Frostbite fallout: analyzing cold burn injuries from the February 2023 twin earthquakes in Kahramanmaraş, Turkey

1. Introduction

Earthquakes are known to cause a significant proportion of orthopedic injuries, accounting for approximately 87% of all injuries [1]. Following earthquakes, common injuries include severe soft tissue injuries, crush injuries to the extremities, long bone fractures, open fractures and compartment syndrome [2]. Additionally, burns are frequently reported as a consequence of earthquakes, with cases documented in the literature [3]. However, thermal burns and scald burns are the predominant types reported. Despite the wealth of literature on earthquake-related injuries, data on hypothermia and cold injuries remain scarce. The Irpinia Earthquake (1980) reported only one case of hypothermia, while the Kashmir earthquake (2005) documented over 100 cases, and the Great East Japan Earthquake reported hypothermia as the cause of 0.2% of deaths [4]. However, there is a lack of literature on cold burns specifically affecting the extremities. Cold burns result from exposure to extreme cold, predominantly affecting the extremities, with initial symptoms including numbness, a sensation of heaviness resembling wood, and throbbing pain [5]. Long-term effects may include persistent pain, numbness and tingling. Assessing the extent of initial damage to the extremities is challenging. Pathophysiologically, cold burns occur through direct cellular freezing or ischemia progressing from the skin [6]. The progressive dermal ischemia is usually more harmful than the direct cell damage, and its cause is similar to the events that lead to reperfusion injury. Inflammatory mediators, such as prostaglandins, thromboxanes, bradykinin, and histamine, lead to edema formation, endothelial injury, and arrest of dermal blood flow. Thawing causes momentary and initial vasoconstriction of arterioles and venules, followed by resumption of capillary circulation and blood flow. Flow is soon disrupted by showers of emboli in microvessels. These emboli and the preexisting endothelial damage cause further tissue loss from progressive thrombosis and hypoxia [7, 8]. Clinically, cold burns are classified into four degrees and the classification is only done after rewarming: first-degree freezing presents with erythema resembling a white plaque; second-degree freezing exhibits erythema, moderate edema, and the formation of soft, clear fluid-filled blisters while maintaining skin perfusion; third-degree freezing is characterized by non-perfused skin, severe edema, and hemorrhagic blisters; and fourth-degree freezing manifests as hard black tissue [6]. Treatment priority involves providing supportive therapy based on the patient’s condition, gradual rewarming to halt direct cellular and dermal damage and active wound care [6].

Türkiye stands out as one of the most earthquake-prone regions globally, with a significant portion of its population residing in areas prone to seismic activity. Consequently, earthquakes resulting in substantial loss of life are not uncommon. Recently, two major earthquakes occurred on the same day, centered in Kahramanmaraş. With the onset of winter and temperatures dropping below 0 degrees Celsius, the risk of cold burns and hypothermia escalates for individuals trapped under rubble. This study aims to assess cases of cold burns on extremities, either brought to our clinic from the rubble or presenting to the outpatient clinic following the earthquakes on 06 February 2023, centered in Kahramanmaraş, with magnitudes of 7.7 and 7.6. The scarcity of data on post-earthquake cold burns underscores the importance of this study.

2. Materials and methods

3. Statistical analysis

Quantitative variables were examined by providing mean, standard deviation, median, 1st and 3rd quartiles, as well as minimum and maximum values. Meanwhile, qualitative variables were evaluated using frequency and percentage. Age and times of extraction from the rubble were considered qualitative variables, whereas gender, location, and depth of cold burns, initial presentation sites of patients, and treatment outcomes for those who could be followed up were considered as quantitative variables. Statistical analysis was carried out using the Statistical Package for Social Sciences (SPSS) version 21 (SPSS Inc., Chicago, IL, USA).

4. Results

The study comprised a total of 17 patients, with 64.70% (n = 11) being male and 35.30% (n = 6) female. Patients had a mean age of 36.76 ± 18.65 years, with a median age [1st Quartile–3rd Quartile] of 37.00 [20.00–52.50] years, and ages ranging from 8.00 to 70.00 years (Table 1). Extraction times from the rubble had a mean and standard deviation of 85.00 ± 19.56 hours, a median extraction time [1st Quartile–3rd Quartile] of 84.00 [69.50–102.50] hours, and ranged from 49.00 to 119.00 hours (Table 1).

