A needful, unique, and in-place evaluation of the injuries in earthquake victims with computed tomography, in catastrophic disasters! The 2023 Turkey-Syria earthquakes: part II

SUMMARY

OBJECTIVE:

This study aimed to determine the computed tomography findings associated with very recent catastrophic 2023 Turkey-Syria earthquake-related injuries and their anatomotopographic distribution in the adult population.

METHODS:

The incorporated computed tomography scans of 768 adult cases who had been admitted to the hospital and had undergone computed tomography imaging after these tragic disasters had been examined on the Teleradiology Reporting System of the Turkish Ministry of Health. To this end, the injuries were classified into six categories: head, thoracic, spinal, pelvic, extremity, and abdominal injury, with three age groups (18–34, 35–64, and ³65 years) and four different imaging intervals (<24, 24–48, 49–72, and >72 h).

RESULTS:

This study incorporated 316 (41.1%) cases on the first day, 57 (7.5%) on the second day, 219 (28.5%) on the third day, and 176 (22.9%) on the fourth day after the earthquake or later. Of the 768 cases, 109 (14.2%) had a head injury, 100 (13.0%) had a thoracic injury, 99 (12.9%) had a spinal injury, 51 (6.6%) had a pelvic injury, 41 (5.4%) had an extremity injury, and 11 (1.4%) had an abdominal injury.

CONCLUSION:

In these regrettable earthquake disasters, we determined a high ratio of head injuries, which was closely followed by thoracic and spinal injuries, in our preliminary outcomes for the pediatric population, Part I. The frequency of abdominal injuries was low among individuals who experienced the earthquake. Last but not least, we have noticed a higher likelihood of spinal injury in individuals older than 65 years in the studied population.

KEYWORDS:
Earthquake; Adult; Tomography; Radiology; Surgery

INTRODUCTION

Ab imo pectore, a regrettable and catastrophic earthquake with a magnitude of at least 7.8 on February 6, 2023, at 4:17 a.m., deeply affecting the south and east of Turkey and the northern and western parts of Syria. Straight after, 9 h after the first earthquake, a second tragic earthquake with a magnitude of 7.6 occurred in the same geographic regions. Official reports state that the earthquake left more than 50,000 people dead and tens of thousands more wounded¹. The earthquake, per se, is estimated to have caused $84.1 billion US dollars’ worth of damage, making it one of the costliest natural disasters ever recorded. In the aftermath of such an unpredictable, huge, and wide-ranging disaster, with regret, thousands of houses collapsed, dozens of hospitals became unusable, tens of thousands of people died, and hundreds of thousands were injured.

After a massive earthquake, multiple traumas such as bone fractures, soft tissue injuries, and organ injuries due to the collapse of buildings or damage by falling objects are the most common reasons for hospital admission²–⁴. In trauma cases, X-rays and computed tomography (CT) are used in the first place to detect damage quickly⁵,⁶. After the disaster affected 11 cities in Turkey, patients were transferred to neighboring cities immediately for treatment management. Patients evaluated according to trauma guidelines were frequently examined via CT scan.

The Teleradiology Reporting System (TRS) of the Ministry of Health is a system that allows accessing images of radiological examinations on the web 7×24, reporting these images, conducting teleconsultations between radiologists, and evaluating medical images and reports in terms of quality (https://teleradyoloji.saglik.gov.tr). After the earthquakes, with the coordination of the Ministry of Health, CT examinations carried out in hospitals serving trauma patients in earthquakes began to be reported immediately by radiologists all over Turkey via the TRS. Thus, it was aimed to alleviate the burden on physicians in the regions affected by such a painful disaster.

Herein, we purposed to investigate CT imaging features seen in adult individuals from areas damaged by this massive earthquake based on images carried out by the TRS.

METHODS

Study design

This present study included patients aged 18 years or older who had a history of trauma associated with the 2023 Turkey-Syria Earthquake and had undergone CT scan imaging between February 6 and February 11, 2023, according to the TRS of the Ministry of Health. Of note, two cases who underwent surgical treatment before CT examination and six who underwent CT imaging for non-earthquake-related causes were excluded from the present study design.

