There has been an average of more than 30 major earthquakes per year since 2005. Many of these resulted in a declaration of a state of emergency, and requests for international assistance. The extraordinary devastating earthquake and subsequent tsunami in Japan in 2011 are still in the news. At the time this post was written, discussion centered around which country would host the 2020 Summer Olympic Games, and how the Olympic Committee might help Japan recover from the 2011 disaster if the games are to be held in Tokyo. [Update: The IOC awarded the Games of the XXXII Olympiad in 2020 to Tokyo on 7 September 2013.]
What if we were on the scene right after the earthquake? Dr. Andres Missair, MD, Department of Anesthesiology, University of Miami–Miller School of Medicine, Miami, FL and colleagues reviewed reports of surgical care in the aftermath of major earthquakes from 1935 to 2012. Their findings appear in this month’s Anesthesia & Analgesia, “A Matter of Life or Limb? A Review of Traumatic Injury Patterns and Anesthesia Techniques for Disaster Relief After Major Earthquakes.”
The authors reviewed articles describing injuries following 15 major earthquakes between 1980 and 2010. More than half (54%) of survivors had traumatic injuries to the limbs. Lower limb injuries exceeded upper limb injuries in almost all of the reports. Injuries ranged from laceration and fracture to compartment syndrome. Head, abdominal, and thoracic injuries occurred in less than 30% of all earthquake survivors. Anesthesia for emergency surgery was approximately divided equally between general and MAC/regional anesthesia. Ketamine was often used, an expected result in trauma patients. In some facilities mechanical ventilation, vital sign monitors, and supplemental oxygen were not available. Intraoperative vomiting was a commonly mentioned complication and laryngospasm was seen even with MAC anesthesia.
Given the extent of limb injuries, the potential benefits of regional anesthesia are clear, although whether regional is safer than general anesthesia is not clear. Certainly, hypotension may occur with regional or neuraxial anesthesia in patients with decreased intravascular volume. Though fluid resuscitation should occur before neuraxial block placement, if this is not possible then neuraxial anesthesia might not be a good option.
It is unclear whether epidural or peripheral indwelling catheters are useful in trauma management following earthquakes. This is partly due to manpower issues (who will actually care for the catheters after the procedure?), increased infection risk, and the need for other supplies such as pumps and tubing. However, there are clear advantages to the use of catheters after procedures, including better control of pain (opioids might be in short supply), and the ability to perform subsequent procedures without an additional regional anesthesia procedure.
Inhaled general anesthetics are frequently used. However, the lack of anesthesia equipment, and the possible lack of electricity, complicate general anesthesia. Manual ventilation might be required. Portability is certainly key: the longer it takes to move equipment to the affected region, the longer the delay in managing patients who need immediate care immediately.
Lastly, most survivors will be found within 24 hours. As a result, international relief efforts must begin the moment the earthquake is reported if they are to make a difference in outcome.