title: A matter of life or limb? A review of traumatic injury patterns and anesthesia techniques for disaster relief after major earthquakes.
abstract: BACKGROUND
  All modalities of anesthetic care, including conscious sedation, general, and regional anesthesia, have been used to manage earthquake survivors who require urgent surgical intervention during the acute phase of medical relief. Consequently, we felt that a review of epidemiologic data from major earthquakes in the context of urgent intraoperative management was warranted to optimize anesthesia disaster preparedness for future medical relief operations. The primary outcome measure of this study was to identify the predominant preoperative injury pattern (anatomic location and pathology) of survivors presenting for surgical care immediately after major earthquakes during the acute phase of medical relief (0-15 days after disaster). The injury pattern is of significant relevance because it closely relates to the anesthetic techniques available for patient management. We discuss our findings in the context of evidence-based strategies for anesthetic management during the acute phase of medical relief after major earthquakes and the associated obstacles of devastated medical infrastructure.
  
  
  METHODS
  To identify reports on acute medical care in the aftermath of natural disasters, a query was conducted using MEDLINE/PubMed, Embase, CINAHL, as well as an online search engine (Google Scholar). The search terms were "disaster" and "earthquake" in combination with "injury," "trauma," "surgery," "anesthesia," and "wounds." Our investigation focused only on studies of acute traumatic injury that specified surgical intervention among survivors in the acute phase of medical relief.
  
  
  RESULTS
  A total of 31 articles reporting on 15 major earthquakes (between 1980 and 2010) and the treatment of more than 33,410 patients met our specific inclusion criteria. The mean incidence of traumatic limb injury per major earthquake was 68.0%. The global incidence of traumatic limb injury was 54.3% (18,144/33,410 patients). The pooled estimate of the proportion of limb injuries was calculated to be 67.95%, with a 95% confidence interval of 62.32% to 73.58%.
  
