A Retrospctive Study of 377 Patients Admitted as an Emergency with Crush Syndrome After the Trkiye-Syria Earthquakes

Introduction

The Türkiye-Syria earthquakes of 2023, occurring on February 6th, were devastating natural disasters with magnitudes of 7.8 and 7.5 These powerful quakes caused widespread destruction across southeastern Türkiye and northern Syria, resulting in significant loss of life and extensive injuries [1]. February 6, 2023 will forever be etched in the memories of the Turkish people, marked by the catastrophic earthquakes leaving an indelible mark on millions of lives. On that day, Türkiye experienced 2 of the most destructive earthquakes of the last century. In the early hours of February 6 in the province of Kahramanmaraş in Türkiye, 2 earthquakes originated at a depth of approximately 7 kilometers below the earth’s surface, and a total of 11 020 aftershocks were recorded [2]. These earthquakes affected more than 16 million people in 11 provinces, including Adana, Adiyaman, Diyarbakir, Gaziantep, Hatay, Kahramanmaraş, Kilis, Malatya, Osmaniye, and Şanliurfa. Türkiye suffered extensive damage and was faced with one of the most devastating disasters in centuries. In response to the severity of the situation, the World Health Organization (WHO) declared a Level 3 emergency following the earthquakes [1,2].

According to the Disaster and Emergency Management Presidency of the Turkish Ministry of the Interior (AFAD; Türkiye), the death toll from the earthquakes was 45 089. The gendarmerie, together with people’s own efforts, has successfully evacuated 1 971 589 people from the affected regions, and their details have been documented through requests to governors and district governors. In the provinces affected by the earthquakes, more than 1.5 million buildings have been inspected for damage assessment. Nearly 200 000 of these structures were identified during the emergency response as either severely damaged or in need of demolition [1–3].

Crush syndrome, often occurring when pressure is released from a crushed limb, are severe conditions linked with rhabdomyolysis. The primary cause is prolonged compression of muscle tissue, leading to cellular ischemia and subsequent necrosis [3,4]. Upon decompression, the sudden release of myoglobin, potassium, and other intracellular components into the bloodstream can result in acute kidney injury (AKI), cardiac arrhythmias, and systemic inflammatory response syndrome (SIRS) [3–5]. Crush syndrome, a severe condition resulting from prolonged muscle compression, is closely associated with AKI. In the literature, crush syndrome is often noted for its complex pathophysiology and significant impact on renal function. Studies indicate that the release of myoglobin and other intracellular components from damaged muscle cells can lead to renal tubular obstruction and subsequent AKI [5]. The condition was first extensively described during the London Blitz of WWII, where victims of bombings presented with renal complications due to muscle crush injuries [3,5]. Since then, various natural disasters and war scenarios have reinforced the critical connection between crush injuries and renal failure [6]. The general consensus in the literature underscores the necessity of early intervention and aggressive fluid resuscitation to mitigate the onset of AKI in patients with CS [7]. Furthermore, advancements in renal replacement therapies have improved outcomes, but the mortality and morbidity associated with crush syndrome remain significant [8].

Crush injuries often lead to systemic effects known as crush syndrome (CS). In most similar disasters, there is a notable increase in mortality at the disaster site, and individuals rescued from the rubble often have CS. CS and CS-related acute kidney injury are generally the most common causes of death in hospitals after earthquakes [9–12]. It has been estimated that CS occurs in approximately 2–5% of individuals injured in catastrophic earthquakes and affects 30–50% of patients with traumatic rhabdomyolysis [10–13].

Crush syndrome and CS-related AKI are 2 critical, potentially reversible complications of crush injury [12,13]. Therefore, it is important to clarify the clinical features and provide an overview of the rescue experience with CS and AKI following a major earthquake [6]. All individuals affected by a disaster, regardless of the severity of their injuries, should be considered as having an increased risk of developing CS [11,13].

