Effect of Crush Syndrome Severity on Clinical Outcomes and Complications After the Earthquakes in Southeastern Türkiye

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The 2023 Kahramanmaraş earthquakes in Türkiye caused extensive crush-related trauma. The objective of this study was to assess the effect of baseline crush syndrome severity on hospitalization outcomes and complications. Methods In this multicentre, retrospective observational study, 962 crush syndrome patients hospitalized after the earthquakes were evaluated. Patients were grouped as mild-moderate vs. severe-critical based on clinical presentation. Demographics, laboratory results, comorbidities, trauma types, complications, and outcomes were assessed. Results Of 962 patients, 232 (24.1%) were classified as severe-critical and 730 (75.9%) as mild-moderate. Severe-critical patients had significantly higher rates of hypotension, ARDS, sepsis, DIC, arrhythmias, compartment syndrome, and ICU requirement (all p < 0.001). Laboratory markers including BUN, creatinine, potassium, phosphorus, liver enzymes, CK, and CRP were all significantly elevated, while calcium and albumin levels were lower in the severe-critical group (p < 0.05). Kaplan–Meier analysis revealed a significantly lower survival rate in the severe-critical group (67.7% vs. 97.7%, p < 0.001). Trauma types such as cranial, abdominal, and thoracic injuries were more frequent in this group, and prolonged entrapment time (median 24 vs. 11 hours, p = 0.031) was associated with increased severity. Conclusions Crush syndrome severity at admission is strongly associated with clinical outcomes, complication rates, and in-hospital survival. Prolonged time under the rubble, systemic complications, and elevated muscle and renal injury markers contribute to worse prognosis. These findings highlight the need for rapid triage, timely fluid resuscitation, and organized multidisciplinary intervention in future disaster scenarios. Crush Syndrome earthquakes acute kidney injury rhabdomyolysis Southeastern Türkiye Figures Figure 1 INTRODUCTION Defined as a clinical condition resulting from prolonged compression of muscle tissue, crush syndrome can lead to severe complications if not promptly recognized and managed such as acute kidney injury (AKI), electrolyte disorders, and multi-organ dysfunction [ 1 ]. Among the leading problems of the injured, most of whom were under debris for a long period of time, was crush syndrome in the aftermath of two devastating earthquakes that happened in southeastern Turkey on February 6, 2023, and seriously affected Kahramanmaraş and its surroundings [ 2 ]. In the Tangshan (1976), Armenia (1988), Kobe (1995) and Marmara (1999) earthquakes, on average range 25% of hospitalized earthquake victims had acute kidney injury, various electrolyte disturbances and the need for intensive care [ 3 ]. This rate may increase as the severity of the trauma increases. Assessing the severity of crush syndrome immediately after an earthquake is crucial for predicting hospital admissions, the risk of AKI, the need for intensive care, and mortality. Likewise, early estimation of the number of patients with severe crush syndrome is essential for anticipating supply requirements. The aim of this study is to investigate the impact of crush syndrome severity at hospital admission on clinical outcomes and complications following the catastrophic earthquakes in Southeastern region in Türkiye. In doing so, the study aims to improve disaster preparedness, resource allocation, and patient management in similar mass casualty events by identifying key predictors of poor outcomes and highlighting the importance of early intervention and aggressive management in high-risk patients. MATERIAL-METHODS Study Design, Subjects and Data Collection This multicentre, retrospective, observational study included patients diagnosed with crush syndrome who were followed up in nephrology clinics across various regions of Türkiye between April and June 2023, following the South-Eastern Anatolia earthquake. The study included participants aged 18 years and older. Patients were followed from the date of hospitalization until discharge or in-hospital death. Patients with missing data and those who presented to different centres more than once were excluded. A nationwide call for participation was initiated by the Turkish Society of Nephrology Renal Disaster Group in March 2023, using a web-based Google Form designed to collect standardized data from nephrology centres across the country. All participating centres granted permission for the use of medical data. Collected variables included patient demographics, medical history, admission vital signs, baseline laboratory data, comorbidities, in-hospital survival and disease severity, crush-related complications (such as hypotension, acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), sepsis, arrhythmia), trauma-related interventions (cranial, abdominal, thoracic trauma, compartment syndrome, fasciotomy, amputation), amount of parenteral fluid administered during the first 3 days, intensive care unit (ICU) requirement, length of hospital stay, and time under the rubble and pre-hospital rescue time. Earthquake victims were divided into groups as mild-moderate crush syndrome and severe-critical crush syndrome according to the crush syndrome severity at the time of admission. Definitions In the data forms, crush syndrome was defined as the presence of one of the systematic manifestations such as AKI, ARDS, hypovolemic shock, DIC, arrhythmias, acidosis, electrolyte disorders and surgical interventions together with crush injury [ 4 ]. Crush syndrome was identified using the diagnostic criteria established during the Marmara earthquake [ 5 ], AKI was diagnosed and staged according to the KDIGO 2012 (Kidney Disease: Improving Global Outcomes) criteria [ 6 ]. Compartment syndrome was defined as a rapid increase in localized pressure within a muscle compartment, leading to compromised circulation and tissue perfusion [ 7 ]. Fasciotomy was performed in cases with confirmed compartment syndrome to prevent irreversible ischemic damage, but it was not routinely or prophylactically employed and was reserved for situations where clinical or diagnostic findings warranted intervention. Upon clinical assessment at admission, patients were classified into two categories based on the severity of their initial clinical presentation. Mild-Moderate Crush Syndrome: This group included patients presenting with localized pain, swelling, and muscle tenderness without evidence of systemic instability. These patients exhibited