Two destructive earthquakes with magnitudes of 7.7 and 7.6 struck Turkey on February 6, 2023, causing heavy damage. Thousands were injured, over 51 thousand lost their lives, and more than 448 thousand were evacuated from the region. The earthquakes affected an area of 108 812 km² covering 11 provinces. 1 Following the earthquakes, a level 3 emergency was declared by the World Health Organization. 2 Kayseri was prioritized for transferring victims and the Kayseri City Training and Research Hospital received the most injured victims. This hospital has a total capacity of 1607 beds and includes 258 Intensive Care Beds, along with various specialized units.
Earthquakes lead to a surge in injuries, especially severe tissue damage, causing complications like compartment syndromes and dislocation-fractures frequently seen in post-earthquake medical emergencies.Reference Ahmad, Ahmad and Rodríguez 3 –Reference Yılmaz, Karakayali and Yilmaz 8
A crush injury occurs when force or compression is applied to a part of the body, usually as a result of an injury, accident or rubble. Such injuries are mostly anatomical injuries associated with direct trauma that occur when 2 heavy objects squeeze a part of the body between them.Reference Yıldız, Özkan, Ay and Kıralp 9 –Reference Portela and Roney 11 A crush injury occurs when a body part is squeezed between heavy objects due to an accident or injury. These injuries are common after earthquakes.Reference Bartels and Vanrooyen 12 –Reference Fethi Ceylan, Serbest and Güven 14
HBOT is a treatment that involves the inhalation of 100% oxygen under high pressure in a closed environment called a pressure chamber and has attracted increasing interest in the treatment of post-traumatic tissue damage in recent years. This treatment method aims to provide adequate oxygen supply to injured areas and has the potential to accelerate the healing process of tissues. However, there is still insufficient data in the literature on the efficacy and outcomes of HBOT in the treatment of post-earthquake traumatic injuries. The effectiveness of HBOT in the treatment of traumatic injuries following the earthquake has begun to be reported in an analysis of recent studies.Reference Torp and Murphy-Lavoie 15 –Reference Myers 18
The aim of this study was to present a retrospective evaluation of patients admitted to hospital after the Kahramanmaraş earthquake, who had tissue damage to body parts and received HBOT. This evaluation aimed to provide important information that will help us better understand the effects and consequences of hyperbaric oxygen therapy on these types of injuries. Additionally, this study aims to provide a valuable contribution towards better planning and optimization of emergency medical interventions following similar natural disasters.
Methods
This study was conducted after the approval of the Clinical Research Ethics Committee of Kayseri City Training and Research Hospital with the number 2023/883. In this study, data of the patients who were admitted to Kayseri City Training and Research Hospital as earthquake victims between February 6, 2023 and March 6, 2023 and who were treated in the HBOT unit for tissue injury after clinical evaluation were retrospectively scanned. Written, signed informed consent was obtained from all patients for the use of their data for scientific purposes. In the case of pediatric patients, consent was obtained from their parents or legal guardians, or from close relatives if the parents were not available. The patient information was recorded in the patient information form. The necessary data were obtained retrospectively from sources such as hospital records, photographs, emergency department reports, clinical epicrisis notes, imaging results, and surgical notes. After being discharged from hospital, the patients were contacted to obtain information about the sensation and function of their extremities. To classify the severity of tissue damage in patients, Mangled Extremity Severity Score (MESS) were employed, based on the scoring of skeletal-soft tissue, shock, ischemia, and age criteria measured at the time of hospital admission.Reference Johansen, Daines and Howey 19 , Reference Özel, Altintaş and Tatliparmak 20
Data Analysis
The data obtained from the study were analysed using the SPSS 22.00 package. In the analysis of the data, descriptive statistics (number, percentage, mean) and Kolmogorov-Smirnov were used to test the suitability of data for normal distribution, and the Mann-Whitney U test was used because data were not normally distributed. Spearman correlation analysis was used to examine the relationship between post-earthquake patient data. The results were accepted with a 95% confidence interval and significance was accepted at the P < 0.05 level.
