Anesthesia & Analgesia:
Critical Care, Trauma, and Resuscitation: Research Report
A Matter of Life or Limb? A Review of Traumatic Injury Patterns and Anesthesia Techniques for Disaster Relief After Major Earthquakes
Missair, Andres MD; Pretto, Ernesto A. MD; Visan, Alexandru MD; Lobo, Laila MD; Paula, Frank DNP, ARNP; Castillo-Pedraza, Catalina MD; Cooper, Lebron MD; Gebhard, Ralf E. MD
From the Department of Anesthesiology, University of Miami–Miller School of Medicine, Miami, Florida.
Accepted for publication May 28, 2013.
Published ahead of print August 19, 2013
Funding: University of Miami–Miller School of Medicine.
The authors declare no conflicts of interest.
Reprints will not be available from the authors.
Address correspondence to Andres Missair, MD, Department of Anesthesiology, University of Miami–Miller School of Medicine, Room C201, 1611 NW 12th Ave., Miami, FL 33136. Address e-mail to AMissair@med.miami.edu.
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.
More than 500,000 earthquakes are documented yearly, of which 3000 are perceptible. In the last 30 years, an annual average of 21 major earthquakes has been reported, defined as those events that cause more than 10 deaths, affect more than 100 individuals, and result in the request for international assistance after a declared state of emergency (Fig. 1). Since 2005, however, this average has increased to more than 30 major events.1 Since 1975, more than 1.2 million deaths have been reported due to seismic events as per the U.S. Geologic Survey,2 with nearly half of all fatalities occurring in the last 10 years as a result of growing urban population density.3
The epidemiology of earthquake-related mortality and injury is distinct from other natural disasters, such as floods and hurricanes. Major earthquakes result in casualty rates between 1% and 8% of the at-risk population.4 A majority of these deaths are immediate and related to traumatic injury of the brain and/or spinal cord, or within hours due to subdural hematomas, hepatic or splenic lacerations, and pelvic fractures.5 Survivable traumatic injuries include bone fractures, soft-tissue lacerations, and crush injury to various parts of the body. This group of earthquake victims presents for urgent medical care in the acute phase of medical relief. It is argued, therefore, that these survivors should be the focus of perioperative medical aid if it is to be most effective.6
During major earthquakes, the associated destruction of local medical infrastructure is often extensive due to the prolonged interruption of supply chains, energy provisioning, and local transport.6 The resulting humanitarian disaster presents concrete challenges for medical relief efforts and, in particular, the anesthetic management of earthquake victims requiring urgent surgical care. Because acutely injured victims usually seek medical care in the first 2 to 5 days after an earthquake, the greatest demand for health care often coincides with the period of least local medical infrastructure availability.7 Consequently, a timely and efficient medical relief response becomes paramount if it is to be effective during the acute phase of humanitarian aid.
All modalities of anesthetic care, including conscious sedation, general, and regional anesthesia have been used to manage earthquake survivors who require urgent surgical intervention. As such, 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 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 the associated obstacles of devastated medical infrastructure.
To identify reports on acute surgical care in the aftermath of natural disasters, a search 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.” Additional primary data were also obtained from official government agency databases (World Health Organization [WHO], Ministry of Health of Pakistan), scientific institutional reports (U.S. Geologic Survey), and humanitarian agency reports (Handicap International) identified during the online search. Because formal earthquake epidemiology only dates back to 1935, we used the time frame 1935 to 2012. Our investigation focused only on studies and reports of acute traumatic injury that specified direct measurements of human health morbidity in the acute phase of medical relief (0–15 days after the event). We only selected articles and reports that described acutely injured survivors who were triaged and received medical care after the earthquake. Particular emphasis was placed on the inclusion of articles and reports that specified actual patient cases and surgical interventions. Patient cases were defined specifically as survivors who suffered earthquake-related injury and received surgical care. Consequently, only case series, cross-sectional, case-control, and cohort studies were included. Surveys and reviews were, therefore, excluded due to the limited availability and specificity of raw patient data. Publications that did not comment on anatomic injury pattern or specified actual case numbers were also excluded from analysis. No language restrictions were used; however, all reports meeting criteria were in English.
