Analysis of 1856 inpatients and 33 deaths in the West China Hospital of Sichuan University from the Wenchuan earthquake

Placing engineering in the earthquake response and the survival chain

Earthquakes injure millions and simultaneously disrupt the infrastructure to protect them. This perspective argues that the current post-disaster investigation paradigm is insufficient to protect communities' health effectively. We propose the Earthquake Survival Chain as a framework to change the current engineering focus on infrastructure to health. This framework highlights four converging research opportunities to advance understanding of earthquake injuries, search and rescue, patient mobilizations, and medical treatment. We offer an interdisciplinary research agenda in engineering and health sciences, including artificial intelligence and virtual reality, to protect health and life from earthquakes.

The Outcome of Orthopedics Treatment of Lombok Earthquake Victim 2018: A Cohort of One-Year Follow-Up Study-Lesson Learned After Lombok Earthquake

Introduction

There was a magnitude 7 on the Richter scale earthquake on Lombok Island in 2018, causing more than 500 deaths. In the event of earthquakes, there is often an imbalance between overcrowding in hospitals and inadequate resources. The initial management of earthquake victims with musculoskeletal injuries is controversial, arguing over whether to utilize debridement, external or internal fixation, or conservative or operative treatment in an acute onset disaster situation. This study aims to determine the outcome of initial management after the 2018 Lombok earthquake, between immediate open-reduction and internal fixation (ORIF) and Non-ORIF procedures after one year follow-up.

Methods

This is a cohort study to evaluate radiological and clinical outcomes one year after orthopedic treatment in the Lombok earthquake 2018. The subjects were recruited from eight public health center and one hospital in Lombok in September 2019. We evaluate radiological outcomes (non/malunion and union) and clinical outcomes (infection and SF-36 score).

Results

Based on 73 subjects, the ORIF group has a higher union rate than the non-ORIF group (31.1% vs. 68.9%; p = 0.021). Incidence of infection only appeared in the ORIF group (23.5%). Clinical outcome as measured by SF36 showed the ORIF group had a lower mean of general health (p = 0.042) and health change (p = 0.039) clinical outcomes than the non-ORIF group.

Discussion

The most affected public group is the productive age with significant impact on social-economy. ORIF procedure is a major risk factor of infection in initial treatment after earthquake. Therefore, definitive operation with internal fixation is not recommended in the initial phase of a disaster. Damage Control Orthopedic (DCO) surgery protocol is the treatment of choice in acute disaster setting.

Conclusion

The ORIF group had better radiological outcomes than the non-ORIF group. However the ORIF group had higher cases of infection and lower SF-36 than the non-ORIF group. Definitive treatment in acute onset disaster setting should be prevented.

Prevalence and Characteristics of Earthquake-Related Head Injuries: A Systematic Review

OBJECTIVE

We conducted a systematic review to determine the prevalence and characteristics of earthquake-associated head injuries for better disaster preparedness and management.

METHODS

We searched for all publications related to head injuries and earthquakes from 1985 to 2018 in MEDLINE and other major databases. A search was conducted using "earthquakes," "wounds and injuries," and "cranio-cerebral trauma" as a medical subject headings.

RESULTS

Included in the analysis were 34 articles. With regard to the commonly occurring injuries, earthquake-related head injury ranks third among patients with earthquake-related injuries. The most common trauma is lower extremity (36.2%) followed by upper extremity (19.9%), head (16.6%), spine (13.1%), chest (11.3%), and abdomen (3.8%). The most common earthquake-related head injury was laceration or contusion (59.1%), while epidural hematoma was the most common among inpatients with intracranial hemorrhage (9.5%) followed by intracerebral hematoma (7.0%), and subdural hematoma (6.8%). Mortality rate was 5.6%.

CONCLUSION

Head injuries were found to be a commonly occurring trauma along with extremity injuries. This knowledge is important for determining the demands for neurosurgery and for adequately managing patients, especially in resource-limited conditions.