  
  CONCLUSIONS
  Based on this analysis, early disaster surgical intervention will focus on surviving patients with limb injury. All anesthetic techniques have been safely used for medical relief. While regional anesthesia may be an intuitive choice based on these findings, in the context of collapsed medical infrastructure, provider experience may dictate the available anesthetic techniques for earthquake survivors requiring urgent surgery.
authors: From the Department of Anesthesiology, University of Miami-Miller School of Medicine, Miami, Florida.
authors: Andres
authors: A
authors: Missair
authors: Ernesto A
authors: EA
authors: Pretto
authors: Alexandru
authors: A
authors: Visan
authors: Laila
authors: L
authors: Lobo
authors: Frank
authors: F
authors: Paula
authors: Catalina
authors: C
authors: Castillo-Pedraza
authors: Lebron
authors: L
authors: Cooper
authors: Ralf E
authors: RE
authors: Gebhard
mesh_terms: D000758:Anesthesia / Q000379:methods* / Q000639:trends; D004189:Disaster Planning / Q000379:methods / Q000639:trends; D004190:Disasters; D055866:Earthquakes; D005121:Extremities / Q000293:injuries*; D006801:Humans; D012066:Relief Work
references: Ramirez M, Peek-Asa C. Epidemiology of traumatic injuries from earthquakes. Epidemiol Rev. 2005;27:47–55
references: Wood DP, Cowan ML. Crisis intervention following disasters: are we doing enough? (A second look). Am J Emerg Med. 1991;9:598–602
references: Schultz CH, Koenig KL, Noji EK. A medical disaster response to reduce immediate mortality after an earthquake. N Engl J Med. 1996;334:438–44
references: Bartels SA, VanRooyen MJ. Medical complications associated with earthquakes. Lancet. 2012;379:748–57
references: Naghii MR. Public health impact and medical consequences of earthquakes. Rev Panam Salud Publica. 2005;18:216–21
references: Sami F, Ali F, Zaidi SH, Rehman H, Ahmad T, Siddiqui MI. The October 2005 earthquake in Northern Pakistan: patterns of injuries in victims brought to the Emergency Relief Hospital, Doraha, Mansehra. Prehosp Disaster Med. 2009;24:535–9
references: Missair A, Gebhard R, Pierre E, Cooper L, Lubarsky D, Frohock J, Pretto EA Jr. Surgery under extreme conditions in the aftermath of the 2010 Haiti earthquake: the importance of regional anesthesia. Prehosp Disaster Med. 2010;25:487–93
references: Tan CM, Lee VJ, Chang GH, Ang HX, Seet B. Medical response to the 2009 Sumatra earthquake: health needs in the post-disaster period. Singapore Med J. 2012;53:99–103
references: Pang HN, Lim W, Chua WC, Seet B. Management of musculoskeletal injuries after the 2009 western Sumatra earthquake. J Orthop Surg (Hong Kong). 2011;19:3–7
references: Fan Z, Li A, Lian B, Zhou W, Wei H, Chen C, Xu P. Injury types of victims in the 12th May 2008 Wenchuan earthquake: analysis of 1,038 patients in Jiangyou City. Eur J Trauma Emerg Surg. 2010;37:3–7
references: Jiang J, Xu H, Liu H, Yuan H, Wang C, Ye J. Anaesthetic management under field conditions after the 12 May 2008 earthquake in Wenchuan, China. Injury. 2010;41:1–3
references: Li R, Wang H, Xiao J, Yang X, Guo L, Lu Q, Tang W, Long J, Liu L, Li X, Tian W. Maxillofacial injuries in the Wenchuan earthquake. J Trauma. 2010;69:1481–5
references: Qiu J, Liu GD, Wang SX, Zhang XZ, Zhang L, Li Y, Yuan DF, Yang ZH, Zhou JH. Analysis of injuries and treatment of 3,401 inpatients in 2008 Wenchuan earthquake–based on Chinese Trauma Databank. Chin J Traumatol. 2010;13:297–303
references: Zhao J, Shi Y, Hu Z, Li H. Sichuan earthquake and emergency relief care for children: report from the firstly arrived pediatricians in the epicenter zone. Pediatr Emerg Care. 2011;27:17–20
references: Xiang B, Cheng W, Liu J, Huang L, Li Y, Liu L. Triage of pediatric injuries after the 2008 Wen-Chuan earthquake in China. J Pediatr Surg. 2009;44:2273–7
references: Dewo P, Magetsari R, Busscher HJ, van Horn JR, Verkerke GJ. Treating natural disaster victims is dealing with shortages: an orthopaedics perspective. Technol Health Care. 2008;16:255–9
references: Mulvey JM, Qadri AA, Maqsood MA. Earthquake injuries and the use of ketamine for surgical procedures: the Kashmir experience. Anaesth Intensive Care. 2006;34:489–94
references: Mulvey JM, Awan SU, Qadri AA, Maqsood MA. Profile of injuries arising from the 2005 Kashmir earthquake: the first 72 h. Injury. 2008;39:554–60
references: Helminen M, Saarela E, Salmela J. Characterisation of patients treated at the Red Cross field hospital in Kashmir during the first three weeks of operation. Emerg Med J. 2006;23:654–6
references: Charuluxananan S, Bunburaphong P, Tuchinda L, Vorapaluk P, Kyokong O. Anesthesia for Indian Ocean tsunami-affected patients at a southern Thailand provincial hospital. Acta Anaesthesiol Scand. 2006;50:320–3
references: Ganjouei KA, Ekhlaspour L, Iranmanesh E, Poorian P, Sohbati S, Ganjooei NA, Rashid-Farokhi F, Karamuzian S. The pattern of injuries among the victims of the Bam earthquake. Iranian J Publ Health. 2008;37:70–6
references: Mohebbi HA, Mehrvarz S, Saghafinia M, Rezaei Y, Kashani SM, Naeeni SM, Motamedi MH, Hoseini SH, Moharamzad Y. Earthquake related injuries: Assessment of 854 victims of the 2003 Bam disaster transported to tertiary referral hospitals. Prehosp Disaster Med. 2008;23:510–5
references: Tahmasebi MN, Kiani K, Mazlouman SJ, Taheri A, Kamrani RS, Panjavi B, Harandi BA. Musculoskeletal injuries associated with earthquake. A report of injuries of Iran’s December 26, 2003 Bam earthquake casualties managed in tertiary referral centers. Injury. 2005;36:27–32
references: Emami MJ, Tavakoli AR, Alemzadeh H, Abdinejad F, Shahcheraghi G, Erfani MA, Mozafarian K, Solooki S, Rezazadeh S, Ensafdaran A, Nouraie H, Jaberi FM, Sharifian M. Strategies in evaluation and management of Bam earthquake victims. Prehosp Disaster Med. 2005;20:327–30
references: Roshchin GG, Mazurenko OV. Ukranian’s Disaster Medicine Team Mission to India following the earthquake of 2001. Prehosp Disaster Med. 2002;17:163–6
references: Roy N, Shah H, Patel V, Coughlin RR. The Gujarat earthquake (2001) experience in a seismically unprepared area: community hospital medical response. Prehosp Disaster Med. 2002;17:186–95
references: Roy N, Shah H, Patel V, Bagalkote H. Surgical and psychosocial outcomes in the rural injured–a follow-up study of the 2001 earthquake victims. Injury. 2005;36:927–34
references: Phalkey R, Reinhardt JD, Marx M. Injury epidemiology after the 2001 Gujarat earthquake in India: a retrospective analysis of injuries treated at a rural hospital in the Kutch district immediately after the disaster. Glob Health Action. 2011;4:7196
references: Bulut M, Fedakar R, Akkose S, Akgoz S, Ozguc H, Tokyay R. Medical experience of a university hospital in Turkey after the 1999 Marmara earthquake. Emerg Med J. 2005;22:494–8
references: Tanaka K. The Kobe earthquake: the system response. A disaster report from Japan. Eur J Emerg Med. 1996;3:263–9
references: Roces MC, White ME, Dayrit MM, Durkin ME. Risk factors for injuries due to the 1990 earthquake in Luzon, Philippines. Bull World Health Organ. 1992;70:509–14
references: Noji EK. The 1988 earthquake in Soviet Armenia: implications for earthquake preparedness. Disasters. 1989;13:255–62
references: De Bruycker M, Greco D, Lechat MF, Annino I, De Ruggiero N, Triassi M. The 1980 earthquake in Southern Italy–morbidity and mortality. Int J Epidemiol. 1985;14:113–7
references: Ortiz MR, Roman MR, Latorre AV, Soto JZ. Brief description of the effects on health of the earthquake of 3rd March 1985–Chile. Disasters. 1986;10:125–40
references: Sánchez-Carrillo CI. Morbidity following Mexico City’s 1985 earthquakes: clinical and epidemiologic findings from hospitals and emergency units. Public Health Rep. 1989;104:482–8
references: Shoaf KI, Sareen HR, Nguyen LH, Bourque LB. Injuries as a result of California earthquakes in the past decade. Disasters. 1998;22:218–35
references: Paix BR, Capps R, Neumeister G, Semple T. Anaesthesia in a disaster zone: A report on the experience of an Australian medical team in Banda Aceh following the ‘Boxing Day Tsunami’. Anaesth Intensive Care. 2005;33:629–34