Image analysis

The CT images of the cases consisting of axial sections, multiplanar reconstruction, coronal, and sagittal sections had been evaluated by two authors using the TRS of the Ministry of Health. As such, the injuries were classified into six categories: (i) head injury, (ii) thoracic injury, (iii) abdominal injury, (iv) spinal injury, (v) pelvic injury, and (vi) extremity injury. Moreover, patient demographic data concerning age, gender, anatomotopographic distribution, and types of injuries had been recorded. Herein, the differences in interpretation have been resolved with the consensus on the relevant issues. To this end, the cranial subcutaneous soft tissue, bones, and brain parenchyma had been examined for head injuries, while the bones, pulmonary parenchyma, and pleura for thoracic; the solid organs, retroperitoneal and intraperitoneal spaces for abdominal; the pelvic bones fractures for pelvic; and the vertebral bodies, the transverse and spinous processes, had been examined for spinal injuries.

Statistical analysis

The data from each patient were input into a Microsoft Excel (Microsoft Corporation, Redmond, WA, USA) chart, and data analysis was conducted on a personal computer using statistics software (SPSS for Windows, version 23.0; SPSS, Chicago). The relevant injuries in six categories were examined with regard to three age groups (18–34, 35–64, and 65 years and older) and four different imaging intervals (<24, 24–48, 49–72, and >72 h) (Figure 1). The Pearson χ² test was used in order to determine the differences associated with the age groups and imaging intervals in the involved body parts. The data were presented as n (%), and p-value lower than 0.05 were considered statistically significant.

Figure 1
The cluster bar graph shows the distribution of earthquake-related injuries by imaging intervals.

RESULTS

This study included 768 patients aged 18 or older who had a tragic earthquake-related history of trauma and had undergone CT scans between February 6 and February 11, 2023, according to the TRS of the Ministry of Health. The anatomical distribution of the injuries was evaluated regarding the four different imaging intervals and three age groups (Table 1), and the injuries were detected in 300 of these 768 cases. Of the 300 patients with injuries, 222 (74%) had injuries in a single anatomical region, 61 (20.3%) had injuries in two anatomical regions, and 17 (5.6%) had injuries in three or more anatomotopographic regions.

Table 1
Distribution of earthquake-related injuries by age, gender, and imaging intervals.

	<24 h (n=316)	24–48 h (n=57)	49–72 h (n=219)	>72 h (n=176)	Total (n=768)
Male	169 (53.5)	28 (49.1)	82 (37.4)	64 (36.4)	343 (44.7)
Female	147 (46.5)	29 (50.9)	137 (62.6)	112 (63.6)	425 (55.3)
Head injury	48 (15.1)	9 (15.8)	39 (17.8)	13 (7.4)	109 (14.2)
Thoracic injury	44 (13.9)	5 (8.8)	36 (16.4)	15 (8.5)	100 (13)
Spinal injury	40 (12.7)	3 (5.3)	34 (15.5)	22 (12.5)	99 (12.9)
Pelvic injury	23 (7.3)	6 (10.5)	15 (6.8)	7 (4)	51 (6.6)
Extremity injury	26 (8.2)	4 (7)	5 (2.3)	6 (3.4)	41 (5.4)
Abdominal injury	4 (1.3)	0 (0)	6 (2.7)	1 (0.6)	11 (1.4)
18–34 years	106 (33.5)	29 (50.9)	79 (36.1)	48 (27.3)	262 (34.1)
35–64 years	145 (45.9)	21 (36.8)	104 (47.5)	85 (48.3)	355 (46.2)
>65 years	65 (20.6)	7 (12.3)	36 (16.4)	43 (24.4)	151 (19.7)

This study included 316 (41.1%) patients examined on the first day, 57 (7.5%) patients examined on the second day, 219 (28.5%) patients examined on the third day, and 176 (22.9%) patients examined on the fourth day after the earthquake or later. A total of 425 female and 343 male patients were included in the study with an age range of 18–95 years and a mean age of 46.1 years. The present study included 262 (34.2%) cases aged between 18 and 34 years, 355 (46.2%) aged between 35 and 64 years, and 151 (19.6%) aged 65 years or older. There was no significant difference between male and female patients in terms of the anatomic location of the injury.