Estimation of the Demand for Hospital Care After a Possible High-Magnitude Earthquake in the City of Lima, Peru

Introduction A model prepared by National Civil Defense (INDECI; Lima, Peru) estimated that an earthquake with an intensity of 8.0 Mw in front of the central coast of Peru would result in 51,019 deaths and 686,105 injured in districts of Metropolitan Lima and Callao. Using this information as a base, a study was designed to determine the characteristics of the demand for treatment in public hospitals and to estimate gaps in care in the hours immediately after such an event.

METHODS

A probabilistic model was designed that included the following variables: demand for hospital care; time of arrival at the hospitals; type of medical treatment; reason for hospital admission; and the need for specialized care like hemodialysis, blood transfusions, and surgical procedures. The values for these variables were obtained through a literature search of the databases of the MEDLINE medical bibliography, the Cochrane and SciELO libraries, and Google Scholar for information on earthquakes over the last 30 years of over magnitude 6.0 on the moment magnitude scale.

RESULTS

If a high-magnitude earthquake were to occur in Lima, it was estimated that between 23,328 and 178,387 injured would go to hospitals, of which between 4,666 and 121,303 would require inpatient care, while between 18,662 and 57,084 could be treated as outpatients. It was estimated that there would be an average of 8,768 cases of crush syndrome and 54,217 cases of other health problems. Enough blood would be required for 8,761 wounded in the first 24 hours. Furthermore, it was expected that there would be a deficit of hospital beds and operating theaters due to the high demand.

CONCLUSION

Sudden and violent disasters, such as earthquakes, represent significant challenges for health systems and services. This study shows the deficit of preparation and capacity to respond to a possible high-magnitude earthquake. The study also showed there are not enough resources to face mega-disasters, especially in large cities. Bambarén C , Uyen A , Rodriguez M . Estimation of the demand for hospital care after a possible high-magnitude earthquake in the City of Lima, Peru. Prehosp Disaster Med. 2017;32(1):106-111.

A Sex Disparity Among Earthquake Victims

OBJECTIVE

Understanding who is most vulnerable during an earthquake will help health care responders prepare for future disasters. We analyzed the demography of casualties from the Christchurch earthquake in New Zealand.

METHODS

The demography of the total deceased, injured, and hospitalized casualties of the Christchurch earthquake was compared with that of the greater Christchurch population, the Christchurch central business district working population, and patients who presented to the single acute emergency department on the same month and day over the prior 10 years. Sex data were compared to scene of injury, context of injury, clinical characteristics of injury, and injury severity scores.

RESULTS

Significantly more females than males were injured or killed in the entire population of casualties (P20% were injured at commercial or service localities (444/2032 males [22%]; 1105/4627 females [24%]). Adults aged between 20 and 69 years (1639/2032 males [81%]; 3717/4627 females [80%]) were most frequently injured.

CONCLUSION

Where people were and what they were doing at the time of the earthquake influenced their risk of injury.

Resource-poor settings: response, recovery, and research: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

Planning for mass critical care in resource-poor and constrained settings has been largely ignored, despite large, densely crowded populations who are prone to suffer disproportionately from natural disasters. As a result, disaster response has been suboptimal and in many instances hampered by lack of planning, education and training, information, and communication.

METHODS

The Resource-Poor Settings panel developed five key question domains; defining the term resource poor and using the traditional phases of the disaster cycle (mitigation/preparedness/response/recovery). Literature searches were conducted to identify evidence to answer the key questions in these areas. Given a lack of data on which to develop evidence-based recommendations, expert-opinion suggestions were developed, and consensus was achieved using a modified Delphi process.

RESULTS

The five key questions were as follows: definition, capacity building and mitigation, what resources can we bring to bear to assist/surge, response, and reconstitution and recovery of host nation critical care capabilities. Addressing these led the panel to offer 33 suggestions. Because of the large number of suggestions, the results have been separated into two sections: part I, Infrastructure/Capacity in the accompanying article, and part II, Response/Recovery/Research in this article.

