical art that incorporates clinical expertise, didactic information, communication ability, coordination, leadership, and decision-making. Planning, rehearsing, and exercising various mass-casualty scenarios encourage the flexibility, adaptability, and innovation required in disaster settings.10 Establishing a Medical Transport Corridor The establishment of a medical transport corridor incorporates the coordination of community transportation systems along highway corridors or other transportation routes working together to create enhanced services for

passengers and patients. Importantly, achieving operating efficiencies through communication, shared resources, and working partnerships is mandatory. The subsequent goal of a medical transport corridor is to provide an avenue for the safe and fast transport of patients to a predefined target. A retrospective study of 6,107 victims of the Kobe earthquake indicated that, after the establishment of a transport corridor, 38% of the patients immediately were transferred to hospitals outside the earthquake impact zone. Approximately 26% went through triage and stabilization in a hospital within the impact zone, and subsequently, were referred to an external hospital facility for further treatment. About 25% of all patients were treated in local hospitals.1113 It is important to note that in all recent earthquakes, mortality in intensive care patients was significantly higher in those treated at the local earthquake-affected hospitals than those treated in unaffected hospitals.11,1315 A possible explanation could be that patients with more severe injuries were taken to the closest local hospitals, and thus, had a lower chance of survival regardless. The establishment of a medical transport corridor is a high-priority task, especially during the first 26 hours after the onset. Often, most of the surviving polytrauma patients have been retrieved by this time. The retrieval rates of patients are highest within the first 24 hours after the onset. Therefore, a rapid establishment of outdoor medical camps for patient care and resuscitation is mandatory within a short period of time.5,1113,16 Evacuation to distant medical centers is a major key for success.8 Injury Patterns General Aspects Dealing with a high number of severely injured patients is challenging, regardless of the location and institution involved. Proper management of an individual victim necessitates adherence to the ABCs of emergency care (airway, breathing, and circulation).17 Airways must be secured and hemodynamics stabilized with the primary survey. Once this is achieved, the next goal is to maintain patient stabilization and establish safe patient transport. There is little time for comprehensive and secondary diagnostics. The performance of secondary surveys is time consuming. On the one hand, the subsequent loss of time can present a challenge to patient management; on the other hand, handing over a patient without adequate diagnosis is not gratifying. Moreover, special conditions call for modifications of typical practice patterns. Skull and Brain Injuries The primary focus in the management of casualties with traumatic skull and/or brain injuries is to minimize the potential for secondary brain injury.18,19 Survival rates of patients with traumatic brain injury in these settings are very poor. Many patients are dead on retrieval or expire during transport due to associated injuries.20 At the scene, the identification of patients with brain injuries and high chances of survival are decisive for aggressive treatment of their already compromised nervous systems. Another key point is the observation and maintenance of a high index of
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Points Age (in years) >30 3050 >50 Shock Systolic blood pressure >90mmHg Transient hypotension Persistent hypotension Limb Ischemia* Pulse reduced or absent, perfusion normal Pulseless; diminished capillary refill, paraesthesias Cool, paralyzed, numb, no sensation Tissue Injury Low-energy (simple fracture, stab wounds) Medium-energy (open or chain fractures, dislocation) High-energy (crush injury) Very high-energy (high contamination and extensive 1 2 3 4 1 2 3 0 1 2 0 1 2