Of the 768 patients included in the present study, 109 (14.2%) had a head injury, while 100 (13.0%) had a thoracic injury, 99 (12.9%) had a spinal injury, 51 (6.6%) had a pelvic injury, 41 (5.4%) had an extremity injury, and 11 (1.4%) had an abdominal injury. The most common types of injury across the six anatomical localizations were, in descending order of frequency, scalp hematoma in 75 patients (7.60%), calvarial bone fracture in 52 (7.60%), and rib fracture in 47 (7.60%). In patients with head injuries, the most common finding was Scalp Hematoma, found in 75 patients, and the most common fracture was a parietal bone fracture. We determined the calvarial bone fractures in 52 cases, the intraparenchymal hematoma in 9, the subdural hematoma in 9, the subarachnoid hemorrhage in 8, the cephalic contusion in 8, the pneumocephalus in 4, the cephalic edema in 3, and the epidural hematoma in 1 patient. Eleven cases had parietal, 10 had frontal, 8 had temporal, 7 had nasal, 5 had zygomatic, 4 had occipital, 3 had maxillary, 2 had ethmoid, and 2 had mandibular fractures. Of these, 62.1% were linear, whereas 22.9% were depressed, and 15% were mixed fractures (Table 2).

Table 2
Distribution of earthquake-related injury types.

Injury		n	%
Head injury types
	SCALP hematoma	75	68.8
	Parietal fracture	11	10
	Frontal fracture	10	9.2
	Intraparenchymal hemorrhage	9	8.2
	Subdural hematoma	9	8.2
	Temporal fracture	8	7.3
	Subarachnoid hemorrhage	8	7.3
	Cephalic contusion	8	7.3
	Nasal fracture	7	6.4
	Zygoma fracture	5	4.5
	Pneumocephalus	4	3.6
	Occipital fracture	4	3.6
	Maxilla fracture	3	2.7
	Cephal oedema	3	2.7
	Ethmoid fracture	2	1.8
	Mandibular fracture	2	1.8
	Epidural hematoma	1	0.9
Thoracic injury types
	Rib fracture	47	47
	Pulmonary contusion	36	36
	Hemothorax	36	31
	Pneumothorax	19	19
	Scapula	13	13
	Clavicular fracture	5	5
	Pneumomediastinum	3	3
	Sternum fracture	1	1
	Laceration	1	1
Spinal injury types
	L1	37	37.4
	L3	34	34.3
	L2	30	30.3
	T12	19	19.2
	T11	14	14.1
	L4	13	13.1
	L5	8	8.1
	T5	7	7.1
	T10	6	6.1
	T4	5	5.1
	T6	5	5.1
	T3	5	5.1
	C6	5	5.1
	T9	4	4
	C7	4	4
	T1	3	3
	T8	3	3
	T2	2	2
	C1	2	2
	T7	2	2
Pelvic injury types
	Pubic fracture	40	78.4
	Sacrum fracture	24	47.1
	Acetabulum fracture	11	21.6
	Iliac fracture	6	11.8
	Coccyx fracture	2	3.9
	Ischium fracture	2	3.9
Extremity injury types
	Femur fracture	21	51.2
	Tibia fracture	8	19.5
	Talus fracture	5	12.2
	Humerus fracture	4	9.7
	Radius fracture	3	7.3
	Ulna fracture	2	4.8
	Patella fracture	2	4.8
	Fibula fracture	1	2.4
	Carpal fracture	1	2.4
Abdominal injury types
	Hemoperitoneum	8	72.7
	Liver	2	18.2
	Renal	1	9.1

The most common finding detected in patients with thoracic injuries was a rib fracture, which affected 47 cases. In addition, 36 cases had lung contusions, 36 hemothorax, 19 pneumothorax, 13 scapular fractures, 5 clavicular fractures, 3 pneumomediastinums, 1 sternal fracture, and 1 lung laceration.

In those with spinal injuries, fractures in levels L1, L3, and L2 were the top three most frequent fractures. The most frequently affected level was the lumbar level, while the least commonly affected level was the cervical level. Of these cases, 16 had bursts, one had translations and one had distraction-type unstable vertebral fractures. These fractures were found in the thoracolumbar levels. Of note, 92 of them are compression fractures in the anterior column of the vertebral corpus and the other vertebral fractures are stable fractures located in the transverse and spinous processes. The levels of spinal fractures are indicated in Table 2.

