Earthquakes Earthquakes are one of the most sudden and destructive natural disasters that can hit society.

Earthquakes cause a large number of deaths and many casualties. At least 1.3 million deaths occurred during the previous century from earthquakes. On average 16 earthquakes resulting in significant loss of life occur every year. What is an earthquake? An earthquake is a sudden tremor or movement of the earths crust. his sudden movement produces vibrations or seismic !aves that radiate out!ard from the focus of the quake. "urface !aves that travel along the earth#s crust have the strongest vibrations and thus produce the greatest damage. Earthquakes tend to recur along fault lines but may also occur in the middle of a plate. Measurement Scales: he intensity of an earthquake is based on the magnitude of the vibrations produced. "eismographs are used to measure these vibrations$ !hose increasing !ave amplitude is associated !ith a stronger earthquake. here e%ist various scales to e%press the magnitude or #si&e# of an earthquake. he 'ichter scale is the one most commonly used to further qualify the strength of an earthquake. he 'ichter "cale is a logarithmic measure calculated from amplitudes of seismic !aves$ e%tending from ( 1 to ). * An earthquake of amplitude 3 on the 'ichter "cale corresponds to a tremor felt over a limited
area * Amplitude +(, can cause light destruction. All tremors measuring + - , or over are internationally recorded. * Amplitude ,(6 causes considerable destruction * Amplitudes . to ) cause very great destruction. Earthquakes over a magnitude ../ have the

potential to cause thousands of deaths and significant structural damage. he largest earthquakes in historic times have been of magnitude slightly over 0$ although there is no limit to the possible magnitude. he most recent large earthquake of magnitude 0./ or larger !as a 0./ magnitude earthquake in 1apan in 2/11 3as of 4arch 2/115$ and it !as the largest 1apanese earthquake since records began. he largest earthquakes that have been recorded under this system are 0.2, 3Alaska$ 10605 and 0., 36hile$ 106/5. he catastrophe can cause thousands of dead and in7ured !ithin a fe! minutes. he emergency creates immediate medical and surgical needs at the site of impact *

the epicentre*!hile ne! health(related needs may arise in the areas to !hich the stricken population has moved for safety.
Effects of earthquakes he effects of earthquakes include$ but are not limited to$ the follo!ing8 "haking and ground rupture are the main effects created by earthquakes$ principally resulting in more or less severe damage to buildings and other rigid structures. he severity of the local effects depends on the comple% combination of the earthquake magnitude$ the distance from the epicenter$ and the local geological and geomorphological conditions$ !hich may amplify or reduce !ave propagation. 9ires. Earthquakes can cause fires by damaging electrical po!er or gas lines. :n the event of !ater mains rupturing and a loss of pressure$ it may also become difficult to stop the spread of a fire once it has started. 9or e%ample$ more deaths in the 10/6 "an 9rancisco earthquake !ere caused by fire than by the earthquake itself. 1