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Table 4Mangled Extremity Severity Score (MESS) *double the score if ischemia duration >6 hours A score of 6 or less is associated with 100% limb salvage rate. A score of 7 or more is associated with 100% amputation rate. (modified after Johansen K, et al J Trauma 1990;30:568)
suspicion in patients with spinal cord injury. Rapid referral to unaffected hospitals with trauma specialists, neurosurgical units, and an intensive care facility should be prompted. Unfortunately, this rarely is achievable, even in developed countries, as time in most cases outruns such efforts.20 Spine, Pelvis, and Extremity Injuries The first step in spine, pelvis, and extremity injuries is proper immobilization of the affected region, thereby establishing and maintaining a secure airway. Large-bore intravenous access is required for quick hemodynamic stabilization.3,21 Spinal injuries in the cervical segment are clinically significant. Therefore, maintenance of cervical alignment at the scene using a cervical collar and a spine board, is crucial for a positive outcome.21,22 Rapid referral to a multidisciplinary medical care facility determines the outcome,23 though it should be kept in mind that complete spinal injuries are essentially untreatable under such settings, a fact to be considered while categorizing the triage level of affected victims.
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Pelvic fractures under disaster settings are a formidable challenge. In most cases, retrieved victims are already dead due to exsanguination. Furthermore, pelvic fractures frequently are accompanied by other severe injuries such as blunt chest trauma or skull and/or brain injury, which can be responsible for the high overall mortality.24 Emergency procedures at the scene must aim to check hemorrhage through stabilization of the fracture site by reducing pelvic diameter via application of anti-shock trousers or external fixation using a pelvic clamp.25 Crush laparotomy, packing, or aortic cross-clamping is futile in such settings. If the necessary equipment, like trousers or external fixation material, is not available, an improvised taping technique can be used for rigid fixation of the torso and pelvis after primary stabilization. Thereafter, transport to the secondary treatment area can be attempted. Despite emergency measures, the mortality associated with pelvic fractures remains high, a feature also present in non-catastrophic settings, indicating that management of pelvic fractures remains a major challenge in trauma care.25 Fractures of extremities can be managed by splinting after securing the ABCs. In a penetrating injury, bleeding control and hemodynamic stabilization must be established.26 If possible, tetanus prophylaxis and intravenous antibiotics can be administered in the secondary resuscitation phase. High suspicion for compartment syndrome often is warranted, especially in bone fractures induced by penetrating trauma. In cases of compartment syndrome and mangling extremity injury (Table 4), crush syndrome must be anticipated and treated, sometimes requiring amputation in order to prevent further systemic deterioration.27 In extremities with compartment syndrome, fasciotomy reduces pain, ischemia, and further necrosis of muscle tissue.2830 Injuries of the Thorax Injuries to the thorax in earthquake settings present a major challenge to the emergency medical staff, as the injured must be retrieved from beneath collapsed rubble such as buildings, pipelines, machinery, or heavy furniture. Approximately 10% of the casualties of a severe earthquake are expected to have thorax and lung injuries.31 Treatment of blunt chest trauma in these settings is frustrating as it would be relatively simple under more stable conditions; however, timely access to the victims often is denied due to inaccessibility, leading to high mortality in these patients. Due to the delay in retrieval, quick triage and referral to an unaffected hospital are essential to ensure a greater chance of survival.32 Airway control and cervical spine immobilization must be safeguarded in all patients who have sustained blunt chest trauma.33 The placement of a tube thoracostomy (TT) is essential, as 8090% of thoracic trauma patients can be managed this way and most injuries are minimized by proper attention to the ABCs of trauma resuscitation.32,33 Alternatively, a needle thoracostomy (NT) can be performed for a temporary decompression of tension pneumothorax. While there is a risk of both procedures being done without proper indication, TT and NT may improve outcomes in a small subset of patients with chest injuries.
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Sternal fractures should raise suspicion of associated myocardial trauma, great vessel injury, pulmonary contusions, and/or vertebral injury. Medical and transport procedures must consider these injuries.34,35 Immediate recognition of simple, hemo- or tension-pneumothorax is warranted, so that pleural drainage is installed on-scene, thus avoiding ventilatory deterioration prior to transport. People injured in a supine position are prone to Perthes syndrome requiring mechanical ventilation and intensive care unit (ICU) monitoring in order to help prevent progression into acute respiratory distress syndrome. The Perthes syndrome is attributed to acute compression in the predominantly valveless veins of the upper half of the body. Symptoms of severe thoracic pressure congestion include cervicofacial cyanosis in combination with characteristic skin alterations, petechial bleeding, and persistent subconjunctival hemorrhage. The prognosis of such patients is poor because of the scarcely available ICU facilities.32 Isolated lung contusions rarely are detected and such cases tend to resolve without sequelae.34 Injuries of the heart and major lacerations of the great vessels rarely are seen. Due to the breakdown of transport infrastructure and retrieval delays, patients with such deep or penetrating chest injuries are unlikely to survive. Contusio cordis is the most cited injury, requiring ECG-monitoring due to the associated risk of cardiac of cardiac dysrhythmia.35 Burn and Inhalation Injuries The key focus in the treatment of burn injuries is aggressive fluid resuscitation.36 The required fluid amounts can be estimated with the help of various formulae (Parkland, Muir-Barclay, etc.). The time of injury, not the time of presentation, is crucial for fluid administration rate. In cases in which fluid administration is erroneously calculated by time, patients can remain hypovolemic at presentation, which can have fatal consequences.37 Burn injuries in earthquake settings represent a special challenge, as they frequently occur in patients who already have severe accompanying injuries such as chest trauma and pelvic fractures. Initial assessment of burn type (thermal, electrical, or chemical), approximate extent, depth, and associated injuries should guide early resuscitation.38 As with every trauma patient, the ABCs must be established under consideration of complications associated with burn injuries. Due to heat generation, soot particles, and inhalation of combustive gas products, airway burns and inhalation injury are suspected. This is true especially if hoarseness, stridor, and/or facial burn signs such as perioral or oral edema, singed nasal hair, or facial burns are present. In such patients, early intubation is advisable because further delay could lead to complete airway obstruction. Rapid mucosal swelling occurs within hours and can result in the inability to intubate, thus, necessitating a surgical airway approach. High energy or prolonged contact with an electrical source may raise suspicion of extensive deep tissue damage, which can lead to rhabdomyolysis. Severe edema of muscles may produce compartment syndrome requiring fasciotomy.37 More people die in a fire from pulmonary insufficiency caused by the inhalation of heat and

