Specific Medical Problems

in Earthquakes

Lek.med.Ignacy Baumberg

1/. THE MAIN SOURCE OF CASUALTIES ARE COLLAPSED BUILDINGS

2/. MOST INJURIES AND FATALITIES ARE CAUSED BY THE ENERGY

TRANSMITTED TO THE BODY OF THE VICTIM AND EXCEEDING THE

VALUE THE BODY CAN WITHSTAND.

3/. MOST COMMON CAUSES OF DEATH ARE MULTIPLY INJURIES, DUST

ASPHYXIATION AND HEAD TRAUMA, DROWNING HAPPENS AS WELL

4/. THE RISK OF DEATH IN EARTHQUAKE IS HIGHER FOR THOSE

LIVING ON HIGHER FLOORS BEFORE COLLAPSE

5/. MOST DEATHS OCCUR IMMEDIATELY

6/. MORE THAN 80% OF LIVING CASUALTIES ARE RESCUED BEFORE 24

HOURS

7/. ENTRAPPED PEOPLE SURVIVED SEVERAL DAYS – TO STOP

SEARCHING IS A DIFFICULT DECISION

MAIN STATEMENTS

1/. CONFINED SPACE MEDICINE – AMERICAN

IDEA – NO CHANCE FOR „SCOOP AND RUN

PHILOSOPHY”

2/. A BIG ROLE OF TECHNICAL EQUIPMENT

A/. SEARCHING:

- SENSITIVE LISTENING DEVICES
- THERMAL IMAGING CAMERAS
- FIBEROPTIC CAMERAS
- SEARCHING DOGS

MEDICAL PROBLEMS IN

EARTHQUAKES- RESCUE

OPERATION

B/. SAFETY:

- HAZMAT DETECTING DEVICES
- LIGHTING EQUIPMENT
- PROTECTIVE GEAR
- VENTILATING DEVICES

C/. ACCESS TO THE CASUALTY

- POWERFUL HYDRAUILIC TOOLS

- POWERFUL PNEUMATIC TOOLS AND DEVICES

- ALL TERRAIN VEHICLES

- HEAVY LOAD LIFTING DEVICES

- POWERFUL STABILISATION SYSTEMS

MEDICAL PROBLEMS IN

EARTHQUAKES- RESCUE

OPERATION

3/. CONFINED SPACE ATMOSPHERE

- EXTREMAL TEMPERATURES
- LACK OF OXYGEN ( BELOW 19,5 % - A NEED FOR

SUPPLEMENTAL OXYGEN !)

- CARBON MONOXIDE PRESENCE – OXYGEN SUPPLY

RISK

- FLAMMABLE GASES PRESENCE – OXYGEN SUPPLY RISK
- DUST PLUS ABOVE – OXYGEN SUPPLY RISK
- NEED FOR INSULATING AIRWAYS FROM AMBIENT

ATMOSPHERE

MEDICAL PROBLEMS IN

EARTHQUAKES- RESCUE

OPERATION

4/. SAFETY ACCESS TO THE CASUALTY

-

MANY SURVIVORS ARE EXTRICATED BY

BYSTANDERS BEFORE ARRIVAL OF RESCUERS

-

ALL SAFETY PRECAUTIONS SHOULD BE FOLLOWED:

-

GLOVES

-

HELMETS

-

COVERALLS

-

GOGGLES

-

RESCUE FOOTWEARS

-

SEARCHLIGHTS

-

PERSONAL LOCATING DEVICES

-

LIFELINES

-

RADIO RECEIVERS

-

PUBLIC ADDRESS SYSTEMS

MEDICAL PROBLEMS IN

EARTHQUAKES- RESCUE

OPERATION

5/. CASUALTY ASSESSMENT
INITIAL:

-

BY VOICE CONTACT ONLY

-

BY USE OF FIBEROPTIC CAMERA

FIRST:

-

OFTEN LIMITED ACCESS

-

ALWAYS ABC

DEFINITE ASSESSMENT AND TREATMENT:

-

ABC

-

ANALGESIA

-

INJURY ASSESSMENT AND TREATMENT

-

PSYCHOLOGICAL SUPPORT ( LONG LASTING
EXTRICATION MAY HAPPEN…)

MEDICAL PROBLEMS IN

EARTHQUAKES- RESCUE

OPERATION

MEDICAL PROBLEMS IN

EARTHQUAKES- RESCUE

OPERATION

6/. MEDICAL PROBLEMS

-

CASUALTIES:

-

HYPOTHERMIA

-

DEHYDRATATION

-

BLOOD LOSS

-

VOMITING

-

ILEUS

-

URINATION

-

DEFECATION

-

CRUSH SYNDROME

-

DIABETES

-

ARRHYTMIA

7/. MEDICAL PROBLEMS –RESCUERS

- HYPERTHERMIA
- HEAT STROKE
- INJURIES
- PSYCHOLOGICAL STRESS
- DEHYDRATATION
- INFECTION

MEDICAL PROBLEMS IN

EARTHQUAKES- RESCUE

OPERATION

8/. CHOSEN PROBLEMS:

- PAIN CONTROL -

ANALGESIA IS A VERY IMPORTANT FACTOR

OF SURVIVAL – SHOULD BE ADMINISTERED AS SOON AS

POSSIBLE WITH APPROPRIATE DOSAGE, INTRAVENOUSLY FOR

BETTER CONTROL

- INFECTIONS –

CONTAMINATED WOUNDS AND AIRBORNE

PULMONARY INFECTIONS – DUST MASKS FOR EVERYBODY AND

ANTIBIOTICS

( CEPHALOSPORINS?) – THE EARLIER- THE BETTER

MEDICAL PROBLEMS IN

EARTHQUAKES- RESCUE

OPERATION

- AIRWAYS/VENTILATION

–

SOMETIMES NEED FOR ENDOTRACHEAL

INTUBATION – MUSCLE RELAXANTS TO BE USED – CAUTION FOR

INTRACRANIAL PRESSURE AND HYPERKALEMIA WHILE USING SCOLINE,

GOOD OPINION OF KETAMINE ANYWAY…

-

„TOMAHAWK APPROACH” – NOT EASY, BUT SOMETIMES THE ONLY

SOLUTION – WAS ANYBODY TRAINED ?

-

NASAL TRACHEAL INTUBATION

-

CRICOTHYROIDOTOMY

-

TRANSTRACHEAL JET INSUFFLATION

-

PORTABLE GAS POWERED VENTILATOR

-

CARBON DIOXIDE DETECTOR

-

PULSE OXIMETER

-

ARDS CONSIDERATION

MEDICAL PROBLEMS IN

EARTHQUAKES- RESCUE

OPERATION

BLAST INJURY

– LIKELY IN TERRORIST ATTACKS

AIR EMBOLISM, TYMPANIC RUPTURE, CARBON MONOXIDE INTOXICATION,

INTESTINAL PERFORATION, TENSION PNEUMOTHORAX, OCULAR INJURIES SPLENIC RUPTURE

, PNEUMOPERITONEUM - WORSE IN CONFINED SPACE

FLUID RESUSCITATION

– ESSENTIAL FOR MANY VICTIMS

TWO 14 G CANNULAS TO BE INSERTED INTO PERIPHERAL VEINS, CENTRAL ACCESS AND/OR

VENOUS

CUTDOWN ARE TOO DIFFICULT AND DANGEROUS FOR ENTRAPPED CASUALTY, BUT

SOMETIMES

NECESSARY…

IN CHILDREN – INTRAOSSEOUS ROUTE TO BE CONSIDERED.

IN CONFINED SPACES PRESSURE INFUSION DEVICES SHOULD BE USED

IN THE RISK OR CONFIRMED HYPOTHERMIA INTRAVENOUS FLUIDS MUST BE WARMED,

OTHERWISE

COULD BE HARMFUL .

BLADDER CATHETERISATION – SHOULD BE CAREFULLY CONSIDERED –

DIURESIS INFO VERSUS THE RISK OF KILLING UROSEPSIS….

MEDICAL PROBLEMS IN

EARTHQUAKES- RESCUE

OPERATION

-

CRUSH INJURY AND CRUSH SYNDROME – „SMILING DEATH”

AMONG VARIOUS ACCIDENTS EARTHQUAKES ARE ASSOCIATED WITH

HIGHEST INCIDENCE OF CRUSH INJURIES. THE SEVERITY OF SYMPTOMS AND

LIFE THREAT DEPEND ON THE AMOUNT OF INJURED MUSCLES. USUALLY THE

MUSCLES OF LOWER LIMBS ARE AFFECTED AND IN FACT THIS INJURY MEANS

TRAUMATIC RHABDOMYOLYSIS AND THE CONTENTS OF DESTROYED

MYOCYTES ARE RELEASED INTO THE BLOOD. POTASSIUM, PHOSPHORUS,

MYOGLOBIN, PROTEOLYTIC ENZYMES ARE AMONG SUBSTANCES THAT MAY

AFFECT THE BODY FUNCTION IF THEIR LEVEL RAISES SUDDENLY. AND IN

FACT, SYMPTOMS APPEAR JUST AFTER RELEASING THE PRESSURE APPLIED

TO THE LIMBS BY THE COLLAPSED ELEMENTS. THE CASUALTY FEELS NO

PAIN IN CRUSHED LIMBS ( THIS IS SIGNIFICANT SYMPTOM) AND IS HAPPY,

SMILING AT APPROACHING RESCUERS. WHILE THE PRESSURE IS RELEASED

TOXIC SUBSTANCES RUSH INTO THE BLOOD STREAM AND MAY CAUSE

SUDDEN DEATH BECAUSE OF VENTRICULAR FIBRILLATION OD ASYSTOLE…..

MEDICAL PROBLEMS IN

EARTHQUAKES- RESCUE

OPERATION

SEVERE HYPERPHOSPHATEMIA AND HYPOCALCEMIA MAY LEAD TO

MYOCARDIAL INSTABILITY. MYOGLOBIN DEPOSIT AND OBSTRUCTION IS A

MAIN FACTOR CAUSING RENAL INSUFFICIENCY, ALSO IRON CAUSES KIDNEY

DAMAGE. THIS ACTIVITY DEPENDS ON THE CONCENTRATION OF THE

SUBSTANCES AND THEREFORE MASSIVE FLUID TRANSFUSION IS

RECOMMENDED. WHILE DIRECTLY CRUSHED CELLS DIE IMMEDIATELY

HYPOVOLEMIA AND ISCHEMIA CAUSE THE MUSCLE CELLS DEATH WITHIN

HOURS. THIS CAUSE THE FLUX OF SUBSTANCES FROM THE CELLS OUTSIDE,

INCREASING TISSUE EDEMA, DECREASING BLOOD FLOW, CAUSING FURTHER

DAMAGE. THE AFFECTED LIMB LOOK NOT TOO BAD, LACK OF PAIN SUGGESTS

SPINAL CORD INJURY ( THE LACK OF „SADDLE ANESTHESIA” AND THE ANAL

SPHINCTER TONE SUGGEST CRUSH INJURY) AND THE PATIENT NEEDS THE

AGGRESIVE FLUID TREATMENT. BEFORE THE RELEASE FROM UNDER THE

PRESSURE APPROX 1500 ML OF NON-ACIDOTIC, CALCIUM FREE FLUID SHOULD

BE ADMINISTER INTRAVENOUSLY AS A BEGINNING OF MASSIVE INFUSION OF

FLUIDS – TO ACHIEVE DIURESIS OF SOME 12 LITERS / 24 HOURS. TO CONSIDER

FASCIOTOMY IS A HOSPITAL PROBLEM

MEDICAL PROBLEMS IN

EARTHQUAKES- RESCUE

OPERATION

MEDICAL PROBLEMS IN

EARTHQUAKES- RESCUE

OPERATION

FIELD AMPUTATION

„TO SAVE A LIFE NOT A LIMB” PHILOSOPHY SOMETIMES LEADS TO THE VERY
DIFFICULT DECISION AS TO THE FIELD AMPUTATION.
THE MAIN INDICATION IS THE EXTERNAL RISK : FURTHER COLLAPSE, FIRE,
HAZARDOUS MATERIALS.
MEDICAL INDICATIONS ARE LIMITED – THE TIME SAVING FOR INTERNAL
BLEEDING TREATMENT – (REASONABLE IN LATE PREGNANCY WITH
PLACENTAL ABNORMALITIES), TO BE DISCUSSED AND DECISION MADE
PREFERABLY BY TWO DOCTORS AND RESCUE TEAM SHARING THE OPINION,
THAT THIS IS THE ULTIMATE SOLUTION.
THE OPERATION IS COMPLICATED IN CONFINED SPACE, BLEEDING CONTROL
IS DIFFICULT AND THE RISK OF INFECTION AND SEPSIS IS VERY HIGH.
THE APPROPRIATE ANALGESIA/ANESTHESIA IS A PROBLEM AND FIRST
RESPONDING GROUPS USUALLY DO NOT HAVE APPROPRIATE INSTRUMENTS…
IN EXTREME SITUATIONS HYDRAULIC TOOLS FROM FIRE SERVICE MAY BE
USED

PSYCHOEMOTIONAL CONSIDERATIONS

FOR ENTRAPPED PERSON THE RESCUER MAY BE THE ONLY CONTACT WITH
EXTERNAL WORLD. THEREFORE THE EMPATHY AND UNDERSTANDING ARE
VERY IMPORTANT. HOWEVER RESCUERS ARE EXPOSED TO MANY STRESSING
FACTORS AND DEHYDRATATION, HUNGER AND OVERLOADING MAY
CONTRIBUTE TO DESTROY THE EMOTIONAL STABILITY.
ALL MEMBERS OF MEDICAL TEAM MUST UNDERSTAND THE NEED AND
IMPORTANCE OF STRESS DEBRIEFING AND DEFUSING

MAJOR EARTHQUAKES ARE DISASTERS THAT OFTEN

AFFECT

PUBLIC HEALTH INFRASTRUCTURE. BELOW ARE SOME
INDICATIONS AS TO THE BASIC REQUIREMENTS THAT

SHOULD

BE CONSIDERED WHILE PREPARING DISASTER RESPONSE

PLAN

FOR THOSE, WHO SURVIVED:

WATER: 15 L/ PERSON/DAY
MINIMUM: 3-6 L
WITH HYGIENE: 20 L
FEEDING CENTRES: 25 – 30 L
HEALTH CENTRES: 60 L
FIELD HOSPITALS: 150 – 310 L
FOOD: 1900 – 2000 KCAL/PERSON/DAY
MINIMUM: 1900 KCAL/PERSON/DAY
1500 TONS OF FOOD FEEDS 1 MILLION PEOPLE FOR 1 MONTH
GRAIN: 85%, VEGETABLE OIL: 3%, BEANS/PROTEIN: 12%

MEDICAL PROBLEMS IN

EARTHQUAKES - PUBLIC HEALTH

MEDICAL PROBLEMS IN

EARTHQUAKES - PUBLIC HEALTH

SHELTER:
MINIMUM LIVING CONDITIONS: 3,5 SQUARE METER FLOOR AREA PER

PERSON

MINIMUM OF WHOLE CAMP SETTLEMENT: 30 SQUARE METER PER

PERSON

TENTS: FAMILY, 6 PERSONS, FIRE RESISTANT, LOW COST
BLANKETS: 1/PERSON ( WOOL/COTTON)
PLASTIC SHEETING: 1/HOUSEHOLD
WATER CONTAINERS: 1/HOUSEHOLD ( 5 GALLONS)
COOKING POTS: 2/HOUSEHOLD ( WITH LIDS)
POT STIRRER: 1 / HOUSEHOLD
SOAP: 200 GR/PERSON/MONTH
MATCHES: CRITICAL ITEM
SANITATION- MINIMUM FOR PUBLIC: 1 LATRINE/50 PERSONS
OPTIMAL: 1 LATRINE/20 PERSONS, MIN 15-30 MTRS FROM WATER

SOURCE – DEPENDING ON SOIL

FUEL: 1 KG OF WOOD/PERSON/DAY, 5-10 KG/HOUSEHOLD/DAY

MEDICAL PROBLEMS IN

EARTHQUAKES - PUBLIC HEALTH

IF THE RESOURCES ARE BELOW THE REQUIREMENTS
LISTED ABOVE PUBLIC IS EXPOSED TO A RISING RATE
OF MORBIDITY AND MORTALITY CAUSED BY NON-
TRAUMA FACTORS.

ALTHOUGH PROBLEMS OF EVERYDAY EXISTENCE
AFTER THE EARTHQUAKE ARE NOT PURE
EMERGENCY/RESCUE ISSUES THEY SHOULD BE
DISCUSSED TOGETHER WITH EMERGENCY PLANS.

MULTIDISCIPLINARY APPROACH IS AN ESSENTIAL
PART OF THE EFFECTIVE EMERGENCY/RESCUE
PHILOSOPHY AND IN FACT EVERYBODY SHOULD BE
INVOLVED AS EVERYBODY COULD BE AFFECTED.