sunami. ;arge !aves produced by an earthquake or a submarine landslide can overrun nearby coastal areas in a matter of minutes. sunamis can also travel thousands of kilometers across open ocean and !reak destruction on far shores hours after the earthquake that generated them. 9loods. A flood is an overflo! of any amount of !ater that reaches land. 9loods may be secondary effects of earthquakes$ if dams are damaged. Earthquakes may cause landslips to dam rivers$ !hich collapse and cause floods. <uman impacts. An earthquake may cause in7ury and loss of life$ road and bridge damage$ general property damage$ and collapse or destabili&ation 3potentially leading to future collapse5 of buildings. he aftermath may bring disease$ lack of basic necessities$ and higher insurance premiums. ':"= 9A6 O'" 9O' :>1?'@ Around movement during an earthquake is seldom the direct cause of death or in7ury. 4ost in7uries result from collapsing structures$ falling masonry$ flying glass$ and falling ob7ects$ or !hen people attempt to move during a quake. he most common causes of in7ury and death may vary depending on its intensity or magnitude$ the season$ the time of the day it occurs$ and the population of the area involved. "tructural failure of a building is generally recogni&ed as the most common cause of death in large earthquakes. he proportions of deaths and of trapped victims significantly rise according to the number of floors in a building. he ground floor being relatively the least risky 3)(, per cent trapped$ 3 per cent dead5$ !ith the proportion increasing to 32 .5 per cent and 12 .3 per cent respectively from the third floor up. here is generally a higher risk of fatal in7ury associated !ith multilevel commercial and residential buildings$ though this is dependent on the construction of the building. he time of the impact is significant8 !hen the earthquake occurs at night$ !ith the population lying in bed$ the fractures involve particularly the pelvis$ the thora% and the spine. Bhen it occurs during the day$ there !ill be more head in7uries and limb fractures. 9ractures of the clavicle are a common feature. "uch forekno!ledge is very useful in mobili&ing the right kind of material and personnel. Earthquake lethality can be magnified by promulgation of secondary disasters. Around vibrations can collapse buildings and bridges$ disrupt gas and electric service$ and trigger landslides$ avalanches$ flash floods$ fires$ and sometimes huge tsunamis. sunamis are a particular risk !hen earthquakes occur near or beneath the ocean floor. :mmense !aves that may reach greater than 1, meters in height and travel at speeds greater than 06/ kilometers per hour can be generated. hese !aves may cause significant damage and loss of life in communities near the ocean. 6are should also be taken to avoid in7uries from aftershocks. hese are smaller quakes that follo! the main seismic event and may cause collapse of previously !eakened or damaged structures. Aftershocks may occur !ithin minutes to !eeks after the main earthquake. 4otor vehicle accidents are also a source of earthquake(related in7ury and death. C:"A" E' 4A>AAE4E> 1. D'EEE> :O> O9 :>1?':E" he best method of in7ury prevention during an earthquake is adequate !arning. ?nfortunately$ earthquakes are not predictable in their magnitude or time of occurrence. his places a premium on preventative strategies to limit loss of life and damage to property. he

first line of public protection is the institution of building codes that ensure construction !ill !ithstand potential earthquake strengths e%pected for the region. he local government$ emergency services$ and public utility companies should have disaster plans in place to mitigate fires$ gas e%plosions$ aftershocks$ and other secondary earthquake effects. ;ocal governments should ensure that the local population is educated through media campaigns to identify earthquake ha&ards !ithin the home. Curing the earthquake those !ho are in buildings constructed to !ithstand earthquakes should not attempt to move and should find cover under sturdy furniture for protection from falling ob7ects. hey should avoid going outside during the quake unless the building is in danger of collapse. Crivers of motor vehicles should make their best attempt to come to a safe stop during the earthquake and remain in their cars !ith seatbelts fastened. hey should not attempt to drive until all ground vibrations have subsided and should proceed cautiously$ avoiding damaged road$ ramp$ and bridge structures. After the earthquake has abated$ people should survey their surroundings for signs of potential danger. Deople should leave buildings in danger of collapse. Aas or other utilities should not be used since there may be damage to lines resulting in increased risk of fire and e%plosion. Fuildings that appear structurally unsound or are partially collapsed should not be entered because subsequent aftershocks might cause their collapse. 2. :> 6A"E O9 EARTHQUAKE he acute and immediate problems are rescue$ triage$ evacuation and medical care. <E E99E6 O9 EARTHQUAKES ON HOSPITALS AND OTHER PHYSICAL FACILITIES <ospitals and clinics are particularly vulnerable to tremors $ as they tend to be

multistory buildings. Even if the principal buildings remain more or less intact$ the vital facilities and equipment*electrical installations$ G(rays$ intensive care service lines$ surgical theatres$ laboratory glass!are and chemicals all tend to become unusable$ and this at a time !hen they are most needed.
<O"D: A; AC4:"":O>" Bith the great numbers of casualties it is evident that there !ill be a large and sudden rush on the out(patient and in(patient facilities$ assuming that the hospital has escaped damage. he peak in deaths and in7uries occurs during the 2+(hour period after an earthquake$ !ith the highest number of fatalities recorded !ithin minutes after the quake. <ospitali&ation for nonfatal in7uries also peaks on the day of an earthquake$ but may also have subsequent peaks depending on the presence of secondary disasters and the strength of aftershocks. :t is$ significant that$ once the initial rush is over$ hospital admission patterns revert to normal as early as the +th(,th day after the earthquake. his has important implications on decision making . <E C:"EA"E D'O9:;E FOLLOWING EARTHQUAKES he number of dead can be enormousH among those !ho survive$ in7uries are the most prevalent 3fractures$ contusions$ cuts$ crush syndrome5 and there is some momentary panic. he immediate response$ therefore$ calls for more surgeons than internists*orthopaedic surgeons in particular* for anaesthetists$ intensive care 3

