Epidemiologic assessment of mortality, building collapse pattern, and medical response after the 1992 earthquake in Turkey. Disaster Reanimatology Study Group (DRSG).

BACKGROUND: Post-earthquake engineering and epidemiologic assessments are important for the development of injury prevention strategies. This paper describes mortality and its relationship to building collapse patterns and initial medical responses following the 1992 earthquake in Erzincan, Turkey. METHODS: The study consisted of: 1) background data collection and review; 2) design and implementation of a field survey; and 3) site inspection of building collapse patterns. The survey included: 1) national (n = 11) and local (n = 17) officials; 2) medical and search and rescue (SAR) workers (n = 38); and 3) a geographically stratified random sample of lay survivors (n = 105). The survey instruments were designed to gather information regarding location, injuries, initial actions and prior training of survivors and responders, and the location, injuries, and management of dead and dying victims. A case-control design was constructed to assess the relationship between mortality, location, and building collapse pattern. RESULTS: There was extensive structural damage throughout the region, especially in the city where mid-rise, unreinforced masonry buildings (MUMBs) incorporating a "soft" first floor design (large store windows for commercial use) and one story adobe structures were most vulnerable to collapse. Of 526 people who died in the city, 87% (n = 456) were indoors at the time of the earthquake. Of these, 92% (n = 418) died in MUMBs. Of 54 witnessed deaths, 55% (n = 28) of victims died slowly, the majority of whom (n = 26) were pinned or trapped (p < 0.05). Of 42 MUMB occupants identified through the survey, those who died (n = 25) were more likely to have been occupying the ground floor when compared with survivors (n = 28) (p < 0.01). Official medical and search and rescue responders arrived after most deaths had occurred. Prior first-aid or rescue training of lay, uninjured survivors was associated with a higher likelihood of rescuing and resuscitating others (p < 0.001). CONCLUSIONS: During an earthquake, MUMBs with soft ground floor construction are highly lethal, especially for occupants on the the ground floor, suggesting that this building type is inappropriate for areas of seismic risk. The vulnerability of MUMBs appears due to a lack of lateral force resistance as a result of the use of glass store front windows and the absence of shear walls. The prevalence of this building type in earthquake-prone regions needs to be investigated further. A large portion of victims dying in an earthquake die slowly at the scene of injury. Prior public first-aid and rescue training programs increase participation in rescue efforts in major earthquakes and may improve survival.

Changes in serum CPK, LDH, and their isoenzymes in the perioperative period in patients undergoing craniotomy.

The perioperative changes in the serum concentration of creatine phosphokinase (CPK) and its isoenzymes MM, MB, and BB and of lactic dehydrogenase (LDH) and its isoenzymes LDH1 to LDH5 were determined during craniotomy in order to distinguish operation-induced changes in these enzymes from those due to acute myocardial infarction and malignant hyperthermia. Twenty-eight male patients, 29 to 76 years of age (mean +/- SD = 58 +/- 13.2 years), undergoing craniotomy for tumor reseaction (n = 26) or cerebral artery aneurysm clipping (n = 2) were included in this study. Ten serial blood samples were obtained from each patient: one sample before and another after induction of anesthesia, and eight samples after the incision, over a period of 70 h. The preinduction serum CPK level of 97 +/- 32 U/L (mean +/- SD) increased gradually and significantly and reached the peak level of 542 +/- 116 U/L 34 h after incision (p <0.05). Whereas all of the CPK isoenzymes increased in terms of U/L after incision, only the MM fraction (expressed as percent of total CPK) increased, and the MB and BB fractions (expressed as percent of total CPK) decreased. The preinduction serum LDH level of 150 +/- 42 U/L (mean +/- SD) increased gradually after incision and reached the peak level of 210 +/- 32 U/L 58 h after incision (p <0.05). LDH2 as a percent of total LDH decreased significantly, but the LDH1/LDH2 ratio did not change. LDH4 and LDH5, as percents of total LDH, increased significantly. The large increases in total serum CPK and the concomitant decrease in MB percent after craniotomy may minimize and/or mask the percentage increase in the MB level following acute myocardial infarction. The perioperative serum CPK level as a marker in the diagnosis of malignant hyperthermia should be interpreted in light of the present results and in conjunction with clinical symptomatology.

Effects of bupivacaine on the membrane properties of nerve cell soma.