Of the 40 patients with pelvic injuries, 24 had pubic, 24 had sacral, 11 had acetabular, 6 had iliac, and 2 cases each had coccyx and ischial fractures. Among patients with extremity injuries, the upper extremities were injured in 37, while the lower extremities were injured in 10, involving femur fractures in 21, tibia fractures in 8, and talus fractures in 5. The levels of the other fractures are presented in Table 2. Eight patients with abdominal injuries had hemoperitoneum, two had liver lacerations, and one had a renal laceration.

DISCUSSION

Natural disasters are ecological phenomena that dramatically disrupt the normal order of life in a population. In comparison to other natural disasters such as floods, landslides, and avalanches, earthquakes can impact a greater area within a short time, resulting in the loss of both life and property⁷. Minimizing their effects requires urgent and organized aid, and the burden of loss associated with a major earthquake is also major⁸. The 1999 Marmara earthquake in Turkey resulted in more than 17,000 casualties. Meanwhile, for this earthquake, a death toll exceeding 45,000 was reported within the borders of Turkey at the time of the present study. For earthquake victims that can be rescued with injuries, a systematic and rapid assessment of the extent of the injury is important. Of note, CT is one of the most frequently employed imaging methods in the evaluation of earthquake-related injuries, in accordance with the current evidence in light of the studies in the literature⁹–¹². Therefore, we selected CT as the imaging modality in order to be utilized for the determination of earthquake-related injury profiles in the present study.

The most common injuries occurring in earthquake-related trauma patients were reported as extremity injuries¹³–¹⁵. However, due to the distribution of anatomical regions in our study, which is not compatible with the English-language literature, we encountered head trauma cases, similar to the very recent study our group conducted with pediatric cases¹². Of note, the lower rate of extremity injuries in adults compared to the literature is attributable to the exclusion of patients who underwent direct radiography but not CT for the diagnosis of isolated extremity injuries, which affected the representation of extremity injuries in the present study.

In the present study, the majority of the cases underwent imaging within 72 h, which is parallel to the study on the 1999 Marmara earthquake in this regard¹³. In this study, head injury, spinal injury, and thoracic injury were the most common injuries encountered within the first 72 h, in descending order of frequency. However, after 72 h, spinal injury, thoracic injury, and head injury were encountered the most frequently, which leads to the conclusion that physicians would have a greater responsibility for patient intervention after a natural disaster.

Determining the treatment priority for patients with injuries in multiple anatomical regions is of vital importance for the patient¹¹. In the present study, approximately 25.9% of earthquake-related trauma cases had injuries affecting two or more regions of the body. Multiple injuries are higher than the 5% reported after the 2008 Sichuan earthquake and the 15% reported after the 1995 South Hyogo and 2005 Kashmir earthquakes¹⁶,¹⁷.

We also specified the topographic sites of injury according to age groups. The most affected anatomical regions in cases aged 18–34, patients aged 35–64, and patients aged 65 or older were the head, the thorax, and the spine, respectively. The ratio of spinal injury was slightly higher above the age of 65, which may be explained by the reduced bone density in those older than 65. As such, the TRS of the Ministry of Health collects CT scans in a pool, and these scans can be interpreted by radiologists approved by the ministry in a very short period of time. Considering that the high number of patient scans would further increase the workload of the radiologists living in the earthquake zone in trauma cases and emergency conditions¹⁸–²¹, who are also victims, and that they might at times experience delays in reporting the scans, the use of the TRS of the Ministry of Health in disasters such as earthquakes offers great benefit in terms of the workload and access to CT reports. On the other hand, potential interruptions to infrastructure, including the Internet, during disasters such as earthquakes may pose a disadvantage for the TRS.

Limitations

Our study has the following three limitations: (i) as a retrospective study, we did not have trauma score data or patient outcomes such as mortality, (ii) only patients with CT images were included in the present study, and (iii) the exclusion of earthquake victims who did not undergo CT scans but were diagnosed using imaging methods such as direct radiography, sonography, or MRI.