CONCLUSIONS

A lack of rudimentary ICU resources and capacity to enhance services plagues resource-poor or constrained settings. Capacity building therefore entails preventative strategies and strengthening of primary health services. Assistance from other countries and organizations is often needed to mount a surge response. Moreover, the disengagement of these responding groups and host country recovery require active planning. Future improvements in all phases require active research activities.

Comparison of Injury Epidemiology Between the Wenchuan and Lushan Earthquakes in Sichuan, China

Objective

We aimed to compare injury characteristics and the timing of admissions and surgeries in the Wenchuan earthquake in 2008 and the Lushan earthquake in 2013.

Methods

We retrospectively compared the admission and operating times and injury profiles of patients admitted to our medical center during both earthquakes. We also explored the relationship between seismic intensity and injury type.

Results

The time from earthquake onset to the peak in patient admissions and surgeries differed between the 2 earthquakes. In the Wenchuan earthquake, injuries due to being struck by objects or being buried were more frequent than other types of injuries, and more patients suffered injuries of the extremities than thoracic injuries or brain trauma. In the Lushan earthquake, falls were the most common injury, and more patients suffered thoracic trauma or brain injuries. The types of injury seemed to vary with seismic intensity, whereas the anatomical location of the injury did not.

Conclusions

Greater seismic intensity of an earthquake is associated with longer delay between the event and the peak in patient admissions and surgeries, higher frequencies of injuries due to being struck or buried, and lower frequencies of injuries due to falls and injuries to the chest and brain. These insights may prove useful for planning rescue interventions in trauma centers near the epicenter. (Disaster Med Public Health Preparedness. 2014;8:541-547)

Retrospective cohort analysis of chest injury characteristics and concurrent injuries in patients admitted to hospital in the Wenchuan and Lushan earthquakes in Sichuan, China

BACKGROUND

The aim of this study was to compare retrospectively the characteristics of chest injuries and frequencies of other, concurrent injuries in patients after earthquakes of different seismic intensity.

METHODS

We compared the cause, type, and body location of chest injuries as well as the frequencies of other, concurrent injuries in patients admitted to our hospital after the Wenchuan and Lushan earthquakes in Sichuan, China. We explored possible relationships between seismic intensity and the causes and types of injuries, and we assessed the ability of the Injury Severity Score, New Injury Severity Score, and Chest Injury Index to predict respiratory failure in chest injury patients.

RESULTS

The incidence of chest injuries was 9.9% in the stronger Wenchuan earthquake and 22.2% in the less intensive Lushan earthquake. The most frequent cause of chest injuries in both earthquakes was being accidentally struck. Injuries due to falls were less prevalent in the stronger Wenchuan earthquake, while injuries due to burial were more prevalent. The distribution of types of chest injury did not vary significantly between the two earthquakes, with rib fractures and pulmonary contusions the most frequent types. Spinal and head injuries concurrent with chest injuries were more prevalent in the less violent Lushan earthquake. All three trauma scoring systems showed poor ability to predict respiratory failure in patients with earthquake-related chest injuries.

CONCLUSIONS

Previous studies may have underestimated the incidence of chest injury in violent earthquakes. The distributions of types of chest injury did not differ between these two earthquakes of different seismic intensity. Earthquake severity and interval between rescue and treatment may influence the prevalence and types of injuries that co-occur with the chest injury. Trauma evaluation scores on their own are inadequate predictors of respiratory failure in patients with earthquake-related chest injuries.

Lessons learnt from the Wenchuan earthquake: performance evaluation of treatment of critical injuries in hardest-hit areas

OBJECTIVES

Critical injury treatment in the hardest-hit areas after a great earthquake was retrospectively analyzed to determine how best to reduce mortality and disability and increase the rehabilitation rate through postquake medical relief.

METHODS

Retrospective analysis, primary sources, and secondary sources were comprehensively retrieved and analyzed.