no signs of circulatory dysfunction, hypotension, multi-organ failure, or neurological impairment. They did not require ICU admission or major surgical interventions such as fasciotomy or amputation. Severe-Critical Crush Syndrome: This group included patients presenting with systemic instability characterized by hypotension, shock, or multi-organ dysfunction, often necessitating ICU admission. These patients frequently had evidence of cranial, thoracic, or abdominal trauma and were at higher risk of developing life-threatening complications such as ARDS, DIC, and/or sepsis. Severe-critical cases often required aggressive management, including fasciotomy, amputation, or mechanical ventilation due to compartment syndrome and systemic organ damage. These classifications were determined at the time of hospital admission and were based primarily on clinical criteria, consistent with disaster nephrology guidelines and previous earthquake-related trauma management protocols, particularly those used during the Marmara earthquake [ 8 ]. Discharge creatinine level was defined as the creatinine level at the time of discharge or at the time of death. ICU Admission Criteria Patients with respiratory failure and requiring or likely to require respiratory support, multi-organ dysfunction syndrome, patients at major risk of morbidity and mortality following surgery, patients with cardiopulmonary arrest, life-threatening arrythmia, DIC, hypovolemic shock, severe head trauma, requirement for haemodialysis in unstable patients were followed in ICU [ 8 ]. Statistical Analysis Statistical analysis of all the statistics was performed using SPSS version 25.0 (IBM Corp., Armonk, NY, USA). Continuous data is expressed as mean ± SD if the data was normally distributed, or median and IQR for non-normally distributed data. Normality was tested by using the Shapiro–Wilk test. Continuous group comparisons were established with the Student's t-test when data were normally distributed, or the Mann–Whitney U test when data were skewed. Group differences for categorical variables are expressed as frequencies and percentages were tested with the chi-square test or Fisher's exact test, respectively. Survival times were compared by the Kaplan–Meier technique and log–rank test to compare survival curves between groups. All statistical tests were two-tailed, and p < 0.05 was considered statistically significant. RESULTS The study population consisted of 1,107 adult patients diagnosed with crush syndrome, reported from 45 nephrology centres across various regions of the country. A total of 145 entries were excluded from the analysis: 69 cases due to duplicate reporting from multiple centres, one patient undergoing chronic peritoneal dialysis, and 13 patients who were under 18 years of age. Additionally, 62 patients were excluded due to missing severity data at the time of admission. The final cohort included 962 patients, comprising 870 survivors and 92 non-survivors. Table 1 compares the demographic and biochemical characteristics of patients with crush syndrome, categorized into mild-moderate (n = 730) and severe-critical (n = 232) groups. Age and gender distribution were similar between groups; both had a median age of 39 years, and the proportion of male patients was 48.1% in the mild-moderate group and 52.6% in the severe-critical group. Patients in the severe-critical group demonstrated significantly higher rates of hypotension (38.8% vs. 2.3%), ARDS (10.2% vs. 1.7%), DIC (8.5% vs. 1.4%), sepsis (31.7% vs. 9.1%), and arrhythmias (11.9% vs. 0.8%), all showing statistical significance (p < 0.05). The prevalence of diabetes mellitus was significantly higher in the mild-moderate group than in the severe-critical group (9.5% vs. 4%, p < 0.05). Laboratory findings showed significantly higher levels of C-reactive Protein (CRP), blood urea nitrogen (BUN), creatinine, potassium, phosphorus, AST, ALT, LDH, Creatine Kinase (CK), albumin, and leukocyte counts in the severe-critical group compared to the mild-moderate group (p < 0.05). The only exception was calcium, which was significantly lower in the severe-critical group. Haemoglobin and platelet counts did not show a statistically significant difference between the groups. Regarding trauma, the incidence of cranial, abdominal, and thoracic trauma and compartment syndrome were significantly higher in the severe-critical group (p < 0.05). The need for amputation was also substantially greater in the severe-critical group (36.9% vs 23.9%, p < 0.05). Additionally, ICU admission rates were markedly higher in severe cases (95.6% vs. 40.9%, p < 0.05), highlighting the increased resource requirements for severe cases. Further details on additional laboratory and clinical parameters are presented in Table 1 . A Kaplan-Meier analysis was performed on the patients (Fig. 1). In the severe-critical group (n = 232), 75 deaths were observed (67.7% survival), with a mean survival time of 59.5 days (SE = 4.9, 95% CI: 49.9–69.1) and a median of 58.0 days (SE = 5.4, 95% CI: 47.4–68.6). In contrast, the mild-moderate group (n = 730) showed only 17 deaths (97.7% survival) and a mean survival time of 103.5 days (SE = 1.9, 95% CI: 99.8–107.2); median survival was not estimated due to extensive censoring. The difference between the groups was statistically significant (Log-rank χ² = 188.468, p < 0.001). DISCUSSION The findings of this study demonstrate that the initial clinical classification of crush syndrome severity at the time of hospital admission is strongly correlated with subsequent clinical outcomes. Patients presenting with severe-critical crush syndrome were more likely to develop complications such as hypotension, sepsis, DIC, and compartment syndrome, resulting in a higher need for ICU admission and surgical interventions such as fasciotomy or amputation. The classification criteria used in this study align with established disaster nephrology guidelines and experiences from previous earthquakes, such as the Marmara earthquake. Our results underscore the importance of early identification of high-risk patients based on clinical features, as this classification effectively predicts the likelihood of adverse outcomes and the need for aggressive management. Although the 2023 Kahramanmaraş earthquake showed a lower overall mortality rate compared to the 1999 Marmara and 2005 Kashmir earthquakes [ 9 – 11 ] -often attributed to improved disaster preparedness, early rescue efforts, and better healthcare infrastructure—it is also possible that this lower mortality reflects selection bias. Severely injured individuals may not have survived long enough