One hundred forty-seven published articles were identified, of which 78 studies were reviewed after a preliminary assessment of inclusion criteria. Thirty-one articles reporting on 15 major earthquakes (between 1980 and 2010) and the treatment of more than 33,410 patients met our specific inclusion criteria. Two articles were referenced but excluded from analysis only due to study design (survey and review) and absence of raw data.
Each article was analyzed for study design (cross-sectional, case series, case-control, or cohort), total hospital or geographic sites sampled, total number of survivors triaged, total number of trauma-injury patients treated, number and location of traumatic injuries, total surgeries performed, anesthetic techniques used, and postoperative anesthesia-related complications. The raw data from these studies were then used to calculate (or recalculate and confirm) the incidence of traumatic injury per anatomic location (limb, head, thorax, and abdomen) for each report.
The predominant injury pattern identified was extremity (upper and lower limb) injury, with a calculated incidence range of 29% to 98% per report. Twenty-nine of 31 studies reported a limb trauma incidence score higher than 50%. The mean incidence of traumatic limb injury per major earthquake was 68.0%, ranging from laceration and fracture to compartment syndrome. Based on the 31 studies analyzed, the global incidence of traumatic limb injury for all sampled earthquake survivors was 54.3% (18,144 of 33,410 patients). In those studies that identified upper versus lower extremity injury, lower limb involvement invariably exceeded upper limb injury in more than 90% of these reports. Conversely, cranial, thoracic, and abdominal injuries combined were <30% of all cases across earthquake survivors8 (Table 1). 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%.
Anesthetic techniques were reported in only 26% (8 of 31) of reviewed studies (Table 2). The anesthetic techniques identified in these 8 reports included general (8 studies), regional/neuraxial (4 studies), monitored anesthesia care (MAC; 7 studies), and local (1 study). The predominant anesthetic modality used was equally distributed (4:4) between general and MAC/regional anesthetic techniques among the 8 studies. Reported perioperative mortality ranged from 0% to 19%. Identified anesthetic complications included laryngospasm, mechanical ventilatory failure, intraoperative hypotension, oxygen desaturation, and postoperative nausea and vomiting (PONV). No statistically significant correlations could be made between anesthetic technique used and incidence or type of anesthetic complication. In 7 of 8 studies, however, conversion from mechanical to manual ventilation was reported during the delivery of general anesthesia due to power and/or compressed gas failures.
Based on this study, the majority (69%) of earthquake-related injuries requiring urgent surgical intervention involved survivors with limb trauma. Our results are consistent with humanitarian aid agency reviews and governmental surveys (not included in our analysis) that found similar incidence scores of traumatic limb injury among survivors of major earthquakes.39,40 In the proceedings of the WHO Symposium on Earthquakes and People’s Health,39 a global incidence of 51.2% (vs 54.3% calculated in our study) was reported for limb injury based on earthquake data from 11 separate epidemiologic studies.
The frequent incidence of limb injury among earthquake-related trauma patients presents a clear opportunity for the use of regional anesthesia as the primary technique for intraoperative management during limited or collapsed medical infrastructure. However, all anesthesia modalities have been safely and successfully used for patient management during acute surgical relief efforts, and it is relevant to discuss the applicability of each in the context of austere medical environments:
The majority of earthquake victims who present for operative management have intravascular volume depletion secondary to dehydration and bleeding.14 In this patient population, therefore, maintenance of intraoperative hemodynamic stability is critical. The unknown fasting status of patients may also increase aspiration risk during anesthetic management. In response to these preoperative anesthetic concerns, the use of ketamine in the earthquake trauma patient is widely reported throughout the literature (5:8 studies). Ketamine can be used with a secured airway as a total IV anesthetic or with an unsecured airway for MAC. Ketamine is characterized by the absence of respiratory depression, preservation of airway reflexes, wide therapeutic range, hemodynamic stability, rapid onset of action, and short half-life.35,41 The safety and efficacy of ketamine as the primary anesthetic drug under disaster conditions is well described by Mulvey et al.20,21 After the 2005 7.8-magnitude earthquake in Kashmir that resulted in 86,000 deaths and more than 80,000 severe injuries, the authors reported on the use of ketamine as the sole anesthetic for 149 patients (adult and pediatric) undergoing emergency surgery under completely devastated hospital infrastructure. The absence of mechanical ventilation, vital sign monitors, and supplemental oxygen reported by the authors are similar conditions as those encountered during the 2010 Haiti earthquake, where Missair et al.10 reported more than 500 surgeries performed with combined ketamine MAC anesthesia and single-shot peripheral nerve block. Both studies describe the use of ketamine as an MAC anesthetic with an unsecured airway and reported <5% complications following its use, comparable with those results found by Paix et al.42 during the 2004 Banda Aceh Tsunami. The most common complication reported by these 3 studies was intraoperative vomiting requiring intubation for airway protection. Mulvey et al.21 reported that 2 of 149 patients experienced laryngospasm during MAC with ketamine. No intraoperative patient deaths were reported in the studies.
Regional anesthetic techniques for management of the earthquake trauma patient can be divided into neuraxial approaches and peripheral nerve blocks. The decreased intravascular volume of this specific patient population should be considered before the use of neuraxial techniques in light of the induced sympathectomy and the potential for severe hypotension. In fact, Jiang et al.14 report significant hypotension after spinal anesthetics in 7 of 9 patients treated in the field. Consequently, it is prudent to fluid resuscitate any patient before placement of a neuraxial block in this context. The time required to safely accomplish this, however, is often limited by the emergent nature of surgeries performed in these scenarios. The use of neuraxial blocks is only reported in 2 of 8 studies we identified and is the least common anesthetic technique used for earthquake trauma patients.
Peripheral nerve blocks provide “excellent operating conditions, profound perioperative analgesia, stable hemodynamics, minimal side effects, and simple portable equipment requirements.”41 Under ketamine MAC, operating conditions are rapidly established with single-shot neural blockade, while postoperative analgesic requirements are fulfilled by the use of long-acting local anesthetic drugs.10,41 This extended analgesic benefit into the postoperative period may help reduce postoperative complications such as narcotic-associated emesis and respiratory depression, as well as decrease the burden on medical personnel caring for those postoperative patients with pain or PONV. No short-term complications specific to regional anesthetic management were reported in the reviewed studies.
For the earthquake trauma patient in the austere medical environment, the placement of indwelling catheters such as epidurals or continuous peripheral nerve blocks (CPNBs) is reported by a few studies. Buckenmaier et al.41 report on the safe use of CPNBs during military field operations; however, it must be emphasized that these patients were either rapidly evacuated to hospitals in military bases abroad or cared for in military field hospitals. In mass casualty scenarios, such as earthquakes, the feasibility and necessary manpower for the subsequent care and monitoring of patients with indwelling catheters should be taken into consideration. In addition, the environmental conditions of the field hospital may present an infection risk for these particular anesthetic techniques. Finally, the additional equipment and supply requirements, such as infusion pumps, IV fluids, tubing, and resuscitation drugs, may preclude the safe and effective implementation of indwelling catheters for anesthesia and postoperative pain management. If safe placement by trained personnel is possible, however, the use of CPNBs in the field can provide substantial benefits to both the patient and medical relief staff. Some advantages include prolonged postoperative analgesia, decreased opioid usage (which might be in limited supply), decreased PONV, and catheter rebolusing for subsequent surgeries, washouts, and dressing changes.