RESULTS

According to incomplete data, 30,620 injured were rescued by themselves among the hardest-hit areas in the 72 hours immediately following the earthquake. Critically injured patients accounted for 22% of total inpatients. Mortality rates declined with greater distance from the epicenter: rates were 12.21% for municipal healthcare centers in the hardest-hit areas, 4.50% for municipal medical units in peripheral quake-hit areas, 2.50% for provincial medical units in peripheral quake-hit areas, and 2.17% for Ministry of Health-affiliated hospitals in peripheral quake-hit areas. The number of injured with fractures on body, limbs or unknown-parts, severe conditions as well as other kinds of non-traumatic diseases received in second-line hospitals was much more than those treated in first-line hospitals with more severe injuries. Among 10,373 injured in stable condition transferred to third-line hospitals, 99.07% were discharged from hospitals within four months, while the mortality rate was 0.017%.

CONCLUSIONS

The medical relief model of "supervising body helping subordinate unit, severely stricken areas assisting hardest-hit areas, least-hit areas supporting both hardest-hit and severely stricken areas, and self help and mutual assistance applied between hardest-hit areas" was roughly established for injured from severely stricken areas after the Wenchuan Earthquake. The "four-centralization" treatment principle, which referred to concentrating patients, experts, resources and treatment for those injured in critical condition effectively reduced the mortality from 15.06% to 2.9%. Timely, scientific, and standard on-site triage and postmedical transfer guided by accurate injury information determine rescue effect for the injured, while there is large space to fulfill as for treatment for critical diseases among the hardest-hit areas under extreme conditions after the Wenchuan earthquake.

Patient influx and trauma types in a front-line hospital and a secondary referral hospital after the Wenchuan earthquake: a retrospectively comparative study

PURPOSE

To better understand the differences of patient influx and types of trauma between front-line and referral hospitals after the Wenchuan earthquake, so as to improve the efficiency of injury management.

METHODS

A retrospective and comparative study was performed in Deyang People's Hospital (a front-line hospital) and West China Hospital (a secondary referral hospital).

RESULTS

A total of 1,106 patients were admitted to the front-line hospital, and 1,775 to the secondary referral hospital. The patient flow peaked within 24 h after the quake, and decreased dramatically thereafter in the front-line hospital, while it peaked 2 days after the disaster in the referral one. Extremities were the most frequent location of all identified injuries (48.4% in the front-line hospital and 49.5% in the second-line hospital). Head and trunk injuries were more frequent in the front-line hospital than the referral hospital. Most of the deaths in the front-line hospital occurred within 24 h (6/8), whilst most in the referral hospital died more than 7 days (29/30) after the earthquake. While the total mortality in the front-line hospital was less than that in the referral hospital (0.7 vs 1.7%), the critical mortality in the former was higher (22.8 vs 9.4%).

CONCLUSIONS

There were dramatically different features in terms of quake-related patient influx and types of injury between the epicenter and less-affected hospitals.

Multiple injuries after earthquakes: a retrospective analysis on 1,871 injured patients from the 2008 Wenchuan earthquake

Introduction

Multiple injuries have been highlighted as an important clinical dimension of the injury profile following earthquakes, but studies are scarce. We investigated the pattern and combination of injuries among patients with two injuries following the 2008 Wenchuan earthquake. We also described the general injury profile, causes of injury and socio-demographic characteristics of the injured patients.

Methods

A retrospective hospital-based analysis of 1,871 earthquake injured patients, totaling 3,177 injuries, admitted between 12 and 31 May 2008 to the People's Hospital of Deyang city (PHDC). An electronic, webserver-based database with International Classification of Diseases (ICD)-10-based classification of earthquake-related injury diagnoses (IDs), anatomical sites and additional background variables of the inpatients was used. We analyzed this dataset for injury profile and number of injuries per patient. We then included all patients (856) with two injuries for more in-depth analysis. Possible spatial anatomical associations were determined a priori. Cross-tabulation and more complex frequency matrices for combination analyses were used to investigate the injury profile.