CONCLUSION

In these regrettable earthquake disasters of extreme severity, with a magnitude of at least 7.8 and 9 h after the first earthquake, a second earthquake with a magnitude of 7.6 affecting the southern and eastern parts of Turkey and the northern and western parts of Syria, we determined a high ratio of head injuries, which was closely followed by thoracic and spinal injuries in the adults, which is similar to the preliminary results of our former study in the pediatric population, Part I. Herein, a low ratio of abdominal injuries among those who experienced the earthquake has been recognized. In addition, those older than 65 years were noticed to have a greater likelihood of experiencing a spinal injury. Herewith, we might hope our results will be useful in the development of protocols, even guidelines, and disaster preparedness for future high-magnitude earthquakes. This issue merits further investigation.

• Funding: none.

ACKNOWLEDGMENTS

The authors thank all the participants involved in this study.

REFERENCES

• ¹
  World Health Organization, Regional Office for Europe. Türkiye earthquake: external situation report no.7: 3–16 April 2023. Geneva: World Health Organization; 2023.
• ²
  Chen TW, Yang ZG, Dong ZH, Chu ZG, Tang SS, Deng W. Earthquake-related crush injury versus non-earthquake injury in abdominal trauma patients on emergency multidetector computed tomography: a comparative study. J Korean Med Sci. 2011;26(3):438-43. https://doi.org/10.3346/jkms.2011.26.3.438
  » https://doi.org/10.3346/jkms.2011.26.3.438
• ³
  Dong ZH, Yang ZG, Chen TW, Chu ZG, Deng W, Shao H. Thoracic injuries in earthquake-related versus non-earthquake-related trauma patients: differentiation via multi-detector computed tomography. Clinics. 2011;66:817-22. https://doi.org/10.1590/s1807-59322011000500018
  » https://doi.org/10.1590/s1807-59322011000500018
• ⁴
  Chu ZG, Yang ZG, Dong ZH, Chen TW, Zhu ZY, Shao H. Comparative study of earthquake-related and non-earthquake-related head traumas using multidetector computed tomography. Clinics. 2011;66(10):1735-42. https://doi.org/10.1590/s1807-59322011001000011
  » https://doi.org/10.1590/s1807-59322011001000011
• ⁵
  Iyama A, Utsunomiya D, Uetani H, Kidoh M, Sugahara T, Yoshimatsu S, et al. Emergency radiology after a massive earthquake: clinical perspective. Japan J Radiol. 2018;36:641-8. https://doi.org/10.1007/s11604-018-0771-y
  » https://doi.org/10.1007/s11604-018-0771-y
• ⁶
  Dong ZH, Yang ZG, Chen TW, Feng YC, Chu ZG, Yu JQ, et al. Crush thoracic trauma in the massive sichuan earthquake: evaluation with multidetector CT of 215 cases. Radiology. 2010;254(1):285-91. https://doi.org/10.1148/radiol.09090685
  » https://doi.org/10.1148/radiol.09090685
• ⁷
  Dong ZH, Yang ZG, Chen TW, Chu ZG, Wang QL, Deng W, et al. Earthquake-related versus non-earthquake-related injuries in spinal injury patients: differentiation with multidetector computed tomography. Critical Care. 2010;14(6):R236. https://doi.org/10.1186/cc9391
  » https://doi.org/10.1186/cc9391
• ⁸
  Mahoney LE, Reutershan TP. Catastrophic disasters and the design of disaster medical care systems. Ann Emerg Med. 1987;16(9):1085-91. https://doi.org/10.1016/s0196-0644(87)80764-3
  » https://doi.org/10.1016/s0196-0644(87)80764-3
• ⁹
  Wintermark M, Mouhsine E, Theumann N, Mordasini P, Melle G, Leyvraz PF, et al. Thoracolumbar spine fractures in patients who have sustained severe trauma: depiction with multi–detector row CT. Radiology. 2003;227(3):681-9. https://doi.org/10.1148/radiol.2273020592
