Disaster of the Century, 2023 Earthquake of Turkey: How Can We Prevent Amputation of Children
Authors: ALDAŞ Şefika , Ersoy Murat , Tosun Mehtap Durukan , Tunç Ali , Gökulu Gamze , Vatansever Esra , Aynacı Fatma Sercan , Katlan Banu , Ozdem Suna , Ozmen Berfin Ozgokçe , Şahin Şanlıay 
Published: January 2024

Objective
Large-scale, sudden-onset natural disasters occur unexpectedly, causing widespread destruction, resulting in injuries and deaths. It is extremely important to determine the clinical profile of vulnerable child victims admitted in emergencies and the characteristics that are associated with the hospital stay. Therefore, we aimed to analyze the experiences of children admitted to a tertiary hospital to improve future preparedness in case of a sudden disaster.
Methods
A total of 356 children who were referred from the pediatric emergency department (PED) were included in the study. All patients were subjected to medical history, vital signs, state of hydration, pulse oximetry, physical examination, and routine laboratory tests. Chest X-ray, abdominal ultrasound, and Computed tomography were also documented. Demographics and physical examination findings, duration of hospitalization, surgical interventions, concomitant complications, and presence of life-threatening conditions like crush syndrome and fasciotomy/amputation were investigated. Medications and additional treatments like hemodialysis, and hyperbaric oxygen and the outcomes were also recorded.
Results
Of the patients, 56.5% were male and median age was 132 months. There was no statistical significance regarding the effect of age and gender on parameters such as hypothermia, dehydration, soft tissue injury, fracture, crush, need for surgery, amputation, length of stay, and need for PICU. Injuries such as falling objects/slipping were more common in boys (P < 0.05). Of the children, only 11.2% were admitted in the first 24 hours and 44.7% were admitted on the third day. 11.8% (n:42) had signs of dehydration, 15.2% had hypothermia and 7% had hypotension/shock. Crush was noted in 41 dehydrated patients, 53 patients having hypothermia, and 24 patients with hypotension/shock. The average length of hospital stay was 6.7 days. The most common injury was being trapped under rubble with 80.3% and the most common injury site was lower extremities at 60.4%. Compartment syndrome developed in 31.7% of the patients, bone fractures were detected in 34.3% of the patients and 2.8% (n:10) of the patients were amputated. Crush syndrome was detected in 75.3% of the patients, and the incidence was higher in patients admitted on the second day or later and the requirement of fasciotomy increased. Elevated creatine phosphokinase (CPK), increased crush injury 61 times and fasciotomy by 16.8 times, Also, elevation of Myoglobin and Uric acid levels were higher in patients with crush injury (P = 0.005). Of patients with crush syndrome, 28.9% (n:103) required/underwent fasciotomy due to compartment syndrome, and a significant relationship was found between crush injury and the need for fasciotomy (P < 0.001). The likelihood of fasciotomy was 26 times higher in crush injury. There was a strong relationship between dehydration and the development of crush injury and the need for fasciotomy (P < 0.001). Anemia, elevated uric acid, BUN and Creatin, and AST/ALT levels and development of crush syndrome and the need for fasciotomy/amputation were higher (P < 0.001).
Conclusion
Dehydration, and hypotension/shock were related to crush injury and fasciotomy. Compartment syndrome and bone fractures may develop in one-third of the children. Anemia and elevated biochemical laboratory parameters must be followed and elevated CPK, myoglobin, and uric acid levels are highly associated with fasciotomy and amputation. Therefore, for the development of preparedness, response, and recovery policies for future disasters the clinical outcomes of children are crucial and treatments like fasciotomy, hyperbaric oxygen, and hemodialysis/plasmapheresis must be administered timely to prevent amputation and development of sequelae.