Results

Out of the 1,871 injured patients, 810 (43.3%) presented with a single injury. The rest had multiple injuries; 856 (45.8%) had two, 169 (9.0%) patients had three, 32 (1.7%) presented with four injuries, while only 4 (0.2%) were diagnosed with five injuries. The injury diagnoses of patients presenting with two-injuries showed important anatomical intra-site or neighboring clustering, which explained 49.1% of the combinations. For fractures, the result was even more marked as spatial clustering explained 57.9% of the association pattern. The most frequent combination of IDs was a double-fracture, affecting 20.7% of the two-injury patients (n = 177). Another 108 patients (12.6%) presented with fractures associated with crush injury and organ-soft tissue injury. Of the 3,177 injuries, 1,476 (46.5%) were fractures. Most injuries were located in the head (22.9%) and lower extremities (30.8%).

Conclusions

Multiple injuries are put forward as an important component of the injury profile after this earthquake. A pattern of injury combinations and spatial aggregation of injuries was also found. Clinical diagnosis and treatment should be adapted to care of these patients. More studies are needed to generalize these findings.

Lessons learned from the Wenchuan earthquake

OBJECTIVES

To conclude experience and lessons from emergency medical rescue after Wenchuan Earthquake from national and overall review for consideration on worldwide catastrophe rescue in the future.

METHODS

To systematically collect huge amount of primary data, and to make analysis, draw conclusions and lessons in terms of five aspects respectively as quake-damage conditions, command system, emergency medical rescue, prevention and control over infectious diseases as well as pairing-assistance for medical system and service reconstruction.

RESULTS

1. Numbers as of the death, injured and migrants made Wenchuan Earthquake ranked one of the top 9 catastrophes around the world during the past two decades. 2. Countermeasures such as four-level linkage by nation-province-city-county model, mutual assistance between military force and local forces, frontline commanding did effectively ensure the dispatch and cooperation among rescue forces. 3. Three-leveled medical transfers, "four concentrations" prevention and treatment besides whole-course rehabilitation at early stage managed to lower mortality and disability rate to minimum levels respectively. 4. "Four-keynote infectious disease control" under whole coverage and "five measures and four reinforcement measures" in settlements made rates as for those infectious diseases under the average level as those in the 3 pre-quake years. 5. Pairing-assistance in terms of talents, finance, materials as well as capacity building between other 18 provinces/municipalities and those 18 extremely-stricken/severely-stricken areas in Sichuan Province guaranteed efficient post-quake reconstruction, system reconstruction and long-term mechanism construction.

CONCLUSIONS

Successful experience from Wenchuan Earthquake could be summarized as: one goal as people-oriented life-rescuing. Two tasks as medical rescue for diseases of those injured and healthcare & anti-epidemic for safe and sound of those lives. Three strategies respectively as medical transfers after on-site triage, treatment for severe diseases in quake-hit areas and rehabilitation in non quake-hit areas for medical rescue, and quick post-quake evaluation, quick promotion for whole coverage and scientific regulation in long term for healthcare & anti-epidemic. Four measures as concentration for patients, experts, resources and treatment respectively for medical rescue, and key regions, key groups, key infectious diseases and key steps for healthcare & anti-epidemic. Five links as overall commanding, medical rescue, healthcare and anti-epidemic, physical/mental rehabilitation and post-quake reconstruction. And whole course surveillance as information guidance, policy guarantee, data collection, evidence producing, effectiveness evaluation, and academic communication.

Predictive factors for acute renal failure in crush injuries in the Sichuan earthquake

INTRODUCTION

The Sichuan earthquake caused a large number of crush injuries and many of them developed acute renal failure (ARF). A retrospective study was performed on victims with crush injuries of West China Hospital to investigate the predictive factors for acute renal failure (ARF) in crush injuries.

