Introduction
On the 6th of February, 2023, known as one of the greatest disasters of the century, several series of massive earthquakes struck south-eastern Turkey including 11 provinces near the border with the Syrian Arab Republic. An earthquake of 7.7 magnitude struck and hundreds of aftershocks caused significant destruction at 04:17 local time with its epicenter located in the Pazarcık district in Kahramanmaraş province (Figure 1). Roughly 15 million people who lived in these areas and around 4.6 million children experienced the highest magnitude earthquake recorded and more than 13,000 aftershocks occurred, destroying hundreds of buildings, including schools. The earthquake devastated this area a week before the beginning of the second period of the school year, and consequently, all schools were closed for weeks in Turkey. Unfortunately, the victims suffered not only physical, but also significant psychological damage. With the addition of limb and organ losses to this situation, pain grew exponentially and it deeply affected the entire community.
According to Disaster and Emergency Management Presidency, more than 45,000 people were reported to have been killed across Turkey as of the 6th of March, more than 115,000 people were injured, and 9.1 million people were affected by the earthquakes (1). Although there is no certain data regarding children, exposure to earthquakes can cause serious health problems, especially in early childhood. The lack of personnel/death of staff during earthquakes and damage to medical infrastructure may lead to an increase in the loss of life and injuries caused by earthquakes. Unfortunately, the injuries presenting needed intensive curative medical and surgical care putting strain on both the local and regional medical services for all territories (2,3). As part of this need, physicians from all over Turkey were sent to the affected regions. Patients from the affected regions were also referred to various clinics outside of the affected regions. The purpose of this case series study was to describe the characteristics of the victims’ demographic features, injuries, and their clinical outcomes, for those cases who were referred from the earthquake zone to the Ege University Faculty of Medicine Children’s Hospital General Pediatric Clinic within the first week after the earthquakes. To the best of our knowledge, this article is one of the first to investigate in depth the medical support and harm/loss profiles of pediatrics victims who were provided with medical and psychological support during the posttraumatic period in the Kahramanmaraş/Turkey earthquake. This case study could contribute to the recovery policies, and so help in improving and developing preparedness for future disasters such as earthquakes.
Materials and Methods
Participants and Data Collection
After the Kahramanmaraş earthquake, in the early hours of the disaster, a contingency plan was immediately launched involving a rescue operation by national and international medical institutions. A number of injured people and children were transferred to other hospitals such as Ege University, Childrens’ Hospital in the first weeks after the earthquake due to the absence of medical equipment and support in the earthquake zone in the first days after the earthquake.
This study retrospectively investigated the clinical records of the admitted patients to the General Pediatric Ward from the earthquake area. The participants were evaluated as earthquake victims by using data between February and March, 2023 from Kahramanmaraş province and the southeastern Anatolia region of Turkey. The participants’ parents and family members provided various information related to their demographic and social data. In addition, detailed information from other hospitals about the management of medical relief work was also obtained via interviews with medical professionals and medical rescue teams. The clinical records of 9 pediatric earthquake victims, who were admitted to our ward based on their medical records database, including demographic data, diagnoses, injury profiles, complaints, etc., were collected by a physician in the general pediatric unit. The diagnoses for patients with injuries or diseases were based on the final diagnosis such as the occurrence of any post-earthquake symptoms experienced by the participants, and systemic dysfunctions and anxieties according to the attending general pediatric unit physician. In the light of this diagnosis and the preliminary diagnoses, the patients were treated in the pediatric clinic, the pediatric sub-disciplines, and other departments for their critical follow-up, and a prosthesis process for amputee patients was started.
Ethical Considerations
This study adhered to the tenets of the Declaration of Helsinki and was approved by the Ege University Faculty of Medicine Clinical Research Ethics Committee (approval no: 23-6.1T/44, date: 06.07.2023).