Examination of cold burn areas indicated the upper extremities were the most affected, with 64.70% of patients (n = 11) showing involvement, 29.4% (n = 5) affecting the lower extremities, and 5.90% (n = 1) involving both extremities. Regarding the depth of cold burns, 58.80% of patients (n = 10) had superficial burns, while 41.20% (n = 7) had deep burns (Table 2).

Among the cold burn cases in earthquake victims brought to the hospital, there were burn degrees of all stages (Fig. 1). Out of the patients, 23.50% (n = 4) visited the outpatient clinic, while 76.50% (n = 13) went to the emergency department. In the emergency department, patients’ vital signs were stabilized, and they received treatment for hypovolemia, hypothermia, rewarming and wound care. Subsequently, patients were transferred to different provincial centers. Unfortunately, due to exceptional circumstances, follow-up for these patients was not possible. Among those who visited the outpatient clinic (n = 4), all developed necrosis, leading to amputation.

Fig. 1.Figures of frostbite cases of different degrees. (a) 3rd and 4th degree burns, necrotic tissue, (b) 3rd degree freezing is characterized by non-perfused skin, severe edema, (c) 2nd and 3rd degree burns, clear fluid-filled blisters, (d) 4th degree frostbite, hard & black texture, (e) 1st degree simple frostbite, (f) 3rd degree burn with multiple trauma.

5. Discussion

Natural disasters have plagued humankind since the beginning of our species, compelling early humans to seek protection against cold through shelter, clothing and fire as they migrated out of Africa 60,000–70,000 years ago. However, despite such measures, natural disasters can still obliterate personal belongings and infrastructure, leaving individuals vulnerable to harsh environments. One devastating consequence is death from accidental hypothermia [4]. Earthquakes, often accompanied by tsunamis, have historically caused more fatalities than any other disaster combined, with millions occurring annually, though most are minor and cause no harm [12]. However, over 80% of earthquake-related deaths have occurred in countries such as China, Japan, Pakistan, Türkiye and others. Earthquakes and tsunamis are rapid-onset disasters, and from 1994 to 2013, they resulted in an estimated 1.35 million deaths and displaced approximately 218 million people [13]. Türkiye is among the most seismically active regions globally, with the majority of its population residing in earthquake-prone areas. Notably, on 06 February 2023, two major earthquakes, with magnitudes of 7.7 and 7.6, struck Kahramanmaraş. Particularly in the aftermath of earthquakes and natural disasters during winter, frostbite injuries become a concern. Frostbite, akin to burn injuries but caused by cold [3], poses a significant risk, especially as temperatures drop below 0 degrees Celsius for those trapped under rubble. In this study, we aimed to assess cases of extremity frostbite in patients brought to our clinic following the aforementioned earthquakes or those presenting to the outpatient clinic thereafter.

The severity of symptoms typically corresponds with the severity of injury, with initial sensations of cold numbness and sensory loss often reported by patients [14]. The affected extremity may feel cold to the touch, accompanied by sensations of clumsiness, likened to a “block of wood”. Thawing and reperfusion often trigger intense pain, followed by throbbing sensations days after rewarming, which may persist for weeks or months, even after tissue demarcation. Some patients report residual tingling sensations, likely due to ischemic neuritis [15, 16]. Initial frostbite appearances seen in emergency departments can be deceptively benign, with some degree of thawing typically occurring. Tissue may appear mottled blue, violaceous, yellowish-white, or waxy, with an initial hyperemia following rapid rewarming, even in severe cases [17]. Of the 17 patients in our study, seven exhibited superficial frostbite, characterized by partial/full-thickness skin freezing, erythema, edema, hyperemia, vesicles, blisters and desquamation. The remaining ten patients had deep frostbite, involving full-thickness skin and subcutaneous freezing, violaceous/hemorrhagic blisters, black eschar formation, skin necrosis and blue-grey discoloration.