Results
Demographic Findings
A total of 51 earthquake survivors, 21 males (39.2%) and 30 females (60.8%), were admitted to the HBOT Unit after clinical evaluations among the patients who received treatment at Kayseri City Training and Research Hospital after the Kahramanmaraş earthquakes. Of these patients, 20 (41.2%) were 18 years old or younger, while 31 (58.8%) were 19 years old or older.
Results of Mangled Extremity Severity Scores (MESS)
MESS Score and Number of Patients (n:51);
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• Number of patients with MESS 6: 15 (29.4%)
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• Number of patients with MESS 7: 2 (4%)
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• Number of patients with MESS 8: 18 (35.2%)
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• Number of patients with MESS 9: 5 (9.8%)
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• Number of patients with MESS 10: 8 (15.7%)
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• Number of patients with MESS 11: 1 (2%)
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• Number of patients with MESS 12: 1 (2%)
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• Number of patients with MESS 13: 1 (2%)
According to the MESS distribution, patients with a score between 1-6 are generally low risk, while scores between 7-14 indicate high risk. In total, the number of patients with a MESS Score between 7-14 who could be considered for amputation was determined to be 36.
In the study, it was determined that patients spent an average of 43.86 ± 31.76 hours under earthquake rubble, ranging from 1-120 hours. The earliest initiation of the first Hyperbaric Oxygen Therapy (HBOT) session occurred at least 12 hours after their extraction from the rubble. The mean number of HBOT sessions per patient was 13.24 ± 7.72, once daily, lasting for 90 minutes at 2.6 atmospheres absolute (ATM), based on the severity of extremity injuries, with sessions ranging from 1 to 30, as detailed in Table 1.
General distribution and mean values of patient data (n:51)
X̄: Arithmetic Mean SD: Standard Deviation HBOT: Hyperbaric Oxygen Therapy
Anatomical distribution and functional results of the treated patients
When examining the localisation of the affected anatomical regions in the patients included in the study, the left lower extremity (29.4%) and the right lower extremity (23.5%) were the most commonly affected. The thorax was only seen in 2.0% of cases. The most common fasciotomy procedures were performed on the left lower extremity (21.6%), followed by the right lower extremity (15.7%). The most common debridement procedures were performed on the lower extremity (51%), followed by the upper extremity (17.6%). Sensory recovery was seen in 64.7% of patients and functional recovery in 62.7% of patients. Five (9.8%) of the patients had minor amputations and 6 (11.8%) had major amputations before coming to our clinic (Table 2).
Distribution of patients and related factors after the earthquake
HBOT: Hyperbaric Oxygen Therapy
Findings for comparison of MESS and related variables
The difference between the mean MESS Scores of post-earthquake patients according to the status of sensory recovery and functional recovery was statistically significant (P < 0.05). The MESS Scores of the group with sensory and functional recovery were significantly lower than those of the group without sensory and functional recovery (Table 3).
Distribution of patient data according to mess score, number of HBOT sessions, number of debridements, and time under rubble and comparison of related variables
X̄: Arithmetic Mean SD: Standard Deviation *Mann Whitney U Test HBOT: Hyperbaric Oxygen Therapy
Findings for the comparison of number of HBOT sessions and related variables
The difference between the mean HBOT session number scores of the post-earthquake patients according to the status of major amputation after HBOT was found statistically significant (P < 0.05). The number of HBOT session of the group without major amputation after HBOT was significantly higher than the group with major amputation after HBOT (Table 3).
Findings on the comparison of the number of hours under rubble and related variables
According to the functional recovery status of the patients after the earthquake; the difference between the mean scores of the hours spent under rubble was found to be statistically significant (P < 0.05). The scores of the group without functional recovery for the hours spent under rubble were significantly higher than those of the group with functional recovery (Table 3).
The photographs of our patients who were treated with HBOT before and after the treatment are given in Figure 1.