and resuscitation teams$ stretchers and stretcher(bearers$ for splints$ traction apparatus and bandages. Also needed$ are teams to dispose of the large numbers of dead. here is quite a strong correlation bet!een the number of dead and the number of in7ured survivors. he ratio is 3 in7ured to 1 dead. his has important implications in emergency planning and calculating the casualty load from the number of deaths. 9rom these numbers one can deduce the kind and volume of emergency supplies that !ill be needed$ the amount of orthopaedic and other medical help required$ and the speed of treatment facilities that must be made available.
:>1?':E" :n7uries during earthquakes are primarily from blunt trauma. Among fatalities$ the head !as the most commonly in7ured body region$ follo!ed by thoracic$ abdominal$ and lo!er e%tremity in7uries. he most common causes of death !ere asphy%ia and body compression from building collapse. Orthopedic in7uries !ere the most common cause of hospitali&ation. 'E"6?E A>C :44EC:A E 6A'E :mmediate rescue and care are of paramount importance$ and it is !orth noting

that any help coming from outside the area almost invariably arrives too late. :n e%tricating the trapped and the in7ured$ the first helpers come to a large e%tent 30/ per cent5 from the same village$ and from the inhabitants of the same building 3.6 2 per cent5. E%tricating !ith unsophisticated means$ such as hands$ shovel$ a%e$ ladder$ accounts for the largest number rescued 306 ) per cent5 as opposed to the use of sophisticated means$ such as tractors or cranes 33(2 per cent5.
E4E'AE>6@ CEDA' 4E> 'EA 4E> As previously described$ most in7uries and fatalities occur !ithin the first 2+ hours after the initial shock. "ince the occurrence of earthquakes is unpredictable$ it is important to have a previously prepared and rehearsed disaster plan that can be rapidly activated. An emergency department should be prepared to treat an anticipated post(event surge in multi(trauma patients. :n situations !here local resources are over!helmed$ all efforts should be made to stabili&e critical patients and e%peditiously transfer stabili&ed individuals to other medical facilities outside the disaster &one. :n situations !here the patient surge completely over!helms the emergency department$ it may be necessary to implement a mass casualty triage approach to ma%imi&e the number of lives saved. :t is also important to ensure that the hospitals and emergency rooms are structurally sound and in no potential danger from secondary earthquake effects. CE;A@EC <EA; < E99E6 " he actual emergency phase after impact is remarkably short *3 to , days. :ndeed almost all the in7uries 30. per cent5 occur immediately or !ithin half an hour of the quake$ and very rapidly hospital admissions resume the pre(impact pattern.

Among the survivors$ ho!ever$ mass population displacements$ cro!ding in improvi&ed shelters$ environmental upheavals$ breakdo!n of garbage disposal and bursting of se!ers$ shortage of !ater and temperature e%tremes may create health ha&ards and lead to outbreaks of infectious diseases. he risk is real and appropriate countermeasures must be taken. <o!ever$ field observations and statistics sho! that such risks and the danger of epidemics are e%tremely rare and such popular but unproven measures as mass vaccination are quite unnecessary. :ndeed they can be counterproductive by diverting much needed help and material a!ay from more urgent tasks. "ensible sanitary measures and hygienic practices !ill do more to obviate any epidemic. Earthquakes are becoming increasingly devastating$ not because they are particularly more frequent but mainly because of the increasing concentration of large populations*as illustrated by the 10), catastrophe !hich hit 4e%ico 6ity !hich has 1) million inhabitants.

his calls for government legislation and disaster planning$ at least in the countries kno!n to be on or along seismic faults. he health system must be properly evaluated in the light of possible risks$ basic as !ell as speciali&ed teams must be trained and facilities made available$ hospitals 3and other buildings5 must be tremor(resistant and built according to risk &ones$ and the population trained and made a!are of the land it lives on. 9or$ !hen disaster strikes$ it is these same people !ho !ill have to take care of their dead and !ounded. Drimary health care and basic health education can do more than many e%perts arriving too late.
9ollo!ing a ma7or disaster$ information !ill be an important step in recovery efforts. One of the first things people should do is to tune to the emergency broadcast station on radio or television to listen for emergency bulletins and safety advisories. Preparedness he ob7ective of earthquake engineering is to foresee the impact of earthquakes on buildings and other structures and to design such structures to minimi&e the risk of damage. E%isting structures can be modified by seismic retrofitting to improve their resistance to earthquakes. Emergency management strategies can be employed by a government or organi&ation to mitigate risks and prepare for consequences. Earthquake warning systems have been developed that can provide regional notification of an earthquake in progress$ but before the ground surface has begun to move$ potentially allo!ing people !ithin the system#s range to seek shelter before the earthquake#s impact is felt. Summary Earthquakes may result in - disease$ - lack of basic necessities$

loss of life$ general property damage$ road and bridge damage$ and collapse of buildings or destabili&ation of the base of buildings !hich may lead to collapse in future earthquakes.