  » https://doi.org/10.1148/radiol.2273020592
• ¹⁰
  Fayad LM, Corl F, Fishman EK. Pediatric skeletal trauma: use of multiplanar reformatted and three-dimensional 64-row multidetector CT in the emergency department. Radiographics. 2009;29(1):135-50. https://doi.org/10.1148/rg.291085505
  » https://doi.org/10.1148/rg.291085505
• ¹¹
  Dong ZH, Yang ZG, Chu ZG, Chen TW, Bai HL, Shao H, et al. Earthquake-related injuries: evaluation with multidetector computed tomography and digital radiography of 1491 patients. J Crit Care. 2012;27(1):103.e1-6. https://doi.org/10.1016/j.jcrc.2011.03.007
  » https://doi.org/10.1016/j.jcrc.2011.03.007
• ¹²
  Cakir IM, Sengul I, Bekci T, Tonkaz G, Eryuruk U, Onder R, et al. A needful, unique, and in-place evaluation of the injuries in earthquake victims with computed tomography, caused by catastrophic disasters! the 2023 Turkey-Syria earthquakes. Rev Assoc Med Bras. 2023 [Epub ahead of print].
• ¹³
  Bulut M, Fedakar R, Akkose S, Akgoz S, Ozguc H, Tokyay R. Medical experience of a university hospital in Turkey after the 1999 Marmara earthquake. Emerg Med J. 2005;22(7):494-8. https://doi.org/10.1136/emj.2004.016295
  » https://doi.org/10.1136/emj.2004.016295
• ¹⁴
  Tanaka H, Oda J, Iwai A, Kuwagata Y, Matsuoka T, Takaoka M, et al. Morbidity and mortality of hospitalized patients after the 1995 Hanshin-Awaji earthquake. Am J Emerg Med. 1999;17(2):186-91.https://doi.org/10.1016/s0735-6757(99)90059-1
  » https://doi.org/10.1016/s0735-6757(99)90059-1
• ¹⁵
  Onder RO, Tosun A, Ibıs E. Earthquake-related head trauma: initial consequences of an earthquake disaster. British J Hosp Med. 2023;84(2):1. https://doi.org/10.12968/hmed.2023.0055
  » https://doi.org/10.12968/hmed.2023.0055
• ¹⁶
  Yoshimura N, Nakagiri K, Azami T, Ataka K, Nakayama S, Ishii N. Profile of chest injuries arising from the 1995 southern Hyogo prefecture earthquake. Chest. 1996;110(3):759-61. https://doi.org/10.1378/chest.110.3.759
  » https://doi.org/10.1378/chest.110.3.759
• ¹⁷
  Mulvey J, Awan S, Qadri A, Maqsood M. Profile of injuries arising from the 2005 Kashmir earthquake: the first 72 h. Injury. 2008;39(5):554-60. https://doi.org/10.1016/j.injury.2007.07.025
  » https://doi.org/10.1016/j.injury.2007.07.025
• ¹⁸
  Detanac D, Filipovic N, Sengul I, Zecovic E, Muratovic S, Sengul D. Extraordinarily rare isolated intraperitoneal urinary bladder rupture in blunt abdominal injury without pelvic fracture: an aide-mémoire. Cureus. 14(8):e28576. https://doi.org/10.7759/cureus.28576
  » https://doi.org/10.7759/cureus.28576
• ¹⁹
  Doklestić K, Lončar Z, Coccolini F, Gregorić P, Mićić D, Bukumiric Z, et al. “Zooming” in strategies and outcomes for trauma cases with injury severity score, ISS, ≥16: promise or passé?. Rev Assoc Med Bras. 2022;68(6):847-52. https://doi.org/10.1590/1806-9282.20220216
  » https://doi.org/10.1590/1806-9282.20220216
• ²⁰
  Soares-Júnior JM, Sorpreso ICE, Motta EV, Utiyama EM, Baracat E. Gynecology and women's health care during the COVID-19 pandemic: patient safety in surgery and prevention. Clinics. 2020;75:e2063. https://doi.org/10.6061/clinics/2020/e2063
  » https://doi.org/10.6061/clinics/2020/e2063
• ²¹
  Milisavljevic S, Spasic M, Milosevic B. Pneumothorax – diagnosis and treatment. Sanamed. 2015;10(3):223-8. https://doi.org/10.5937/sanamed1503221m
  » https://doi.org/10.5937/sanamed1503221m

Publication Dates

• Publication in this collection
  14 Aug 2023
• Date of issue
  2023

History

• Received
  06 May 2023
• Accepted
  14 May 2023