In our study, we aimed to anticipate factors influencing the development of AKI in patients who admitted to our clinic after the February 6 earthquake in Kahramanmaraş and were followed up with a diagnosis of CS. In addition, as we are located in an earthquake-prone country, we are required to draw attention to rapid and accurate treatment approaches for earthquake victims in potential similar disaster situations.

Material and Methods

STUDY DESIGN AND SETTING:

Our hospital is situated in the capital city and admits around 500 000 patients annually. It is one of the biggest hospitals in the country, with a total bed capacity of 4190, including 1010 in intensive care. The hospital has treated many earthquake victims in the past, using its own resources and air and ground ambulances.

The study was conducted upon the approval of E1-23-3361 dated 05.04.23 and numbered 3361 of the Number 1 Clinical Applications Ethics Committee of the Ankara Bilkent City Hospital. After receiving approval from the ethics committee, this observational study retrospectively reviewed data of patients who presented to the emergency department between 6 February and 16 February 2023 and were diagnosed with CS. Patients whose data could not be accessed from the hospital’s automated system were excluded from the study. Patient demographics, vital signs, earthquake region of origin, post-earthquake time, time under debris, blood parameters, need for hemodialysis, patient outcome (discharged/deceased), length of hospital stay, 7-day mortality, diagnoses received, and treatment protocols were recorded. Data on the duration of being trapped under rubble were meticulously collected and documented by search and rescue teams operating at the disaster sites. These teams were equipped with specialized tools and protocols to record the time each individual spent trapped under debris. Upon reaching and rescuing the victims, the search and rescue personnel noted the exact duration of entrapment, which was then systematically entered into an automated tracking system for all patients.

Acute kidney injury was diagnosed using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. AKI was defined by an increase in serum creatinine by ≥0.3 mg/dL within 48 h, an increase to ≥1.5 times baseline within the last 7 days, or urine output less than 0.5 mL/kg/h for 6 h [14]. Additionally, the RIFLE and AKIN criteria were used for cross-validation [15]. These criteria ensured consistent and accurate assessment of renal function in all patients.

Our hospital has established a common consensus for many diagnoses due to disasters. The consensus for the diagnosis of crush syndrome was that the creatine kinase (CK) value was increased 3-fold and there was concomitant end-organ damage. Patients were diagnosed with crush syndrome with the same protocol in the entire inpatient services and these patients were included in our study. The treatment consists of aggressive volume replacement followed by forced diuretic therapy, which can combat the shock and resolve the hyperkalemia. If AKI has occurred, regular hemodialysis was indicated.

STATISTICAL ANALYSIS:

The statistical analysis of the research was performed using SPSS version 22.0. Descriptive statistics, including mean and standard error for continuous variables, and frequency and percentage for categorical variables, were reported. Normal distribution adequacy was assessed through the Kolmogorov-Smirnov and Shapiro-Wilk tests. The chi-square test was applied for comparing categorical variables. In cases where the assumption of normal distribution was not fulfilled for quantitative data, the Mann-Whitney U test was applied for comparisons. Spearman correlation analysis was utilized to measure correlation levels. Values with P<0.05 were considered statistically significant.

Results

DEMOGRAPHICS:

During the planned study period, 1682 earthquake victims were admitted to the emergency service; 408 of the patients were followed up with a diagnosis of crush syndrome, and 31 patients for whom information could not be accessed from the data automation system were excluded, and 377 patients diagnosed with crush syndrome were included in the study. The mean age of the patients was 33.51±0.89 years and 51.7% (n=195) were male. The major sites of crush injury were in the lower extremities (82%), the upper extremities (11%), and the trunk (7%). Limb fractures, pelvic fractures, and abdominal injuries were the most frequently associated injuries. The mean time under debris was 24.92±1.62 h and the mean hospital stay was 34.39±1.20 days. The mean arterial pressure was 89.57±0.60. Hemodialysis was adminstered to 91 patients (24.1%) and 20 patients (5.3%) died. Those with creatinine levels above 2.0 mg/dL and urea levels above 40 mg/dL were considered to have AKI. AKI developed in 23.1% (n=87) of the patients, and 30.5% (n=115) were under debris for more than 24 h. Blood gas, biochemistry, and complete blood count values are shown in Table 1.