:n7ury(causing factors8 Fuilding collapse 3most in7uries and deaths result from this5 Other blunt trauma 9ires Aftershocks. 6ommon in7uries e%perienced during and after earthquakes8 6uts$ scrapes I lacerations 3torn or ragged !ounds5 Fone fractures 6ontusions 3bruises that do not break the skin5 6rush syndrome 3muscle in7ury and kidney failure5 :nfected !ounds Dulmonary complaints related to inhalation of dust Furns 6ommon health issues e%acerbated by the event8 disease 3e.g. asthma$ bronchitis$ emphysema5$ heart attacks 4ental health issues

chronic obstructive pulmonary

CR S! "#$ R%&CR S! S%#'R(ME Earthquakes and manmade disasters are the leading causes of crush in7uries and an increased incidence of crush syndrome. he estimated incidence are J2/K and J2L,K$ respectively. <o!ever$ given the global climate of !ar and acts of terrorism$ !e should anticipate a rise in manmade disasters in the future. Fy!aters and Feall offered the first classic description of crush syndrome in ;ondoners treated during the Aerman Flit& in 10+/L+1. Mhi(@ong described its devastation in one of history#s !orst natural catastrophes$ the 10.3 angshan earthquake in 6hina$ !here the death toll !as 2+2$.60 and the additional in7ured 16+$),1. he mechanism of in7ury is entrapment of victims under collapsed structures for periods of + hours or longer. :n crush(in7ured victims$ deaths !ithin the first hours are caused by shock and hyperkalemia$ !hile deaths days later are from myoglobinuric acute renal failure. he pathogenesis of all crush in7uries begins !ith rhabdomyolysis$ !hereby increased and prolonged pressure on skeletal muscle leads to cellular death and the release of its intracellular contents. Bhile generally resistant to ischemia$ muscle tissue is very sensitive to pressure. :t impairs the cellular >aN$=N(A Dase pump and calcium transport$ resulting in a rise in intracellular free calcium$ !hich in turn activates neutral proteases that disrupt myofibrils and leads to cellular damage and death. his cascade of events leads to the clinical features of myoglobinemia$ hyperphosphatemia$ hyperkalemia$ hyperuricemia$ hypocalcemia$ metabolic acidosis$ C:6$ and hypovolemic and hemodynamic shock$ the hallmark of crush syndrome. <yperkalemia !ith acute renal failure is the most immediate and life(threatening complication$ occurring hours to days after a patient#s e%trication. An o%ygen(binding heme protein found in skeletal and cardiac muscle$ myoglobin is rapidly cleared from plasma primarily through renal e%cretion. Bith massive muscle destruction$ the release of myoglobin surpasses its clearance$ resulting in the typical discoloration of pink spun plasma and reddish