to reach healthcare facilities due to delays in rescue or inaccessible terrain, resulting in a hospital cohort composed of relatively less critical patients. This possibility should be considered when interpreting mortality data from disaster settings, as it may partly explain the observed differences in survival outcomes despite improved medical response systems. Nevertheless, our findings emphasize that even with these advances and possible confounding factors, severe crush syndrome and its complications—particularly sepsis and ARDS—remain key drivers of mortality. In our study, the time under the rubble was longer in those with severe-critical crush syndrome compared to those with mild-moderate crush syndrome (p < 0.05). This finding suggests that the increased entrapment is related to worse outcomes, likely due to the exacerbation of crush-related complications such as severe rhabdomyolysis, hyperkalaemia, hypothermia, and delayed medical treatment. These results are in accordance with earlier findings demonstrating that increased duration under the rubble is associated with increased risk for severe crush syndrome [ 9 ]. Earlier research has also revealed conflicting data, however, with some studies finding no clear association between time under the rubble and AKI, the development of crush syndrome, or short-term mortality [12; 13]. One of the reasons for these inconsistencies can be the influence of other factors, i.e., severity of the initial injury, presence of oxygen while entrapment, and completeness of early resuscitation. Second, individuals with less severe injuries can be more prone to survive longer entrapment, as suggested by previous disaster reports [12; 14; 15]. These findings highlight the overriding importance of timely rescue efforts to improve survival and reduce the severity of crush-related complications. While survival beyond 10 days has been described in rare occasions, such as a remarkable instance of an individual rescued without any serious injury after 164 hours following the 2023 Kahramanmaraş earthquake [ 16 ], prolonged entrapment remains a strong risk factor for mortality and serious crush-related complications. This highlights the critical need for continued refinement of search-and-rescue operations and early medical interventions in future disaster responses. In our comparison of mild-moderate and severe-critical crush syndrome groups, neither BUN nor creatinine levels showed statistically significant differences. Elevated creatinine levels are often attributed to rhabdomyolysis-induced muscle damage, with creatinine released from injured muscle cells contributing to its rise. However, in mild-moderate versus severe-critical crush syndrome patients in our cohort, the lack of significant differences in creatinine levels may indicate that creatinine levels could be reflecting the severity of kidney injury, rather than the severity of rhabdomyolysis. There are also studies in the literature suggesting that creatinine levels are not increased by rhabdomyolysis [17; 18]. Our findings highlight the dynamic nature of BUN and creatinine as markers in disaster scenarios. This underscores the need for comprehensive clinical and laboratory evaluations in disaster medicine. Serum potassium levels in our study were considerably greater in non-survivors than in survivors (p < 0.001), underscoring the crucial role that hyperkalaemia plays in crush syndrome mortality. This result is consistent with evidence from earlier earthquakes [19; 20]. Additionally, potassium levels were higher in the severe-critical crush syndrome group compared to the mild-moderate group, further emphasizing the association between hyperkalaemia and the severity of crush-related complications. Given the high prevalence of hyperkalaemia in patients with large muscle mass, particularly in male patients, and the potentially fatal outcomes it may cause, recent recommendations underscore the need for early empirical anti-hyperkaliaemic treatment in high-risk individuals, as well as the deployment of portable point-of-care potassium analysers in the field to ensure rapid diagnosis and timely intervention [ 19 ] Hypocalcaemia is a well-known marker of severe rhabdomyolysis, often exacerbating the cardiotoxic effects of hyperkalaemia, making early diagnosis and treatment crucial in disaster settings. In our study, calcium levels were significantly lower in the severe-critical crush syndrome group (median: 7.3 mg/dL vs. 7.8 mg/dL, p < 0.05), suggesting a link between hypocalcaemia and disease severity. In contrast, phosphorus levels were significantly higher in the severe-critical group, indicating severe muscle damage and impaired renal clearance. Elevated phosphorus is strongly associated with AKI and secondary hypocalcaemia, necessitating close monitoring. Similarly, data from the Marmara earthquake identified hyperphosphatemia as a key predictor of dialysis requirement, further emphasizing its clinical significance in crush syndrome [ 20 ]. These findings highlight the importance of phosphorus control and calcium monitoring to prevent metabolic complications and improve patient outcomes. In crush syndrome, both hyponatremia and hypernatremia have been reported, reflecting the complex fluid and electrolyte disturbances [21; 22]. Hyponatremia is often linked to fluid resuscitation and non-osmotic release of vasopressin [ 22 ], while hypernatremia may result from dehydration, insensible water loss, or delayed rehydration during a disaster. In our study, sodium levels did not significantly differ between the mild-moderate and severe-critical crush syndrome groups, suggesting that sodium disturbances may not be directly associated with disease severity. This underscores the importance of individualized fluid management to maintain electrolyte balance in patients with crush syndrome. In our study, albumin levels were significantly lower in the severe-critical crush syndrome group (p < 0.05), likely reflecting systemic inflammation as a negative acute-phase reactant [1; 20]. Hypoalbuminemia may impair myoglobin clearance, contributing to renal damage and emphasizing the need for monitoring and correction in disaster settings to improve outcomes [ 23 ]. In our study, haemoglobin levels did not significantly differ between the mild-moderate and severe-critical crush syndrome groups, suggesting that haemoconcentration may not be directly related to disease severity. This contrasts with previous disaster data, such as the Marmara earthquake, where lower haemoglobin levels were interpreted as a marker of effective fluid resuscitation, particularly in oliguric