Pre-treatment (A, B, C) and post-treatment (A-1, B-1, C-1) images of patients receiving HBOT.
Discussion
HBOT is a method of delivering oxygen to hypoxic tissues by inhaling pure oxygen at high pressure. This treatment is commonly used to increase oxygen delivery to tissues and promote tissue healing.Reference Torp and Murphy-Lavoie 15 , Reference Shah 16 , Reference Myers 18 , Reference Zamboni, Roth and Russell 21 This study demonstrates that HBOT has the potential to protect both lives and limbs in cases of earthquake injuries. Of the 51 patients who underwent HBOT in our study, 35 (68.6%) had a MESS Score between 7-14 and were at high risk of amputation. Following treatment, sensory and functional recovery rates were 64.7% and 62.7%, respectively. Minor amputations were performed on 19.6% of patients, while major amputations were carried out on 9.8% of patients after treatment. Interestingly, the amputation rate did not increase as the MESS Scores of the patients increased. However, the sensory and functional recovery rates decreased as the MESS Scores increased. Importantly, no patients died during treatment. In a study concerning the prediction of amputation based on the severity of earthquake injuries, 79 patients were examined and the amputation rate was found to be 24.1%.Reference Özel, Altintaş and Tatliparmak 20 In another study investigating the necessity of amputation, 41.3% of 140 patients underwent the procedure.Reference Bingol, Karlidag and Keskin 22 Comparing these studies, which involved similar age groups, with our own study, the amputation rate of 9.8% observed in our study may indicate that HBOT reduces the rate of amputation.
Traumatic conditions such as post-earthquake crush injuries and compartment syndrome are often associated with tissue damage and impaired circulation. HBOT increases oxygen levels in the blood, allowing more oxygen to be transported to the tissues. This can accelerate tissue healing and contribute to the healing process of damaged tissues.Reference Kulakoğlu, Uzunay and Pota 7 , Reference Yıldız, Özkan, Ay and Kıralp 9 , Reference Torp and Murphy-Lavoie 15 , Reference Shah 16 , Reference Ulusoy, Kılınç and Oruç 23 –Reference Dougherty 25 In its most recent publication, Indications for Hyperbaric Oxygen Therapy (12th edition), the Undersea and Hyperbaric Medical Society recommends “Crush injury, compartment syndrome, and other acute traumatic ischemia” as one of the 13 indications for HBOT.Reference Shah 16
Many research and clinical studies show that HBOT can have positive effects on tissue healing, infection control, swelling reduction, and healthy regeneration of injured tissues.Reference Kulakoğlu, Uzunay and Pota 7 , Reference Torp and Murphy-Lavoie 15 , Reference Ulusoy, Kılınç and Oruç 23 , Reference Seaman 26
In a randomized double-blind placebo-controlled clinical trial measuring the efficacy of HBOT in the treatment of crush injuries, Bouachour et al.Reference Bouachour, Cronier and Gouello 27 reported that HBOT was effective in promoting wound healing and reducing repeat surgery.
Garcia-Covarrubias et al.Reference Garcia-Covarrubias, McSwain and Van Meter 28 in their evidence-based literature review of the efficacy of adjuvant HBOT in the treatment of crush injury and traumatic ischemia, reported that HBOT showed a beneficial effect in 8 of the 9 studies included in the review.
Yıldız et al.Reference Yıldız, Özkan, Ay and Kıralp 9 evaluated the efficacy of HBO treatment in 52 patients diagnosed with compartment syndrome due to post-earthquake crush injury and recommended the addition of HBOT as an adjunct to fasciotomy, wound debridement, and antibiotherapy in patients with compartment syndrome.
In a case series study of the effectiveness of HBOT in lower extremity trauma, Oley et al.Reference Oley, Oley and Noersasongko 29 reported that HBOT has many benefits in terms of wound healing, prevention of complications and helping patients with lower extremity trauma return to daily activities.