bro!n urine. he urine dipstick !ill test positive as it reacts !ith the heme(containing myoglobin. o differentiate bet!een heme and myo( globin as opposed to hemoglobin$ a microscopic e%amination of the bro!n urine !ill reveal an absence of red blood cells. he direct renal to%ic effect of myoglobin and its secondary obstructive effects as it precipitates in the renal tubules play a critical role in the development of acute renal failure. An estimated ,/K of the crush(in7ured patients !ith severe rhabdomyolysis !ill develop acute renal failure secondary to myoglobinemia. :t is important to note that the degree of creatine phosphokinase elevation and the presence of myoglobinemia do not predict those !ho !ill go on to develop A'9. Other important factors include hypovolemia$ metabolic acidosis$ and age. Dresentation Datients !ith crush in7ury !ill typically present !ith flaccid paralysis and sensory loss in the affected limbs. Bhile they can appear like victims of spinal cord in7ury$ their deficits do not correspond to a nerve distribution. On neurologic e%amination$ their rectal tone and urinary( bladder function !ill also be preserved. :nitially$ e%tricated patients appear relatively !ell and !ithout systemic signs metabolic derangement. he compressive force that entrapped the limbs in effect acts as a tourniquet$ preventing systemic return of metabolic byproducts of cellular ischemia and necrosis. Bith rescue and decompression$ a parado%ical acceleration to shock and hemoconcentration may develop. his may account for reports of victims dying immediately after e%trication from collapsed structures. 4anagement Anticipating and preventing the systemic and renal complications of crush syndrome is essential. Aggressive fluid resuscitation should begin during patient rescue$ since a delay of 12 hours or more is associated !ith up to 1//K incidence of acute renal failure. A large(bore intravenous line should be established as soon as a free limb is available and normal saline infused at a rate of 1., liters per hour. :t is generally e%pected that + to ) hours are needed to fully free an entrapped victim and remove them to the medical treatment area. Dostponement of full e%trication has been suggested until adequate fluid resuscitation has been achieved. Bith stabili&ed blood pressure and urine flo!$ forced mannitol alkaline diuresis should be initiated to prevent hyperkalemia and acute renal failure. his therapy generally occurs in the medical facilities$ !here input and output are strictly monitored. Alkaline urine prevents the precipitation of myoglobin in the renal tubules !hile mannitol aids in the osmotic diuresis of myoglobin. he fluid of choice is C, /.,>"$ !ith each liter containing 1/ g of mannitol as a 2/K solution and +/ mmol of bicarbonate. he goal is to maintain a urine output of J3// mlOh and urine p< P6., until myoglobinuria resolves. his aggressive fluid management usually leads to a positive fluid balance of + liters per day. Bhile !ell tolerated in young adults$ this therapy must be tailored to the elderly. :f the patient becomes oliguric$ a bolus of 2/ g of mannitol along !ith 12/ mg of furosemide may be used. he theoretical disadvantage of urine acidification by loop diuretics is out!eighed by its benefits. :t is important to note that mannitol in e%cess of 2// gOd may produce acute renal failure and thus should be avoided. :f anuria and renal failure develops despite treatment$ daily hemodialysis must be instituted. 6O4DA' 4E> "@>C'O4E he mechanism of crush !ith entrapment is the ideal setting for compartment syndrome. :t is defined as elevated pressure !ithin a closed tissue space that impairs neurovascular function$ leading to tissue death. 6ompartment pressure can rise either from e%ternal compression or from internal volume e%pansion 3hematoma or third spaced fluid5. >ormal tissue pressure is usually less than 1/ mm <g. At 2/ mm <g$ capillary blood flo! diminishes. Above 3/L+/ mm <g$ tissue !ill be at risk for ischemic necrosis$ !ith nerve being more susceptible than muscle. "ince all skeletal muscle groups are invested in fascia$ compartment syndrome can

occur any!here in the body. he compartments most frequently involved by this syndrome are those in the forearm and the lo!er leg. he classic presentation of those !ith compartment syndrome !ill be muscle !eakness and pain that is out of proportion to their in7ury or e%amination. On inspection$ there might be s!elling$ ecchymosis$ and deformity suggesting an underlying fracture. On palpation of the muscle$ severe pain !ill be elicited. Active contraction or passive stretching of muscle !ithin the compartment !ill also !orsen the pain. <ypoesthesia in the distribution of the nerves that traverse the involved compartment can occur. Co not !ait for the classic description of pain$ pallor$ paresthesia$ pulselessness$ and paralysis 3the ,Ds5$ as they are late findings and suggest irreversible damage. o confirm the diagnosis$ compartment pressures must be measured. 6ontroversy e%ists regarding absolute criteria that mandates fasciotomy$ a surgical procedure that carries high morbidity of bleeding$ infection$ and loss of limb. Dressures that e%ceed +/ mm <g are generally accepted as indications for surgery. "ome authors recommend a trial of intravenous hypertonic mannitol first to decompress compartment pressures. Bhen effective$ relief of symptoms$ si&e of s!ollen limb$ and compartment pressures are e%pected !ithin appro%imately +/ minutes of treatment. "hould conservative management fail$ emergent fasciotomy is needed. his entails longitudinal incisions over the skin$ and then the fascia of the affected compartment to release the s!ollen and in7ured muscle. :n a disaster setting !here the crush victim might be neurologically impaired$ a high inde% of suspicion in needed. Early and multiple repeat compartment pressures might be needed to make the diagnosis. reatment initiated !ithin + hours of the onset of symptoms has an e%cellent prognosis to full recovery of function.