patients [ 20 ]. The absence of a significant difference may reflect inter-individual variability or limitations in assessing early resuscitation efforts. These observations reinforce the complex interplay of fluid management, tissue injury, and systemic inflammatory responses in the aftermath of large-scale disasters. C-reactive protein, a sensitive marker of systemic inflammation, showed unexpected patterns in our study. CRP levels were surprisingly higher in the mild-moderate crush syndrome group compared to the severe-critical group. This counterintuitive finding may be explained by differences in clinical status and treatment interventions. Patients with severe crush syndrome, characterized by severe vital illnesses, hypotension, shock, visceral organ damage, or brain injury requiring intensive care, often receive aggressive treatments such as antibiotics and anti-inflammatory therapies, which can suppress the inflammatory response and lower CRP levels [ 24 ]. In our study, AST, ALT, CK, and LDH levels were significantly higher in the severe-critical crush syndrome group compared to the mild-moderate group, indicating a strong association between higher muscle enzyme levels and disease severity. In our study, trauma types played a critical role in determining the severity of crush syndrome. Cranial, abdominal, and thoracic traumas were significantly more prevalent among patients in the severe-critical group, indicating that these injury patterns contribute to more severe clinical presentations and complications. In contrast, extremity fractures were similarly distributed across both severity groups, suggesting their limited utility in predicting disease severity despite being the most common injury overall. These findings are consistent with previous earthquake reports, where central body traumas were also more commonly associated with poor outcomes [5; 18; 20; 25; 26]. Compartment syndrome, a critical complication of crush injuries, was significantly more frequent in patients with severe-critical crush syndrome in our study. Consistent with previous reports, it is strongly associated with increased mortality and morbidity in disaster settings. While fasciotomy is essential, timely intervention is crucial to prevent irreversible damage. However, routine fasciotomy is not recommended, as it increases the risk of sepsis and death [26; 27]. In this present study, patients with severe crush syndrome had a statistically significant greater number of amputations, even though fasciotomy rates were comparable in the mild-to-moderate and severe crush syndrome groups. Complications such as ARDS, sepsis, DIC, arrhythmias, and hypotension were significantly more frequent in severe-critical crush syndrome patients, highlighting their role in poor outcomes. Hypotension (38.8%) was a key determinant of mortality, worsening perfusion and multiorgan dysfunction, consistent with prior studies emphasizing the importance of early resuscitation [ 26 ]. Sepsis (31.7%) and ARDS (10.2%) reflected severe systemic inflammation and pulmonary injury, while DIC (8.5%) led to microvascular thrombosis and haemorrhagic complications, all of which have been strongly linked to poor prognosis in disaster settings [ 26 ]. These findings reinforce the need for rapid intervention and multidisciplinary care to manage life-threatening complications. Kaplan-Meier analysis further demonstrated a significant association between crush syndrome severity and survival outcomes. The severe-critical group had a lower survival rate (67.7%) and a median survival time of 58.0 days, while the mild-moderate group had a 97.7% survival rate (Log-rank χ² = 188.468, p < 0.001). Severe crush patients had significantly higher levels of inflammatory markers, muscle enzymes, renal dysfunction markers, and systemic complications, reinforcing the impact of prolonged entrapment, metabolic derangements, and multiorgan failure. The higher mortality rate in the severe-critical group likely reflects extensive muscle damage and systemic complications such as hypotension, sepsis, ARDS, and arrhythmias. Despite advancements in disaster preparedness and healthcare infrastructure, these findings emphasize the need for early intervention, optimized fluid resuscitation, and aggressive management to improve survival in disaster victims. Conclusions This study proves that the severity of crush syndrome at admission is a reliable predictor of clinical outcome and mortality in earthquake survivors. Mild-moderate group experienced fewer complications and demonstrated significantly better outcomes, whereas severe-critical group had increased complications, multi-organ dysfunction and higher mortality. These findings highlight the importance of early triage, early intervention, and aggressive treatment to improve survival and minimize complications in future disasters. Abbreviations ALT Alanine Aminotransferase ARDS Acute Respiratory Distress Syndrome AST Aspartate Aminotransferase BUN Blood Urea Nitrogen CK Creatine Kinase CKD Chronic Kidney Disease CRP C-reactive Protein DBP Diastolic Blood Pressure SBP Systolic Blood Pressure DIC Disseminated Intravascular Coagulation DM Diabetes Mellitus HT Hypertension ICU Intensive Care Unit LDH Lactate Dehydrogenase Declarations Conflict of interest: None Ethical approval: Approval for the study was obtained from the Istanbul University Ethics Committee dated 17.02.2023 with the approval number 04. Author Contribution K.T, S.C.K wrote the main manuscript text and S.O. prepared figure, All authors reviewed the manuscript. Acknowledgement None References Vanholder R, Sever MS, Erek E, Lameire N. 2000. Rhabdomyolysis. J Am Soc Nephrol 11:1553–61 Turgutalp K, Kıykım AA, Oto ÖA, Demir S, Çobanoğlu D, et al. 2024. 