smoke than they do from the direct burn injury, thus airway management is a priority. Abdominal Injuries Blunt trauma raises the possibility for spleen, liver, or kidney lesions, which primarily are managed by cardiopulmonary stabilization and monitoring. Unfortunately, patients with exsanguinating intra-abdominal hemorrhage have a very low chance of being retrieved alive. The extent of injuries frequently is larger than expected, due to the various mechanisms of blunt abdominal trauma (e.g., direct hit, acceleration-deceleration, or shearing forces). Close clinical monitoring is important in order to detect developing peritonism, hypovolemic shock, or signs of ileus so that an early referral for exploratory laparotomy can occur.39,40 Special attention must be given to early recognition of, and suspicion for, ruptured hollow viscus, bladder rupture, and traumatic hernia of the diaphragm, as these injuries occur more frequently in earthquake settings.3,6,39 Peritonism, fever, ileus, and ability to void must raise suspicion to hollow viscus or bladder rupture, especially in association with pelvic fractures. To diagnose a diaphragmatic rupture at the scene is almost impossible, though theoretically dyspnea, referred pain to the shoulders, and intrathoracic bowel sounds can be indicators. If suspected, special attention must be given while introducing a tube thoracostomy in order to avoid perforation of displaced abdominal organs.3,40,41 Key attention should be given to hemodynamic stabilization and transport to a secondary treatment area in order to minimize fatal under treatment through frequent clinical monitoring.39,40,41 Kidney and Crush Injuries Ninety to 95% of traumatic urogenital injuries are of limited severity and can be treated by conservative measures. After primary survey and clinical investigation for urinary tract injury, Foley catheter placement can be useful as the follow-up may disclose evolving signs of injury (e.g., hematuria, anuria).4244 However, catheter placement should be avoided if there is blood at the urethral meatus, indicating a possible tear of the urethra. In contrast, management of the crush syndrome requires rapid assessment, and the initiation of therapy at the scene.45 Due to the previously mentioned difficulty in obtaining access to buried victims, the damage progresses rapidly.4 Further deterioration occurs through reperfusion of liberated, crushed extremities leading to systemic effects, i.e., multi-organ damage and capillary-leak syndrome.46 Post-Traumatic Stress Disorder In the past, post-traumatic stress disorder (PTSD) has been underscored or even ignored, especially in calamitous settings.47 Recent studies and increasing knowledge about PTSD have led to greater awareness and the implementation of diagnostic tools for early recognition. Every natural calamity and its circumstances exert psychological stress on the people affected. Concerns about future existence, the loss of family members, loss of property, and disability due to injury, together with fear, neglect, and helplessness can disrupt mental equilibrium.

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Several diagnostic tools such as the DSM-IV and DSM-III-R criteria, the World Health Organization Life Assessment scales, or the SPAN-scale are useful in identifying prone individuals.48,49 Cardinal features of PTSD are emotional numbing and avoidancethe early numbing being especially predictive for later PTSD.50,51 Co-morbidity with affective or anxiety disorders is extensive. Individuals require rapid recognition in order to prevent further functional impairment. Early mental health intervention is essential in order to detect and subsequently address early signs of disturbance so as to prevent the progression of more chronic mental health issues.48,52 Conclusions In order to minimize trauma-related mortality after an earthquake, knowledge about local medical facilities and equipment is essential. Additionally, the regional and geographical obstacles and the extent of impairment of local
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sanitary and transport infrastructure must be included in triage and treatment planning. Triage goals must aim to optimize the use of limited medical resources in order to provide medical care to as many survivors as possible. Consideration of typical injury patterns helps establish diagnosis and predict treatment requirements at the scene with the goal of stabilizing the patients for transport and referral to the next available, appropriate medical facility. To enable safe and fast patient transport, the establishment of transport evacuation corridors is essential in order to provide the multiple-injured victims a better chance of survival. Simple diagnostic and therapeutic measures are sufficient to reduce mortality and under-triage during such mass casualty situations. Efficient retrieval and evacuation of victims require wellorganized rescue units trained in several disciplines. At the same time, information services should maintain a communication network in order to coordinate the combined efforts.
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45. Erek E, Sever MS, Serdengecti K, et al: An oview of morbidity and mortality in patients with acute renal failure due to crush syndrome: The Marmara earthquake experience. Nephrol Dial Transplant 2002;17:3340. 46. Rock P, Yao Z: Ischemia reperfusion injury, preconditioning and critical illness. Curr Opin Anaesthesiol 2002;15:139146. 47. Montazeri A, Baradaran H, Omidvari S, et al: Psychological distress among Bam earthquake survivors in Iran: A population-based study. BMC Public Health 2005;11:4. 48. Feeny NC, Zoellner LA, Fitzgibbons LA, et al: Exploring the roles of emotional numbing, depression and dissociation in PTSD. J Trauma Stress 2000;13:489498.

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