Inhaled General Anesthesia
Infrastructure collapse during the acute phase of perioperative medical care will often preclude any reliable capability for mechanical ventilation during extended periods of time. Interruptions in electricity, compressed gas delivery, and the availability of suction and scavenging systems are all limitations for the use of mechanical ventilators in the postdisaster field.12 Consequently, the use of manual ventilation is often reported throughout the reviewed studies (>90%). In many reports, temporary field hospitals served as the primary surgical centers when medical relief staff were evacuated from local hospitals due to building collapse or risk of subsequent collapse. The size, weight, and associated power/compressed gas requirements to run mechanical ventilators create a logistical obstacle to their rapid deployment and implementation during the acute phase of medical field operations. The limited portability of mechanical ventilators, therefore, was another reported factor in favor of simpler, manual ventilation during the earliest phases of surgical intervention requiring general anesthesia in the field. In response to these limitations, a ketamine or propofol total IV anesthesia technique was reported by some studies.12,21
A foreign field hospital must be operational and on-site 24 hours after the event to be effective in the acute phase of medical relief (2–14 days).25 This goal, however, is rarely achieved due to the logistical obstacles created by the earthquake itself. For these reasons, the WHO recommends that emergency medical relief during disasters should be handled by local authorities and provided by local medical resources.34,35 During the major earthquakes in Armenia (1988), Japan (1995), Pakistan (2003), and Haiti (2010), field hospitals could not be established for the first 4 to 14 days after the disaster despite intact local medical facilities, equipment, and personnel only 30 to 40 km away.10,25,33,35 Rapid and streamlined deployment is crucial to respond during the first 24 hours. For this reason, portability is a critical factor when developing an anesthesia preparedness plan for disaster response. Access to the impact zone is often via helicopter, horseback, or on foot once the relief personnel reach the nearest airport, seaport, or available mass transit point. The portability characteristics of the selected anesthesia management modality, therefore, directly impact the speed of its implementation in the disaster response scenario of austere medical environments. At our institution, for example, a portable regional anesthesia carry-on kit for 60 patients was developed in response to these field requirements and the need for rapid deployment (Fig. 2).
We emphasize that the quality of earthquake epidemiologic data varies greatly and is the greatest obstacle to making evidence-based recommendations. The articles we identified reported that survivors of earthquakes presented most commonly with extremity injuries, and of those, 90% were to the lower extremity. Of the literature we reviewed, general anesthesia was used as often as regional anesthesia/MAC and was reported to be equally effective and safe. There is no ideal anesthetic to manage these patients; in practice, the safest and most effective anesthetic may be dictated by the circumstances, by the available personnel, supplies and equipment, and by the expertise of the available anesthesia providers. Independent of the type of anesthetic, difficulty with the airway, ventilation/oxygenation, and hypotension were the most commonly reported intraoperative problems.
Name: Andres Missair, MD.
Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.
Attestation: Andres Missair has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.
Name: Ernesto A. Pretto, MD.
Contribution: This author helped design the study.
Attestation: Ernesto A. Pretto has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
Name: Alexandru Visan, MD.
Contribution: This author helped conduct the study and write the manuscript.
Attestation: Alexandru Visan has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
Name: Laila Lobo, MD.
Contribution: This author helped conduct the study, analyze the data, and write the manuscript.
Attestation: Laila Lobo has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
Name: Frank Paula, DNP, ARNP.
Contribution: This author helped analyze the data.
Attestation: Frank Paula has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
Name: Catalina Castillo-Pedraza, MD.
Contribution: This author helped conduct the study and write the manuscript.
Attestation: Catalina Castillo-Pedraza has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
Name: Lebron Cooper, MD.
Contribution: This author helped design the study.
Attestation: Lebron Cooper has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
Name: Ralf E. Gebhard, MD.
Contribution: This author helped design and conduct the study.
Attestation: Ralf E. Gebhard has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
This manuscript was handled by: Steven L. Shafer, MD.
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