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J Trauma 42:470–5; discussion 5–6 Sever MS, Luyckx V, Tonelli M, Kazancioglu R, Rodgers D, et al. 2023. Disasters and kidney care: pitfalls and solutions. Nat Rev Nephrol 19:672–86 Sever MS, Erek E, Vanholder R, Ozener C, Yavuz M, et al. 2002. The Marmara earthquake: admission laboratory features of patients with nephrological problems. Nephrol Dial Transplant 17:1025–31 Safari S, Eshaghzade M, Najafi I, Baratloo A, Hashemi B, et al. 2017. Trends of Serum Electrolyte Changes in Crush syndrome patients of Bam Earthquake; a Cross sectional Study. Emerg (Tehran) 5:e7 Zhang L, Fu P, Wang L, Cai G, Zhang L, et al. 2013. Hyponatraemia in patients with crush syndrome during the Wenchuan earthquake. Emerg Med J 30:745–8 Ward MM. 1988. Factors predictive of acute renal failure in rhabdomyolysis. Arch Intern Med 148:1553–7 Nehring SM, Goyal A, Patel BC. 2025. C Reactive Protein. In StatPearls . Treasure Island (FL) ineligible companies. Disclosure: Amandeep Goyal declares no relevant financial relationships with ineligible companies. Disclosure: Bhupendra Patel declares no relevant financial relationships with ineligible companies.: StatPearls Publishing Copyright © 2025, StatPearls Publishing LLC. Number of. Sever MS, Erek E, Vanholder R, Akoglu E, Yavuz M, et al. 2002. Clinical findings in the renal victims of a catastrophic disaster: the Marmara earthquake. Nephrol Dial Transplant 17:1942–9 Sever MS, Erek E, Vanholder R, Koc M, Yavuz M, et al. 2004. Lessons learned from the catastrophic Marmara earthquake: factors influencing the final outcome of renal victims. Clin Nephrol 61:413–21 von Keudell AG, Weaver MJ, Appleton PT, Bae DS, Dyer GSM, et al. 2015. Diagnosis and treatment of acute extremity compartment syndrome. Lancet 386:1299–310 Tables Table 1 Baseline laboratory findings and complications observed during hospitalization according to the admission-based classification of crush syndrome severity. Mild-moderate crush syndrome (n = 730) Severe-critical crush syndrome (n = 232) Gender, Male, n (%) 351 (48.1) 122 (52.6) Age (year) 39 (28–53) 39 (28–49) SBP (mmHg)* 120 (110–135) 119.5 (97.5–134) DBP (mmHg)* 73 (66–80) 67 (60–80) Heart rate (minute)* 89 (80–100) 104 (89–116) Fever ( 0 C) 36.5 (36-36.8) 36.5 (36.1–37) Oxygen saturation (%) > 95%* 90–95% < 90%* 280 (57.6) 28 (20.7) 178(36.6) 53 (39.3) 28 (5.8) 54 (40) BUN (mg/dL)* 37 (19.5–62) 48.6 (34–77) Creatinine (mg/dL)* 1.6 (0.8–3.4) 2.82 (1.9–4.1) Sodium (mmol/L) 136 (132–139) 136 (132–140) Potassium (mmol/L)* 4.795 (4.2–5.5) 5.95 (4.9–6.6) Calcium (mg/dL)* 7.8 (7.3–8.4) 7.3 (6.6-8) Phosphorus (mg/dL)* 4.3 (3-6.1) 6.6 (4.8-9) AST (IU/L)* 336 (108–758) 712.5 (308–1374) ALT (IU/L)* 154.5 (58–309) 303 (134–594) LDH (IU/L)* 852 (460–1533) 1509 (750–3148) CK (IU/L)* 9500 (2246–46506) 27634.5 (2834–88049) CRP (mg/dL) Normal, (n) 1–5 times upper, (n)* 5–10 times upper, (n)* 10–20 times upper, (n) > 20 times upper, (n)* 14 2 82 9 132 25 190 52 261 124 Albumin (gr/dL)* 3.1 (2.6–3.7) 2.7 (2.2–3.2) Leukocyte (103/mm3)* 14575 (10640–20010) 17420 (11640–24570) Hemoglobin (gr/dL) 12.45 (10.4–14.7) 12.4 (9.3–15.6) Thrombocyte (103/mm3) 237.5 (180–300) 211 (152–279) Amount of parenteral fluid given in the first three days (ml/hour) 5 (3–8) 6 (4–6) Discharge creatinine (mg/dL)* 0.7 (0.5-1) 1.265 (0.6–2.8) Hypotension, n (%)* 15 (2.3) 73 (38.8) ARDS, n (%)* 11 (1.7) 19 (10.2) DIC, n (%)* 9 (1.4) 15 (8.5) Sepsis, n (%)* 60 (9.1) 58 (31.7) Arrythmia, n (%)* 5 (0.8) 21 (11.9) ICU need, n (%)* 296 (40.9) 219 (95.6) Comorbidity, n (%) CKD HT DM* Ischemic heart disease 17 (2.6) 5 (2.8) 95 (14.4) 17 (9.6) 63 (9.5) 7 (4) 40 (6.2) 9 (5.1) Time under the rubble (hours)* 10 (6–33) 18 (8–40) Length of hospital stays (days) 12 (6–27) 10.5 (3–30) Cranial trauma, n (%)* 68 (9.9) 43 (22.4) Abdominal trauma, n (%)* 50 (7.3) 45 (23.1) Thoracic trauma, n (%)* 170 (24.3) 98 (48) Extremity fractur, n (%) 224 (31.3) 65 (32) Compartment syndrome, n (%)* 263 (36.9) 115 (53.5) Fasciotomy, n (%) 201 (77.0) 79 (71.8) Amputation, n (%)* 62 (23.9) 41 (36.9) Survival, n (%)* 713 (97.7%) 157 (67.7%) Non-survival n (%)* 17 (2.3%) 75 (32.3%) Note : * p < 0.05 Abbreviations: ALT: Alanine Aminotransferase, ARDS: Acute Respiratory Distress Syndrome, AST: Aspartate Aminotransferase, BUN: Blood Urea Nitrogen, CK: Creatine Kinase, CKD: Chronic Kidney Disease, CRP: C-reactive Protein, DBP: Diastolic Blood Pressure, SBP: Systolic Blood Pressure, DIC: Disseminated Intravascular Coagulation, DM: Diabetes Mellitus, HT: Hypertension, ICU: Intensive Care Unit, LDH: Lactate Dehydrogenase Additional Declarations No competing interests reported. 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15:23:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7030768/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7030768/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86643097,"identity":"189eb4ff-171f-4b88-967f-c61f223adb2a","added_by":"auto","created_at":"2025-07-14 08:34:49","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":69650,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7030768/v1/47eb9150d2f44caf475e1d74.jpg"},{"id":86687607,"identity":"91f1e565-5f05-4639-b858-7578e3ec43dd","added_by":"auto","created_at":"2025-07-14 14:08:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1362505,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7030768/v1/4f84c227-4763-4b9a-89fa-5ff034110d4c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of Crush Syndrome Severity on Clinical Outcomes and Complications After the Earthquakes in Southeastern Türkiye","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eDefined as a clinical condition resulting from prolonged compression of muscle tissue, crush syndrome can lead to severe complications if not promptly recognized and managed such as acute kidney injury (AKI), electrolyte disorders, and multi-organ dysfunction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Among the leading problems of the injured, most of whom were under debris for a long period of time, was crush syndrome in the aftermath of two devastating earthquakes that happened in southeastern Turkey on February 6, 2023, and seriously affected Kahramanmaraş and its surroundings [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the Tangshan (1976), Armenia (1988), Kobe (1995) and Marmara (1999) earthquakes, on average range 25% of hospitalized earthquake victims had acute kidney injury, various electrolyte disturbances and the need for intensive care [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This rate may increase as the severity of the trauma increases. Assessing the severity of crush syndrome immediately after an earthquake is crucial for predicting hospital admissions, the risk of AKI, the need for intensive care, and mortality. Likewise, early estimation of the number of patients with severe crush syndrome is essential for anticipating supply requirements.\u003c/p\u003e\u003cp\u003eThe aim of this study is to investigate the impact of crush syndrome severity at hospital admission on clinical outcomes and complications following the catastrophic earthquakes in Southeastern region in T\u0026uuml;rkiye. In doing so, the study aims to improve disaster preparedness, resource allocation, and patient management in similar mass casualty events by identifying key predictors of poor outcomes and highlighting the importance of early intervention and aggressive management in high-risk patients.