Improving Management of Limb Injuries in Disasters and Conflicts

Base excess is superior to creatinine in predicting haemodialysis: A multicenter study conducted Kahramanmaraş earthquake victims

PURPOSE

This study had two main goals: to determine which rhabdomyolysis patients need haemodialysis; and to highlight the significance of blood gas parameters, particularly base excess, as predictors of the need for haemodialysis.

METHOD

A total of 270 patients were included in this multicentre, retrospective study. Among the patients who were transferred in from the earthquake region and developed rhabdomyolysis, those with creatine kinase (CK) values >1000 U/L were included in our study. The need for renal replacement in these patients was determined via laboratory tests, urine output monitoring and clinical follow-up.

FINDINGS

A total of 270 patients were included in our study. Univariate and multivariate regression analyses of laboratory parameters were performed to identify predictors of HD treatment. According to the univariate regression analysis, BE, HCO3, creatinine, CK, lactate, alanine transaminase (ALT) and aspartate transaminase (AST) levels were found to be significantly associated with receiving HD treatment. According to multivariate regression analysis, only BE (p = 0.003) was found to be a significant predictor of HD treatment. ROC analysis revealed that the optimal cutoff value for BE was -2.6; at this value, the sensitivity and specificity of BE for predicting HD treatment were 89% and 77.1%, respectively (AUC: 0.912; 95% CI: 0.872-0.943; p < 0.001).

CONCLUSION

Base excess is an effective predictor of the need for haemodialysis in patients with crush-related injuries that cause rhabdomyolysis and in patients who develop acute renal failure due to elevated CK.

Assessing primary healthcare disaster preparedness: a study in Northern Italy

AIM

The aim of this paper is to outline the steps taken to develop an operational checklist to assess primary healthcare (PHC) all-hazards disaster preparedness. It then describes a study testing the applicability of the checklist.

BACKGROUND

A PHC approach is an essential foundation for health emergency and disaster risk management (H-EDRM) because it can prevent and mitigate risks prior to disasters and support an effective response and recovery, thereby contributing to communities' and countries' resilience across the continuum of the disaster cycle. This approach is in line with the H-EDRM framework, published by the World Health Organization (WHO) in 2019, which emphasizes a whole-of-health system approach in disaster management and highlights the importance of integrating PHC into countries' H-EDRM. Nevertheless, literature focusing on how to practically integrate PHC into disaster management, both at the facility and at the policy level, is in its infancy. As of yet, there is no standardized, validated way to assess the specific characteristics that render PHC prepared for disasters nor a method to evaluate its role in H-EDRM.

METHODS

The checklist was developed through an iterative process that leveraged academic literature and expert consultations at different stages of the elaboration process. It was then used to assess primary care facilities in a province in Italy.

FINDINGS

The checklist offers a practical instrument for assessing and enhancing PHC disaster preparedness and for improving planning, coordination, and funding allocation. The study identified three critical areas for improvement in the province's PHC disaster preparedness. First, primary care teams should be more interdisciplinary. Second, primary care services should be more thoroughly integrated into the broader health system. Third, there is a notable lack of awareness of H-EDRM principles among PHC professionals. In the future, the checklist can be elaborated into a weighted tool to be more broadly applicable.

Influence of systemic inflammatory indices on hospital stay and dialysis post-earthquake: A clinical study

Natural disasters pose significant challenges to medical response due to the surge of patients and emergent injuries. Amid such scenarios, where personnel for patient monitoring might be scarce, effective biomarkers are crucial for guiding treatment plans and predicting patient prognosis. We aimed to evaluate the correlation between systemic inflammatory indices and morbidity in earth-quake-induced crush injuries. Additionally, we assessed the potential of these indices as prognostic markers for adverse outcomes. We studied 140 patients with earthquake-related crush injuries (ECR) admitted between February and March 2023 and compared them to 200 healthy controls (CG) chosen using a simple random method. Using the complete blood count data upon admission, we computed and statistically compared indices including NLR (neutrophil lymphocyte ratio), PLR (platelet lymphocyte ratio), MLR (monocyte lymphocyte ratio), SII (systemic immune-inflammatory index), SIRI (systemic inflammatory response index), and PIV (pan-immune inflammation value). Regression analyses determined the prediction of hospitalization duration and dialysis necessity. PLR and MLR upon admission significantly predicted the length of hospital stay. MLR and SIRI were significant predictors for dialysis requirement, with Exp(B) values of 0.306 (p = 0.024) and 1.261 (p = 0.038), respectively. Systemic inflammatory indices can serve as valuable prognostic tools in disaster scenarios. Utilizing these indices can enhance patient management, effectively allocate resources, and potentially save lives in the aftermath of earthquakes.