Despite the availability of primary data on anatomic locations of orthopedic extremity injuries for individual major earthquakes, no review has compiled detailed epidemiological data from these studies. While several reviews broadly characterize injury patterns as “lower limb” or “upper limb” and “open” or “closed” [2, 18], they lack detailed epidemiological information. Notably, a report on the 2011 Van earthquake indicated a higher incidence and mortality rate of flame burns. Similarly, scald injuries were predominant in the lower extremities among 40 recorded cases in the 1999 Düzce earthquake [19]. Examination of cold burn areas in our study revealed that the upper extremities were most affected, with 64.70% exhibiting upper extremity involvement, 29.4% lower extremity involvement, and 5.90% involvement of both extremities. Most studies on frostbite among civilians have noted a significant proportion of patients exhibiting cognitive impairment due to alcohol, drugs or psychiatric issues. These individuals are more commonly male, tend to develop frostbite on their extremities, and fall within the age group of 30 to 49 years [20, 21]. However, during natural disasters and earthquakes, there is no reported evidence regarding the involvement of specific age ranges or genders in these publications. In our study, out of the 17 patients examined, 64.70% were male and 35.30% were female. Frostbite cases should be transferred to the hospital without any attempt at unconscious rewarming [3]. Patients must be protected from the wind and any wet clothing should be removed, replacing it with dry garments. Vigorous rubbing must be avoided, as this can cause additional harm. Upon arrival at the emergency service, heating should be initiated as part of the treatment, but it must be done gradually [3]. To achieve this, the affected area should be slowly warmed by immersing it in warm water at approximately 40–42 degrees Celsius for 15–30 minutes. Rapid warming can lead to further damage due to secondary inflammation. For patients with systemic hypothermia, it’s important to first raise the core temperature above 35 degrees Celsius using warm intravenous fluids before addressing the warming of affected extremities. However, once warming is administered, the patient may start to experience pain, necessitating pain management. Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are used to manage pain and prevent further inflammation, though stronger pain relief, including narcotics, may be necessary.

While some sources suggest draining or excising white or cloudy blisters, hemorrhagic blisters should generally be left untouched. As with burn injuries, preventing infections and dehydration is crucial [22, 23].

Additionally, gentle cleaning and debridement are recommended. Local wound care should be provided to the affected areas [3]. In the emergency department, patients’ vital signs were stabilized, and hypovolemia and hypothermia were addressed. Reheating and wound care procedures were performed. Subsequently, the patients were referred to facilities in various provinces. Unfortunately, due to the exceptional circumstances, follow-up for these patients could not be conducted. Among all patients admitted to the outpatient clinic, amputation was necessary due to the development of necrosis. Thus, four patients who visited the outpatient clinic underwent amputation due to the progression of necrosis.

There are several limitations in our study. The first and most important of these is the chaotic healthcare system experienced in the hospital after the earthquake. In this confusion, the accuracy of patient record files may have been compromised. Another limitation is that our study is single-centered.

6. Conclusions

While frostbite injuries remain potentially disastrous and are associated with high morbidity, their risk during natural disasters in cold, temperate, and even subtropical regions can be mitigated through early warming, prompt medical treatment, and effective local wound care. Before a disaster occurs, it is vital to take preventive actions, such as conducting precise evaluations of disaster risks in particular regions and implementing hazard mapping and warning mechanisms. Additionally, safeguarding current structures within hazard zones to the maximum extent, erecting buildings outside these zones, and coordinating effective rescue efforts are imperative. Performing assessments after disasters to pinpoint shortcomings and apply remedies will aid in diminishing the likelihood of cold-related injuries in subsequent disasters.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Author contributions

MK—made conception and design, analysis and interpretation of data, drafting the manuscript. ET and LŞ—made analysis and interpretation of data and revising it critically for important intellectual content. RK—drafting the manuscript. MŞS and YO—made acquisition of data. All of the authors approved the final version to be published.

Ethics approval and consent to participate

Due to the extraordinary circumstances, we secured verbal consent from all patients, as written consent was not feasible. Our study, characterized by its retrospective observational-descriptive approach, received ethical approval from the Ethics Committee of the Faculty of Medicine, Kafkas University, under protocol number 80576354-050-99/433, dated 30 April 2024. We rigorously adhered to the ethical principles outlined in the Helsinki Declaration throughout the study.

Acknowledgment

Not applicable.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest.