Emergency Surgery Workshop Davos 2011: Presentation by Mahtab Poor Zamany, MD, Assistant Professor, Dep. of Anesthesia, Labbfinejad Hospital, Shaheed Beheshti University of Medical Sciences, Tehran, Iran.

1. Bam-Iran 2003 Earthquake

2. Iran Iran is a disaster prone country. Among the all ( 40) different types of natural disasters observable in different parts of the world, 31 types have been identified in the Islamic Republic of Iran. Major natural disasters include frequent serious earthquakes, floods, droughts, landslides, desertification, deforestation, storms and the like.

3. Iran is part of the Alp-Himalaya orogenic belt and is known as part of the youngest and last orogenic regions of the world.

5. Earthquakes have killed more than 180,000 people during the last 90 years.

6. On a very cold and dark night on the 25 th of December 2003 As usual the people of Bam and its surrounding villages were sleeping not knowing what lay ahead for tomorrow, but the next day… thousands of its people were not woken up.

7. Imagine the shock

9. Bam’s citadel was the largest mud-brick structure in the world

10. The citadel changed to a massive mound

11. Additionally, 85% of the city has been severely damaged or destroyed, leaving the major city centre uninhabitable. Electricity, water distribution, and sanitation services were significantly affected or destroyed, while all major static health services were irreparably damaged.

12. Past experiences show: In developing countries such as Iran, health facility centers are vulnerable to natural events. for example when people were affected by an earthquake they needed hospital services more than ever, local hospitals would be encountered by direct and indirect impacts and usually couldn’t continue their functions.

13. During the Bam’s Disaster The entire health system has been destroyed or severely affected by the quake.

14. Among the list of resources destroyed were: the 95 community health houses (first aid depots) that had been the centre for outreach within the city and its surrounding areas. This coupled with the loss of the 14 rural health centers, 10 urban health centers and both Bam’s hospitals, as well as the 50% of trained medical staff that were killed or missing, Which has left a palpable lack in the static health infrastructure of the Bam area.

15. Therefore, Almost all injured people were sent to hospitals far away in provincial capitals, approximately hundreds of kilometers away from the devastated city of Bam.

16. Which types of Injuries and disorders you may encounter in an earthquake event?

17. Minor fractures

18. Minor injuries but in the critical parts of the body

19. Multiple traumas

21. Searching for a miracle

22. Even CPR, couldn’t save him

23. Please don't leave us in this situation

24. Waiting for a helping hand

25. Many people who were picked out from the rubble, were suffering of traumas to different parts of their bodies, 20% of these patients were crushed victims. Distribution of trauma in different site of the body The Iranian Society of Nephrology and ISN research on 2962 Bam’s hospitalized cases

26. Crushed victims (n=611) were divided into: 1- Crush injured as CPK>1000 IU/L, moderate habdomyolysis (n=411). 2- Crush Syndrome as crush injured with acute renal failure or other systemic manifestations, severe rhabdomyolysis. (n=200). Non-crushed victims were defined to hospitalized patients with mild rhabdomyolysis or without rhabdomyolysis as CPK<1000 (n=2351).

27. One of the most common complications after an earthquake especially in crushed victims is Rhobdomyolisis, while its so important, it can easily prevented by rapid medical response.

28. Comparison of mean of different parameters between crushed and non-crushed CPK, Creatine phosphokinase; LDH, Lactate Dehydrogenize; TUR, time of being under the rubble #Mean of first 3 days of admission for biochemical parameters is used *Mean IV intake in first 5 days of admission Parameters # Crushed (n=611) SD Non crushed (n=2351) SD P value Bun(mg/dl) 36.6 35.4 21.7 13.8 <0.001 Creatinine(mg/dl) 1.6 1.6 0.8 0.3 <0.001 Calcium (mg%) 7.2 1.8 7.7 1.8 =0.9 Phosphorous (mg %) 3.6 1.7 3.4 1.08 <0.05 Potassium(meq/l) 4.6 1 4.1 0.5 <0.001 Sodium(meq/l) 138 5.2 139 4.2 =0.9 Uric acid(mg/dl) 4.8 2.7 3.4 1.2 <0.001 CPK(IU/L) 7000 1345 473 268 <0.001 LDH(IU/L) 1541 2092 652 512 <0.001 TUR(h) 4.8 4.1 2.6 2.1 <0.001 IV intake*(L) 3.6 2.6 2.5 2.6 <0.001

29. TUR and T-R (Time to Rescue) can help us to predict severity of crushing, before doing laboratory tests Hours of ischemia 0 2 4 6 Tolerable-no permanent histological changes Irreversible anatomic and functional changes Muscle necrosis TUR (Time Under the Rubble)

30. Comparison of complications between crushed and non-crushed Complication Non crushed (n=2351) Crushed (n=611) P value Sepsis 9(30%) 21(70%) P<0.001 DIC 1(7%) 13(93%) P<0.001 ARDS 13(41%) 18(59%) P<0.001 Death 19(39%) 29(61%) P<0.001

31. Comparison of different parameters between patients with crush injury and crush syndrome CPK, Creatine phosphokinase; LDH, Lactate Dehydrogenize; TUR, time of being under the rubble #Mean of first 3 days of admission for biochemical parameters is used *Mean IV intake in first 5 days of admission Parameters Crush injury (n=411) SD Crush syndrome (n=200) SD P value Bun(mg/dl) 23.8 15.4 88.8 45.1 <0.001 Creatinine(mg/dl) 0.9 0.3 4.5 4.1 <0.001 Calcium (mg%) 7.6 1.7 6.05 1.7 <0.001 Phosphorous (mg %) 3.1 1.2 5.6 1.7 <0.001 Potassium(meq/l) 4.2 0.6 6.09 1.1 <0.001 Sodium(meq/l) 139 4.1 134 7.2 <0.001 Uric acid(mg/dl) 3.7 1.4 8.7 2.9 <0.001 CPK(IU/L) 9348 5978 25561 28569 <0.001 LDH(IU/L) 968 851 4929 3565 <0.001 TUR(h) 2.7 2.4 6.6 4.4 <0.001 IV intake*(L) 3.9 2.7 2.7 2.3 <0.001

32. Comparison of complications between crush injured and crush syndrome patients Complication Crush injury (n=411) Crush syndrome (n=200) P value Sepsis 1(4%) 20(96%) P<0.001 DIC 1(7%) 12(93%) P<0.001 ARDS 1(5%) 17(95%) P<0.001 Death 6(20%) 23(80%) P<0.001

33. For decreasing morbidity and mortality of these victims, rescue and triage and treatment teams need to pay attention to the prevention of crush syndrome and its consequences such as Compartment Syndrome and AKI. What who Note 1 Reduce TUR Rescue teams 2 Reduce T-R Triage teams Do the greatest good for the greatest number of casualties. 3 Use hydration therapy Treatment teams Early hydration therapy, while checking the most essential clinical and paraclinical factors Using high doseage prophylactic hydration therapy (more than 10 liters/day) only in those whom are at risk of AKI and dialysis

38. 2- Lack of a comprehensive hospital disaster plan 3- Lack of proper inter-agency planning and flow of information 4- Fragile and vulnerable structures in urban critical facilities particularly structures of the two hospitals of the city.

39. for your kind attention. Thank you END