In an international, multicentre, randomised clinical trial of the efficacy of HBOT for lower extremity trauma, Millar et al.Reference Millar, Lind and Jansson 30 reported that early HBOT reduces tissue necrosis and the likelihood of long-term complications and improves functional outcomes in severe lower extremity trauma.
In our study, it may seem that the rate of major amputations decreased as the average number of HBOT sessions increased. However, this could be misunderstood as implying that major amputations increased among those who received fewer HBOT sessions. In reality, the result may be due to the fact that patients with major amputations did not necessarily continue HBOT sessions while others did.
Our study concludes that HBOT is effective in preserving functional limbs. However, we should consider the potential impact of patient age on these results. Because the sample included a high proportion of children, it’s possible that their higher regenerative capacity could contribute to lower amputation rates. To better understand how age affects the effectiveness of HBOT, future studies could compare the outcomes of HBOT treatment between children and adults with similar injuries. These studies should also aim to understand the biological processes that underlie the differences in response to HBOT based on age. Additionally, assessing the long-term effects of HBOT would be beneficial to determine if the initial benefits observed in children lead to lasting improvements over time.
This study focused on evaluating the effects of HBOT for post-earthquake damaged tissue. This study aims to provide new insights and advancements in the field of medicine, particularly in the treatment of traumatic tissue injuries. According to this study, HBOT has been shown to preserve both life and limbs in earthquake injuries, thereby supporting its use in emergencies following natural disasters. The findings suggest that HBOT has the potential to save sensory and functionally damaged limbs even in severe injuries. This implies that HBOT could be used in conjunction with physical therapy and surgical techniques for sensory and functional recovery. Furthermore, this study has contributed to developing medical intervention strategies following similar natural disasters. This suggests that HBOT could be integrated into emergency medical services during events such as earthquakes. This study’s results offer new insights into the positioning and effectiveness of HBOT in clinical applications, potentially encouraging its use in combination with surgical and conservative treatments. The limited availability of data in the literature on the effectiveness of HBOT in treating post-earthquake traumatic injuries underscores the significance of this study. This research enriches the scientific literature in this field and could guide clinicians in tailoring the application of HBOT to the needs of patients.
Our results showed that as the MESS Score increased in patients receiving HBOT, there was a significant decrease in the recovery of sensation and function, although there was no increase in the risk of amputation. In other words, these results suggest that HBOT rescues both functional extremities and, in severe cases, numb and dysfunctional extremities. In any case, salvaged numb and dysfunctional extremities are candidates for future restoration of sensation and function with physiotherapy and surgical techniques.
Limitations
Following a major earthquake, there was a large influx of patients to our hyperbaric unit. This situation required us to make quick and effective decisions about limb salvage and we used the MESS scoring system to assess the severity of injuries. A limitation of our study is that some MESS parameters, such as shock assessment and age scoring, may not be appropriate for children.
The study’s retrospective design and problems, such as lack of data and loss of information in a chaotic environment such as an earthquake, limit the study. Larger scale, better-planned studies are needed to evaluate the effect of HBOT on earthquake injuries.
Conclusion
These results suggest that HBOT may protect life and extremities in earthquake injuries, and it may also save numb and non-functioning extremities.
Declaration of Congress Abstract
This study has not been published anywhere before. However, the first findings obtained from the study were presented as an oral presentation at the 16th National Underwater Medicine and Hyperbaric Medicine Meeting and the oral presentation was awarded the second prize.
Author contribution
M.Ö. (0000-0002-7797-1353): Concept and design, data collection, interpretation of results, critical review, statistical analysis, manuscript writing, final approval.
L.D. (0000-0001-6600-7414): Data collection, literature search, statistical analysis, practices, final approval, interpretation of results.
Acknowledgements
The authors would like to thank Kayseri City Training and Research Hospital Orthopedic Clinic Specialist Doctor Murat Kahraman for his contributions.
Competing interests
None declared.
Ethical standard
In this study, national, and international ethical rules were observed. This study was conducted after the approval of the Clinical Research Ethics Committee of Kayseri City Training and Research Hospital with the number 22.08.2023/883.