\u003c/p\u003e"},{"header":"MATERIAL-METHODS","content":"\u003cp\u003e\u003cb\u003eStudy Design, Subjects and Data Collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis multicentre, retrospective, observational study included patients diagnosed with crush syndrome who were followed up in nephrology clinics across various regions of T\u0026uuml;rkiye between April and June 2023, following the South-Eastern Anatolia earthquake. The study included participants aged 18 years and older. Patients were followed from the date of hospitalization until discharge or in-hospital death. Patients with missing data and those who presented to different centres more than once were excluded.\u003c/p\u003e\u003cp\u003eA nationwide call for participation was initiated by the Turkish Society of Nephrology Renal Disaster Group in March 2023, using a web-based Google Form designed to collect standardized data from nephrology centres across the country. All participating centres granted permission for the use of medical data. Collected variables included patient demographics, medical history, admission vital signs, baseline laboratory data, comorbidities, in-hospital survival and disease severity, crush-related complications (such as hypotension, acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), sepsis, arrhythmia), trauma-related interventions (cranial, abdominal, thoracic trauma, compartment syndrome, fasciotomy, amputation), amount of parenteral fluid administered during the first 3 days, intensive care unit (ICU) requirement, length of hospital stay, and time under the rubble and pre-hospital rescue time.\u003c/p\u003e\u003cp\u003eEarthquake victims were divided into groups as mild-moderate crush syndrome and severe-critical crush syndrome according to the crush syndrome severity at the time of admission.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDefinitions\u003c/strong\u003e\u003cp\u003eIn the data forms, crush syndrome was defined as the presence of one of the systematic manifestations such as AKI, ARDS, hypovolemic shock, DIC, arrhythmias, acidosis, electrolyte disorders and surgical interventions together with crush injury [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003c/p\u003e\u003cp\u003eCrush syndrome was identified using the diagnostic criteria established during the Marmara earthquake [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], AKI was diagnosed and staged according to the KDIGO 2012 (Kidney Disease: Improving Global Outcomes) criteria [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Compartment syndrome was defined as a rapid increase in localized pressure within a muscle compartment, leading to compromised circulation and tissue perfusion [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Fasciotomy was performed in cases with confirmed compartment syndrome to prevent irreversible ischemic damage, but it was not routinely or prophylactically employed and was reserved for situations where clinical or diagnostic findings warranted intervention.\u003c/p\u003e\u003cp\u003eUpon clinical assessment at admission, patients were classified into two categories based on the severity of their initial clinical presentation.\u003c/p\u003e\u003cp\u003eMild-Moderate Crush Syndrome: This group included patients presenting with localized pain, swelling, and muscle tenderness without evidence of systemic instability. These patients exhibited no signs of circulatory dysfunction, hypotension, multi-organ failure, or neurological impairment. They did not require ICU admission or major surgical interventions such as fasciotomy or amputation.\u003c/p\u003e\u003cp\u003eSevere-Critical Crush Syndrome: This group included patients presenting with systemic instability characterized by hypotension, shock, or multi-organ dysfunction, often necessitating ICU admission. These patients frequently had evidence of cranial, thoracic, or abdominal trauma and were at higher risk of developing life-threatening complications such as ARDS, DIC, and/or sepsis. Severe-critical cases often required aggressive management, including fasciotomy, amputation, or mechanical ventilation due to compartment syndrome and systemic organ damage.\u003c/p\u003e\u003cp\u003eThese classifications were determined at the time of hospital admission and were based primarily on clinical criteria, consistent with disaster nephrology guidelines and previous earthquake-related trauma management protocols, particularly those used during the Marmara earthquake [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDischarge creatinine level was defined as the creatinine level at the time of discharge or at the time of death.\u003c/p\u003e\u003cp\u003e\u003cb\u003eICU Admission Criteria\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePatients with respiratory failure and requiring or likely to require respiratory support, multi-organ dysfunction syndrome, patients at major risk of morbidity and mortality following surgery, patients with cardiopulmonary arrest, life-threatening arrythmia, DIC, hypovolemic shock, severe head trauma, requirement for haemodialysis in unstable patients were followed in ICU [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eStatistical analysis of all the statistics was performed using SPSS version 25.0 (IBM Corp., Armonk, NY, USA). Continuous data is expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD if the data was normally distributed, or median and IQR for non-normally distributed data. Normality was tested by using the Shapiro\u0026ndash;Wilk test. Continuous group comparisons were established with the Student's t-test when data were normally distributed, or the Mann\u0026ndash;Whitney U test when data were skewed. Group differences for categorical variables are expressed as frequencies and percentages were tested with the chi-square test or Fisher's exact test, respectively. Survival times were compared by the Kaplan\u0026ndash;Meier technique and log\u0026ndash;rank test to compare survival curves between groups. All statistical tests were two-tailed, and p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe study population consisted of 1,107 adult patients diagnosed with crush syndrome, reported from 45 nephrology centres across various regions of the country. A total of 145 entries were excluded from the analysis: 69 cases due to duplicate reporting from multiple centres, one patient undergoing chronic peritoneal dialysis, and 13 patients who were under 18 years of age. Additionally, 62 patients were excluded due to missing severity data at the time of admission. The final cohort included 962 patients, comprising 870 survivors and 92 non-survivors.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e compares the demographic and biochemical characteristics of patients with crush syndrome, categorized into mild-moderate (n\u0026thinsp;=\u0026thinsp;730) and severe-critical (n\u0026thinsp;=\u0026thinsp;232) groups. Age and gender distribution were similar between groups; both had a median age of 39 years, and the proportion of male patients was 48.1% in the mild-moderate group and 52.6% in the severe-critical group.\u003c/p\u003e\u003cp\u003ePatients in the severe-critical group demonstrated significantly higher rates of hypotension (38.8% vs. 2.3%), ARDS (10.2% vs. 1.7%), DIC (8.5% vs. 1.4%), sepsis (31.7% vs. 9.1%), and arrhythmias (11.9% vs. 0.8%), all showing statistical significance (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The prevalence of diabetes mellitus was significantly higher in the mild-moderate group than in the severe-critical group (9.5% vs. 4%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003eLaboratory findings showed significantly higher levels of C-reactive Protein (CRP), blood urea nitrogen (BUN), creatinine, potassium, phosphorus, AST, ALT, LDH, Creatine Kinase (CK), albumin, and leukocyte counts in the severe-critical group compared to the mild-moderate group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The only exception was calcium, which was significantly lower in the severe-critical group. Haemoglobin and platelet counts did not show a statistically significant difference between the groups.\u003c/p\u003e\u003cp\u003eRegarding trauma, the incidence of cranial, abdominal, and thoracic trauma and compartment syndrome were significantly higher in the severe-critical group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The need for amputation was also substantially greater in the severe-critical group (36.9% vs 23.9%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, ICU admission rates were markedly higher in severe cases (95.6% vs. 40.9%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), highlighting the increased resource requirements for severe cases. Further details on additional laboratory and clinical parameters are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eA Kaplan-Meier analysis was performed on the patients (Fig.\u0026nbsp;1). In the severe-critical group (n\u0026thinsp;=\u0026thinsp;232), 75 deaths were observed (67.7% survival), with a mean survival time of 59.5 days (SE\u0026thinsp;=\u0026thinsp;4.9, 95% CI: 49.9\u0026ndash;69.1) and a median of 58.0 days (SE\u0026thinsp;=\u0026thinsp;5.4, 95% CI: 47.4\u0026ndash;68.6). In contrast, the mild-moderate group (n\u0026thinsp;=\u0026thinsp;730) showed only 17 deaths (97.7% survival) and a mean survival time of 103.5 days (SE\u0026thinsp;=\u0026thinsp;1.9, 95% CI: 99.8\u0026ndash;107.2); median survival was not estimated due to extensive censoring. The difference between the groups was statistically significant (Log-rank χ\u0026sup2; = 188.468, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe findings of this study demonstrate that the initial clinical classification of crush syndrome severity at the time of hospital admission is strongly correlated with subsequent clinical outcomes. Patients presenting with severe-critical crush syndrome were more likely to develop complications such as hypotension, sepsis, DIC, and compartment syndrome, resulting in a higher need for ICU admission and surgical interventions such as fasciotomy or amputation. The classification criteria used in this study align with established disaster nephrology guidelines and experiences from previous earthquakes, such as the Marmara earthquake. Our results underscore the importance of early identification of high-risk patients based on clinical features, as this classification effectively predicts the likelihood of adverse outcomes and the need for aggressive management. Although the 2023 Kahramanmaraş earthquake showed a lower overall mortality rate compared to the 1999 Marmara and 2005 Kashmir earthquakes [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] -often attributed to improved disaster preparedness, early rescue efforts, and better healthcare infrastructure\u0026mdash;it is also possible that this lower mortality reflects selection bias. Severely injured individuals may not have survived long enough to reach healthcare facilities due to delays in rescue or inaccessible terrain, resulting in a hospital cohort composed of relatively less critical patients. This possibility should be considered when interpreting mortality data from disaster settings, as it may partly explain the observed differences in survival outcomes despite improved medical response systems.\u003c/p\u003e\u003cp\u003eNevertheless, our findings emphasize that even with these advances and possible confounding factors, severe crush syndrome and its complications\u0026mdash;particularly sepsis and ARDS\u0026mdash;remain key drivers of mortality.\u003c/p\u003e\u003cp\u003eIn our study, the time under the rubble was longer in those with severe-critical crush syndrome compared to those with mild-moderate crush syndrome (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This finding suggests that the increased entrapment is related to worse outcomes, likely due to the exacerbation of crush-related complications such as severe rhabdomyolysis, hyperkalaemia, hypothermia, and delayed medical treatment. These results are in accordance with earlier findings demonstrating that increased duration under the rubble is associated with increased risk for severe crush syndrome [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEarlier research has also revealed conflicting data, however, with some studies finding no clear association between time under the rubble and AKI, the development of crush syndrome, or short-term mortality [12; 13]. One of the reasons for these inconsistencies can be the influence of other factors, i.e., severity of the initial injury, presence of oxygen while entrapment, and completeness of early resuscitation. Second, individuals with less severe injuries can be more prone to survive longer entrapment, as suggested by previous disaster reports [12; 14; 15]. These findings highlight the overriding importance of timely rescue efforts to improve survival and reduce the severity of crush-related complications. While survival beyond 10 days has been described in rare occasions, such as a remarkable instance of an individual rescued without any serious injury after 164 hours following the 2023 Kahramanmaraş earthquake [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], prolonged entrapment remains a strong risk factor for mortality and serious crush-related complications. This highlights the critical need for continued refinement of search-and-rescue operations and early medical interventions in future disaster responses.