Results
General Profile
The mean age of the hospitalized patients in the General Pediatrics Unit of Ege University Childrens’ Hospital was 3.8 years. Of these, 6 (66.6%) were male. Due to this natural disaster situation with its transfer chain, the number of hospitalized patients reached a peak in the first week after the disaster. The admissions of the 9 patients is shown in the table which also shows their demographic data, reason for hospital admission, and injury diagnosis (Table I). During this period, only 9 patients were referred from the earthquake zone. Four of the patients presented with multiple injuries (44.4%), and the others with a single or no injury. Among the patients trapped under the rubble with multiple injuries, 3 patients with crush syndrome and rhabdomyolysis presented with acute renal injury and renal insufficiency. There were only four patients who were followed up for observations and clinical progress for respiratory problems such as pneumonia and bronchiolitis.
One of the most harrowing patients was an orphaned 6-year-old male patient who was trapped for unknown hours under the earthquake debris. Before transporting the child to our hospital, he was evaluated by physicians for general progress and injuries. His bilateral thigh was edematous and painful. Laboratory results revealed creatinine: 1.58 mg/dL, potassium: 6.11 mmol/L, serum pH: 7.35, bicarbonate: 16.8 mmol/L, lactic acid: 5.48 mmol/L and creatinine phosphokinase (CPK) of 25,700 U/L. Despite fluid and bicarbonate infusion, his renal function deteriorated, and his bilateral thighs became more tense resulting in a compulsory fasciotomy. He required 2 additional sessions of hemodialysis before complete resolution of the acute renal failure caused by traumatic rhabdomyolysis. By that time (24 h after hospital admission), the bilateral lower extremity was severely cold and cyanotic despite fasciotomy, so above-knee amputation was performed. He was transferred to our hospital’s general pediatrics ward 5 days after admission to begin rehabilitation and administration of the general health follow-up with a stable cardiorespiratory state (SpO2 of 98%, heart rate of 89 bpm, blood pressure of 96/62 mmHg and a respiratory rate of 18/min). On presentation, he was evaluated as having a Glasgow Coma Scale of 14 and showed a deeply depressed mood. Initially, the boy was evaluated by pediatric orthopedic surgeons for the first stage of damage control. Clinical examination revealed no pathological sign except two-leg above-knee amputation. Biochemical studies revealed aspartate amino transferase of 232 IU/L, alanine aminotransferase of 131 IU/L, and gamma-glutamyl transpeptidase of 10 IU/L, CPK: of 5,636 U/L, C-reactive protein of 1.6 mg/dL, creatinine of 0.4 mg/dL with normal urine output and urinary analysis. He was examined in the pediatric psychiatric department for trauma symptoms, which may be associated with long-term negative psychological changes in children experiencing disasters. General systemic disease screening and other necessary examinations were performed along with biochemical controls, as well as consultations for vaccinations and rehabilitation with social workers and the social pediatrics department. He was finally discharged 11 days later with a follow-up plan.
Discussion
Earthquakes are natural disasters characterized by strong terrestrial movements in a short period of time and they may cause destruction to health and the medical infrastructure. It was stated that 387 natural hazards and disasters occurred worldwide resulting in the loss of 30,704 lives affecting 185 million individuals in 2022 according to Emergency Event Database ‘‘EM-DAT’’, International Disaster Database. Earthquakes have injured more than 60 million people and approximately 400,000 have been killed during the last 30 years (4). Regrettably, our country is located in the Mediterranean-Alpine-Himalayan belt which produces at least one earthquake with a magnitude ranging from 5.0 to 6.0 every year. Turkey is one of the most earthquake prone countries in the world. In Turkey, on average, once every five years, a major earthquake occurs causing a loss of life and property damage on a large scale (5). On February 6th, 2023, two major earthquakes of magnitudes 7.7 and 7.6 with a 9-hour interval, and also a total of 11,020 aftershocks occurred on the Eastern Anatolian Fault Line, violently shaking 11 provinces in the Eastern and Southeastern Anatolia regions. Pazarcık and Elbistan of Kahramanmaraş province were determined as being the worst affected districts of the earthquake (6).
The management of polytraumatized pediatric patients suffering from earthquakes needs to be handled via a multidisciplinary approach including pediatric and orthopedic surgeons with the aim of damage control. The first stage of treatment to prevent death is to control any bleeding, to reduce contamination, to implement renal replacement therapy, to provide a temporary fixation on extremities, to supply a fluid-electrolyte balance, and to consider any surgical requirements (i.e., debridement, fasciotomy, or amputation) (7,8). Several earthquake studies have mostly reported that fractures were a large share of injuries, followed by soft tissue injury, contusions and lacerations. In an adult study on the 2013 Lushan Earthquake in China conducted by Peng Kang et al. (9), fractures accounted for 41.5% of the injuries, soft tissue injuries accounted for 27.5%, and contusions and lacerations accounted for 25.0%. The lower extremities and pelvis have been determined to be the most frequently injured anatomic sites, followed by the body surface, head, and spine in other earthquake studies (10). In our study, the patients suffering from earthquake-related physical trauma showed higher incidences of orthopedic injuries, particularly extremity problems of the lower limbs and traumatic rhabdomyolysis resulting in amputations and renal injuries. The most often injured anatomic areas were the extremities, followed by the body surfaces, and head. After stabilizing life-threating conditions, the patients need to be evaluated with a systemic approach, with both physical and psychological support in order to improve their life conditions. Orphaned children should be consulted by a social worker and the social pediatrics department. Our patients were evaluated by multiple departments, pediatrics divisions, and other disciplines during their hospitalization.
Earthquake-related mortality and morbidities generally originate from multiple-traumas, multiple fractures, soft tissue injuries, and crush injuries caused mostly by building collapses for individuals with poor socioeconomic conditions, who live in poor quality structures. One of the most threatening events in major earthquakes is traumatic rhabdomyolysis, also known as crush syndrome, which leads to acute kidney injury and failure. The mechanism of this syndrome is characterized firstly by ischemia and the reperfusion of decompressed extremities. During compression and ischemia, an intracellular influx of calcium occurs due to low production of adenosine triphosphate causing muscles lysis (8). Traumatic rhabdomyolysis has been reported following several earthquakes from all over the world, including Turkey. In the Marmara earthquake in 1999, crush syndrome accounted for 33% among hospitalized patients (11). Another earthquake study reported 48.9% of survivors were trapped under rubble and were diagnosed with extremity crush injuries (12). In the present study, 3 patients (33.3%) were identified with crush syndrome and presented with renal injury.
Earthquake-related injuries are mostly influenced by the location and/or being awake or asleep. Due to the fact that the victims could not escape due to the building collapses, numerous people were trapped under the rubble in their homes during the earthquake at 04:17 local time. Due to the fact that children are vulnerable to trauma and their body mass is small, they are more likely to be affected by major traumas. Amputations are the most difficult decision regarding crush injuries despite their life-saving aspect (13). In this present study, the extremities were the most injured anatomic part and needed to be amputated in two patients.
Study Limitations
The present study had several limitations. Firstly, the case series were retrospective in nature and secondly, there could have been a lack of record keeping or incomplete record keeping among the parents or other family members.
Conclusion
Earthquakes are natural disasters with the potential of causing death and homelessness. On February 6th, 2023, a large number of people and children who had been trapped under rubble needed a thorough evaluation, and most of those pulled from under the rubble were unfortunately admitted to hospitals as deceased. It is not possible to predict where and when earthquakes will occur or their severity despite todays’ technological improvements. In order to avoid unfavorable consequences during earthquakes and earthquake-related deaths and injuries, policies for preparedness, response, emergency response systems, and disaster loss reduction strategies should be planned and implemented by government institutions.
Acknowledgments
We thank the general pediatrics clinic staff for contributing in the application of this survey.
Ethics
Ethics Committee Approval: Ethics committee approval was obtained from the Ege University Faculty of Medicine Clinical Research Ethics Committee (approval no: 23-6.1T/44, date: 06.07.2023).
Informed Consent: Informed consent with verbal consent was taken from the participants’ parents.
Peer-review: Externally peer-reviewed.
Authorship Contributions
Surgical and Medical Practices: Ş.G., B.E.D., B.A., Concept: Ş.G., B.E.D., Design: Ş.G., B.E.D., Data Collection or Processing: B.E.D., B.A., Analysis or Interpretation: Ş.G., B.E.D., Writing: Ş.G., B.E.D.
Conflict of Interest: No conflict of interest is declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.