PATIENTS AND METHODS

Medical records of injured victims treated in West China Hospital within the first week after the Sichuan earthquake were retrospectively reviewed and 101 patients with crush injury were enrolled in the study. We divided them into an ARF group and a non-ARF group. The clinical data of included patients were extracted and analysed.

RESULTS

Patients with ARF accounted for 42% of the included population. Patients younger than 20 made up the biggest age category (45%), and the entrapped time under the debris (22 [IQR 3.5-38]h) was longer than previous reports. In univariate analysis, male gender, multiple crush injuries, medical comorbidities, surgical interventions and infections were more frequent in patients with ARF than in those without ARF. Mean arterial pressure was higher in the ARF group. Besides, the risk of ARF was increased by creatine kinase >14,494.5IU/L most significantly, followed by time under the rubble >4h, aspartate transaminase >453.5IU/L, albumin <27.15g/L and white blood cell >11.8×10(9)/L. In multivariate analysis, male gender, time under the rubble, multiple crush injuries, surgical interventions, infections and creatine kinase level were independently associated with ARF in crush injuries.

CONCLUSIONS

The entrapped time under the debris, multiple crush injuries, male gender, infections, and creatine kinase level are predictive factors for ARF in crush injuries.

Emergency medical rescue efforts after a major earthquake: lessons from the 2008 Wenchuan earthquake

Major earthquakes often result in incalculable environmental damage, loss of life, and threats to health. Tremendous progress has been made in response to many medical challenges resulting from earthquakes. However, emergency medical rescue is complicated, and great emphasis should be placed on its organisation to achieve the best results. The 2008 Wenchuan earthquake was one of the most devastating disasters in the past 10 years and caused more than 370,000 casualties. The lessons learnt from the medical disaster relief effort and the subsequent knowledge gained about the regulation and capabilities of medical and military back-up teams should be widely disseminated. In this Review we summarise and analyse the emergency medical rescue efforts after the Wenchuan earthquake. Establishment of a national disaster medical response system, an active and effective commanding system, successful coordination between rescue forces and government agencies, effective treatment, a moderate, timely and correct public health response, and long-term psychological support are all crucial to reduce mortality and morbidity and promote overall effectiveness of rescue efforts after a major earthquake.

Risk factors of earthquake inpatient death: a case control study

Introduction

At 2:28 p.m. on 12 May, 2008, a devastating earthquake measuring 8.0 on the Richter scale hit Wenchuan County, Sichuan Province in southwest China, and resulted in the deaths of thousands of people. To date, few epidemiological studies have been conducted on the determinants of the mortality of patients hospitalised after an earthquake. This paper is aimed at identifying the contributing factors of mortality and providing a clinical reference for the management of those injured in earthquakes.

Methods

A hospital-based case-control study was conducted. Cases included all deaths (n = 36) due to earthquake injuries in the West China Hospital. Controls were the quake survivors from the same hospital by at a ratio of four survivors to one death matched for sex and age. Data sources included death certificates and medical records. A conditional logistic regression was performed to assess the odds ratio (OR) of variables used in the study. A chi-squared test for trend was performed to reveal the possible relations between risk factor (variable) number and case fatality.

Results

People with a severe traumatic brain injury (TBI) had the greatest risk of death (adjusted OR = 253.3, 95% confidence interval (CI) = 8.9 to 7208.6), followed by patients with multiple system organ failure (MSOF; adjusted OR = 87.8, 95% CI = 3.9 to 1928.3). Prior major disease and infection significantly increased the risk of earthquake-related death (adjusted OR = 14.9, 95% CI = 1.9 to 119.0; adjusted OR = 13.7, 95% CI = 1.8 to 103.7; respectively). The number of fatal cases increased as the risk factor numbers also increased.

Conclusions

Severe TBI, infection, MSOF and prior major disease are the significant determinants of earthquake-related inpatient death in the 2008 Wenchuan earthquake. Future research with a large sample size including macro- and micro-level factors is needed.