Injuries after an earthquake

by Prof. Dr. Dr. Bernd Domres, Ruth Bücker, 2011/11/01

As already after the devastating earthquake in Haiti in January 2010, the experienced relief doctor Prof. Dr. Dr. Bernd Domres also participated in the first humedica mission after the heavy earthquake in Turkey. In an interview, the surgeon from Tübingen describes the typical injuries after an earthquake and which dangers they entail:

Bruises, bone fractures and contusions are comparably harmless injuries. Photo: humedica/Ruth Bücker

"The most frequent and mostly comparably harmless injuries after a heavy earthquake are bruises, abrasions and cuts caused by bursting glass panes and falling objects.

Also bone fractures and severe contusions are among the injuries that are typically caused during an earthquake, when people are buried below heavy objects or rubble of collapsing buildings.

More severe and acute earthquake injuries are the so-called compartment syndrome and the crush syndrome that frequently results from it. The most tragic event is the so-called sudden death on rescue.

Compartment syndrome

The term compartment is used to describe the space that contains muscles and blood vessels, nerves and lymphatics. In our lower legs, for example, there are four of these compartments that are formed by fascias (thin separating walls of connective tissue) and are attached to the bone.

After a heavy earthquake, the lives of thousands of persons lie in ruins. Photo: humedica/Ruth Bücker

In each of these compartments there usually is a pressure of 11 millimetres hg (mercury). Blood pressure in the small muscular vessels usually is 20 to 30 millimetres hg and is thus higher than the pressure within the compartment, as long as it is not exposed to excessive pressure.

If heavy objects or rubble e.g. of buildings that collapsed during an earthquake exercise high pressure on the buried person over a longer period of time, the muscle cell reacts by building up fluid in the cell itself and by accumulating fluid between the muscle fibres.

These fluid accumulations are referred to as oedema. The formation of an oedema results in an increasing volume within the compartment and therefore in rising pressure. If this pressure exceeds the pressure of the smaller surrounding vessels, the blood flow within the muscle vessels is interrupted, the muscle no longer is supplied with oxygen and as a consequence it dies.

Treatment of the compartment syndrome

When being faced with the imminent formation of a compartment syndrome, the first reaction is to implement a shock treatment and supply the patient's body by means of drip infusions. At the same time it is necessary to counteract over-acidification of the body (acidosis) and to prevent the body from reaching too high a content of potassium (hyperkalemia) in order to prevent cardiac arrest and organ failure.

Furthermore it is necessary to administer medications for strengthening the kidney function in order to intensify the urinary flow and hence promote natural blood purification.

In order to decrease the pressure that has built up and can result in the muscle dying off, a surgical splitting of the skin and the underlying fascias is implemented (fasciotomy). However, if the muscle tissue is already dead or damaged to an extent that a recovery is impossible, the dead tissue needs to be removed In the worst case the limb must be amputated in order to safe the patient's life.

Crush syndrome

Often, an existing compartment syndrome is accompanied by the so-called crush syndrome. If muscle tissue died due to exceeded pressure, protein contained in the muscle (myoglobin) is released from the dead muscle and from there finds its way to the kidneys.

If this is accompanied by shock, blood loss due to injuries and metabolic over-acidification, the kidney function fails, which is referred to as crush syndrome.

The term crush syndrome was coined by English scientists in 1941, who - after bomb attacks on London - conducted experiments with buried persons who had died after being rescued.

Treatment of the crush syndrome

The kidney failure caused by the proteins released from the dead muscle can be treated by means of a blood purification (dialysis). There are two dialysis procedures.

At the makeshift emergency department in Ercis patients are examined and, depending on how severe they are injured, they are transported to the surrounding hospitals. Photo: humedica/Ruth Bücker

In Germany, hemodialysis is the most common procedure implemented for blood purification. Through the artery, the blood is guided out of the body. By means of a device called dialyzer, toxic components are filtered out of the blood, which is no longer automatically purified by the kidneys. Then the purified blood is returned to the body once more through the patient's vein.

The second form of dialysis is called peritoneal dialysis. During this procedure, a dialysis solution is inserted into the patient's abdominal body cavity. The toxic components that can no longer be filtered out by the kidneys enter the abdominal cavity and the blood is purified there, instead of in the kidneys. Then the toxic components together with the dialysis solution are drained out of the patient's body. The disadvantage of this kind of dialysis is the large quantity of liquid needed, a quantity that mostly is not granted in disaster regions.

Death on rescue

Death on rescue is the term to describe a tragic phenomenon that cannot be counteracted by doctors. Death on rescue means that the buried persons, who has been lying below the rubble for several days, can at first be rescued happily and without apparent severe injuries, but that the rescue measures themselves have possibly caused further injuries that could not be avoided.

The reasons of the tragic and sudden death on rescue. Illustration: humedica/Bernd Domres

The severity of the existing injury is intensified and the buried persons who has been rescued dies in the arms of his rescuer within only a few minutes.

This sudden death is caused by several factors. The person buried under the rubble suffers from enormous stress and the stress hormones adrenaline and cortisone are released. In combination with prior loss of blood and the existing shock, they merely ensure that the central blood circulation is maintained and that vital organs receive just enough blood to maintain their function.

If the buried person is rescued and freed of the pressure and loads, all the blood - which is low in supply anyway - immediately enters the skin, muscles and all organs again. Now, however, the blood volume is no longer large enough to supply all vital organs and sudden death occurs as a consequence of cardiac arrest.

Then there is the fact that, due to the removal of the pressure on the body, the venous backflow from the compartments is released and acid metabolic products, potassium and muscle protein released from dead tissue (myoglobin) find their way into the bloodstream, which can also cause a heart failure.

Please continue to support our relief measures in Turkey also in future by means of a targeted donation. These measures will not end after first medical aid. Thank you very much.

      humedica e.V.
      Donation reference “Earthquake Relief Turkey”
      Account 47 47
      Bank Code 734 500 00
      Sparkasse Kaufbeuren

You can achieve great things by means of a little text message: send the reference DOC to 8 11 90 and you will make a donation of 5 euros, with 4.83 euros of this amount being directly channelled into the humedica disaster relief projects.

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