The 2023 Turkey Earthquake: Management of 627 Pediatric Musculoskeletal Injuries in the First Month

(1) Background: On 6February 2023, two consecutive earthquakes hit Kahramanmaraş and surrounding ten cities, killing over 50,000 people. We aimed to reveal the treatment process of pediatric patients admitted to Adana City Hospital (ACH) in the first month after the earthquake. (2) Methods: Demographic data of the patients, time of presentation to the emergency department, injury locations, treatment procedures, and patient file information were recorded retrospectively and evaluated statistically. (3) Results: There were 1246 patients under the age of 18. A total of 560 patients were hospitalized in the orthopedic clinic; 42% were admitted in the first 24 h and 58% in the first three days. Of these children, 69 (12%) were referred, 52 (10%) were transferred to other departments within the hospital, and 421 (75.2%) were discharged in stable condition. The number of patients with large bone fractures was 77 (34 open fractures). Fasciotomy surgery was performed on 131 patients, 78 of whom had bilateral procedures. Of the 31 patients who underwent amputation, 17 (55%) were performed within the first 24 h and 28 (90%) within the first week. (4) Conclusions: Almost all injured children are admitted to the hospital during the first few days after an earthquake. The management of earthquake injuries in pediatric patients requires specialized care and immediate attention during the treatment process.

Crush syndrome: a review for prehospital providers and emergency clinicians

INTRODUCTION

Disasters and accidents have occurred with increasing frequency in recent years. Primary disasters have the potential to result in mass casualty events involving crush syndrome (CS) and other serious injuries. Prehospital providers and emergency clinicians stand on the front lines of these patients' evaluation and treatment. However, the bulk of our current knowledge, derived from historical data, has remained unchanged for over ten years. In addition, no evidence-based treatment has been established to date.

OBJECTIVE

This narrative review aims to provide a focused overview of, and update on, CS for both prehospital providers and emergency clinicians.

DISCUSSION

CS is a severe systemic manifestation of trauma and ischemia involving soft tissue, principally skeletal muscle, due to prolonged crushing of tissues. Among earthquake survivors, the reported incidence of CS is 2-15%, and mortality is reported to be up to 48%. Patients with CS can develop cardiac failure, kidney dysfunction, shock, systemic inflammation, and sepsis. In addition, late presentations include life-threatening systemic effects such as hypovolemic shock, hyperkalemia, metabolic acidosis, and disseminated intravascular coagulation. Immediately beginning treatment is the single most important factor in reducing the mortality of disaster-situation CS. In order to reduce complications from CS, early, aggressive resuscitation is recommended in prehospital settings, ideally even before extrication. However, in large-scale natural disasters, it is difficult to diagnose CS, and to reach and start treatments such as continuous administration of massive amounts of fluid, diuresis, and hemodialysis, on time. This may lead to delayed diagnosis of, and high on-site mortality from, CS. To overcome these challenges, new diagnostic and therapeutic modalities in the CS animal model have recently been advanced.

CONCLUSIONS

Patient outcomes can be optimized by ensuring that prehospital providers and emergency clinicians maintain a comprehensive understanding of CS. The field is poised to undergo significant advances in coming years, given recent developments in what is considered possible both technologically and surgically; this only serves to further emphasize the importance of the field, and the need for ongoing research.

The Ethical Triage and Management Guidelines of the Entrapped and Mangled Extremity in Resource Scarce Environments: A Systematic Literature Review

OBJECTIVE

A systematic literature review (SLR) was performed to elucidate the current triage and treatment of an entrapped or mangled extremity in resource scarce environments (RSEs).

METHODS

A lead researcher followed the search strategy following inclusion and exclusion criteria. A first reviewer (FR) was randomly assigned sources. One of the 2 lead researchers was the second reviewer (SR). Each determined the level of evidence (LOE) and quality of evidence (QE) from each source. Any differing opinions between the FR and SR were discussed between them, and if differing opinions remained, then a third reviewer (the other lead researcher) discussed the article until a consensus was reached. The final opinion of each article was entered for analysis.

RESULTS

Fifty-eight (58) articles were entered into the final study. There was 1 study determined to be LOE 1, 29 LOE 2, and 28 LOE 3, with 15 determined to achieve QE 1, 37 QE 2, and 6 QE 3.

CONCLUSION

This SLR showed that there is a lack of studies producing strong evidence to support the triage and treatment of the mangled extremity in RSE. Therefore, a Delphi process is suggested to adapt and modify current civilian and military triage and treatment guidelines to the RSE.