LABORATORY PARAMETERS:

Patients’ laboratory parameters were compared with their requirement for hemodialysis (Table 2). Accordingly, those requiring dialysis had lower pH, HCO3, base excess, sodium, calcium, hemoglobin and PLT values (P<0.001, P<0.001, P<0.001, P<0.001, P<0.001, P=0.002, and P=0.001, respectively), whereas creatine kinase, creatinine, urea, AST, ALT, LDH, potassium, phosphorus and white blood cell values were higher (P<0.001).

OUTCOME OF PATIENTS:

We assessed the correlation between the outcome of patients receiving hemodialysis, the duration of hospital stay, the prevalence of acute kidney injury, and the duration of being buried under debris (Table 3). The mortality rate was higher in those who received hemodialysis, as were the rates of both hospital stay and acute kidney injury (P<0.001, P=0.003, and P<0.001, respectively). Those who remained buried under debris for more than 24 h had a lower rate of receiving hemodialysis (P=0.043).

When assessing the impact of renal markers on outcome deceased patients had lower pH and calcium levels (P=0.002 and P=0.006), while creatinine, urea, potassium, and phosphorus levels were higher (P=0.001, P<0.001, P=0.007, and P<0.001 respectively) (Table 4).

Correlation analysis was performed between laboratory values and other study parameters (Table 5). It was observed that with increasing age, pH, creatine kinase, AST, ALT, LDH, phosphorus, WBC and PLT values decreased (P=0.006, P<0.001, P<0.001, P<0.001, P<0.001, P<0.001, P=0.033, and P=0.002, respectively), while creatinine, urea, and sodium values increased (P<0.001, P<0.001, and P<0.001, respectively). As the duration of remaining buried under debris increased, pH, base excess, AST, ALT, and LDH values increased (P<0.001, P=0.005, P=0.017, P=0.015, and P=0.020, respectively), while creatinine and calcium values decreased (P=0.006 and P=0.009, respectively). High creatinine, sodium, calcium, and hemoglobin values were associated with shorter hospital stay (P=0.044, P<0.001, P<0.001, and P<0.001, respectively), while high AST, ALT, LDH, WBC, and PLT values was associated with longer hospital stay (P=0.008, P=0.008, P<0.001, P<0.001, and P=0.023, respectively).

In patients with AKI, pH, HCO3, base excess, sodium, calcium, hemoglobin (P=0.006) and PLT were lower (P<0.001), whereas creatine kinase, creatinine, urea, AST, ALT, LDH, potassium, phosphorus and WBC were higher (P<0.001) (Table 6).

Remaining buried more than 24 h under debris was associated with longer hospital stay and higher pH, HCO3, base excess, WBC, and PLT values (P=0.010, P<0.001, P=0.007, P<0.001, P<0.001 and P=0.018, respectively), whereas creatinine, urea, and phosphorus values were lower (P<0.001, P=0.021 and P=0.001, respectively) (Table 7).

Discussion

LIMITATIONS:

A protocol specific to our hospital has been established for the diagnosis of crush syndrome. This may create a limitation in terms of comparison with other studies. The treatments initiated in the earthquake zone are not clear. The study has limitations due to its retrospective design and being conducted at a single center. There is a need for multi-centered studies that collect data from all earthquake victims.

Conclusions

Overall, these results emphasize the importance of early and aggressive management of crush syndrome, particularly in monitoring renal function and biochemical markers, to improve patient outcomes. The study provides valuable insights into the pathophysiological mechanisms underlying crush syndrome and highlights critical factors influencing the prognosis of affected patients. We observed a high incidence of acute kidney injury in these patients, as well as a high requirement for hemodialysis and high mortality. Most earthquake victims remained under debris for over 24 h. We are confident that early aggressive fluid replacement treatments can prevent this situation. These treatments should be initiated before hospital admission, in the field, before and during extrication, and afterward. Hospitals need to emphasize the importance of early fluid therapy in their disaster planning for field personnel and should regularly provide up-to-date information.