While the effects of local anaesthetics on axonal conduction and axonal membrane have been extensively studied, there is little information about the actions of these agents on nerve cell soma. Therefore, the effects of the amide local anaesthetic bupivacaine on the electrophysiologic properties of the nerve cell soma were studied on isolated superfused superior cervical ganglia of rats. Administration of 100-200 nM of bupivacaine to the preparation produced marked changes in membrane properties of the cell soma. The resting membrane potential did not change, but the membrane resistance decreased 20% (P less than 0.01). The firing threshold, the action potential duration at 50% of maximal amplitude, and the intracellular current threshold for firing the cells increased significantly (P less than 0.01), while the action potential amplitude decreased significantly (P less than 0.01), before its complete blockade. The results show that the cell soma is a major site of action of local anaesthetics. The implication of the results is that when local anaesthetics are applied to areas where cell bodies and processes (axons and dendrites) are present together, such as during celiac plexus block, lumbar sympathetic block, stellate ganglion block, etc., they will all be effectively depressed and/or blocked.

Bilateral Horner's syndrome and hoarseness complicating lumbar epidural anesthesia.

A case of bilateral Horner's syndrome associated with hoarseness resulting from single-dose lumbar epidural analgesia for relief of low back pain in a 57-year-old man is reported. The pathophysiology of Horner's syndrome and hoarseness is discussed.

Serum creatine phosphokinase, lactic dehydrogenase, and their isoenzymes in the perioperative period.

The purpose of the present investigation was to determine the normal perioperative variations in the serum concentration of creatine phosphokinase (CPK) and its isoenzymes MM, MB, and BB, and of lactic dehydrogenase (LDH) and its isoenzymes LDH1 to LDH5 to distinguish operation-induced changes in these enzymes from those due to acute myocardial infarction or malignant hyperthermia. In 30 patients, 52 to 75 years of age undergoing elective orthopedic operations, 10 serial blood samples were obtained in the perioperative period: two samples before skin incision and eight samples after the incision over a time span of 70 hours. The preinduction mean serum CPK level of 141 U/L increased gradually and significantly and reached a maximum mean concentration of 809 U/L 34 hours after incision (p less than 0.01). The CPK-MM percent increased after incision, whereas that of CPK-MB and CPK-BB decreased, although their absolute values in terms of U/L rose. The preinduction mean serum LDH value of 173 U/L increased gradually after incision and achieved peak levels at 34 hours (203 U/L) and 58 hours (210 U/L) after incision (p less than 0.05). The LDH1:LDH2 ratio did not change. The LDH5 percent increased and peaked 10 hours after incision (p less than 0.05). There was a significant correlation between severity of operation-induced tissue damage and the serum CPK concentration (p less than 0.001). The large increase in total CPK (primarily MM fraction) occurring after surgery may minimize the percentile effects caused by an increase in MB level due to myocardial infarction.

Transurethral prostatectomy complicated by intraperitoneal extravasation of irrigating fluid.

A patient underwent transurethral resection of the prostate (TURP), which was complicated at the outset of the procedure by an inadvertent puncture wound of the dome of the bladder and the peritoneum. Shortly after resection was initiated, the patient developed shoulder pain and a tensely distended abdomen, although at this time the serum sodium concentration remained normal. Over the next several hours the patient developed significant hyponatremia. The prolonged and gradual time course of this development suggests that fluid and electrolyte shifts occurred via diffusion across the peritoneal membrane. This case illustrates a rare but potentially dangerous complication of TURP that requires recognition prior to initiation of appropriate therapy.

Unrecognized tracheo-oesophageal fistula.

A patient with a retropharyngeal carcinoma was anaesthetized for laryngoscopy, oesophagoscopy and biopsy. Suggestive symptoms of a tracheo-oesophageal fistula were absent and a barium swallow did not demonstrate its presence. Sign of an abnormal communication appeared for the first time after the patient had been intubated and positive airway pressure applied. Measures which might be taken to overcome this problem are suggested.

Reaction to indigo carmine.

The commonly encountered cardiovascular effects of intravenous indigo carmine administration is transient alpha-receptor stimulation, namely increased total peripheral resistance, diastolic and systolic blood pressure, and central venous pressure with decreased cardiac output, stroke volume and heart rate. These usually cause no problems and frequently go undetected unless the patient is monitored closely during that brief interval. However, significant problems occur occasionally and its use is not totally without risks.

Hazards in use of anode endotracheal tube a case report and review.

While the design and manfacture of plastic tubes have been greatly improved in recent years, spiral-metal-bound latex tubes are still subject to a number of hazards, among them herniation of the intramural cuff-inflating tube into the lumen of the anode tube, preventing entry or exit of gases through the anode tube after cuff inflation. Problems may also occur at the bevel and at juctions. Until better-designed anode tubes are available, extra care is required in their use.