\u003c/p\u003e\u003cp\u003eIn our comparison of mild-moderate and severe-critical crush syndrome groups, neither BUN nor creatinine levels showed statistically significant differences. Elevated creatinine levels are often attributed to rhabdomyolysis-induced muscle damage, with creatinine released from injured muscle cells contributing to its rise. However, in mild-moderate versus severe-critical crush syndrome patients in our cohort, the lack of significant differences in creatinine levels may indicate that creatinine levels could be reflecting the severity of kidney injury, rather than the severity of rhabdomyolysis. There are also studies in the literature suggesting that creatinine levels are not increased by rhabdomyolysis [17; 18]. Our findings highlight the dynamic nature of BUN and creatinine as markers in disaster scenarios. This underscores the need for comprehensive clinical and laboratory evaluations in disaster medicine.\u003c/p\u003e\u003cp\u003eSerum potassium levels in our study were considerably greater in non-survivors than in survivors (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), underscoring the crucial role that hyperkalaemia plays in crush syndrome mortality. This result is consistent with evidence from earlier earthquakes [19; 20]. Additionally, potassium levels were higher in the severe-critical crush syndrome group compared to the mild-moderate group, further emphasizing the association between hyperkalaemia and the severity of crush-related complications. Given the high prevalence of hyperkalaemia in patients with large muscle mass, particularly in male patients, and the potentially fatal outcomes it may cause, recent recommendations underscore the need for early empirical anti-hyperkaliaemic treatment in high-risk individuals, as well as the deployment of portable point-of-care potassium analysers in the field to ensure rapid diagnosis and timely intervention [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eHypocalcaemia is a well-known marker of severe rhabdomyolysis, often exacerbating the cardiotoxic effects of hyperkalaemia, making early diagnosis and treatment crucial in disaster settings. In our study, calcium levels were significantly lower in the severe-critical crush syndrome group (median: 7.3 mg/dL vs. 7.8 mg/dL, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), suggesting a link between hypocalcaemia and disease severity. In contrast, phosphorus levels were significantly higher in the severe-critical group, indicating severe muscle damage and impaired renal clearance. Elevated phosphorus is strongly associated with AKI and secondary hypocalcaemia, necessitating close monitoring. Similarly, data from the Marmara earthquake identified hyperphosphatemia as a key predictor of dialysis requirement, further emphasizing its clinical significance in crush syndrome [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These findings highlight the importance of phosphorus control and calcium monitoring to prevent metabolic complications and improve patient outcomes.\u003c/p\u003e\u003cp\u003eIn crush syndrome, both hyponatremia and hypernatremia have been reported, reflecting the complex fluid and electrolyte disturbances [21; 22]. Hyponatremia is often linked to fluid resuscitation and non-osmotic release of vasopressin [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], while hypernatremia may result from dehydration, insensible water loss, or delayed rehydration during a disaster. In our study, sodium levels did not significantly differ between the mild-moderate and severe-critical crush syndrome groups, suggesting that sodium disturbances may not be directly associated with disease severity. This underscores the importance of individualized fluid management to maintain electrolyte balance in patients with crush syndrome.\u003c/p\u003e\u003cp\u003eIn our study, albumin levels were significantly lower in the severe-critical crush syndrome group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), likely reflecting systemic inflammation as a negative acute-phase reactant [1; 20]. Hypoalbuminemia may impair myoglobin clearance, contributing to renal damage and emphasizing the need for monitoring and correction in disaster settings to improve outcomes [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn our study, haemoglobin levels did not significantly differ between the mild-moderate and severe-critical crush syndrome groups, suggesting that haemoconcentration may not be directly related to disease severity. This contrasts with previous disaster data, such as the Marmara earthquake, where lower haemoglobin levels were interpreted as a marker of effective fluid resuscitation, particularly in oliguric patients [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The absence of a significant difference may reflect inter-individual variability or limitations in assessing early resuscitation efforts. These observations reinforce the complex interplay of fluid management, tissue injury, and systemic inflammatory responses in the aftermath of large-scale disasters.\u003c/p\u003e\u003cp\u003eC-reactive protein, a sensitive marker of systemic inflammation, showed unexpected patterns in our study. CRP levels were surprisingly higher in the mild-moderate crush syndrome group compared to the severe-critical group. This counterintuitive finding may be explained by differences in clinical status and treatment interventions. Patients with severe crush syndrome, characterized by severe vital illnesses, hypotension, shock, visceral organ damage, or brain injury requiring intensive care, often receive aggressive treatments such as antibiotics and anti-inflammatory therapies, which can suppress the inflammatory response and lower CRP levels [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn our study, AST, ALT, CK, and LDH levels were significantly higher in the severe-critical crush syndrome group compared to the mild-moderate group, indicating a strong association between higher muscle enzyme levels and disease severity. In our study, trauma types played a critical role in determining the severity of crush syndrome. Cranial, abdominal, and thoracic traumas were significantly more prevalent among patients in the severe-critical group, indicating that these injury patterns contribute to more severe clinical presentations and complications. In contrast, extremity fractures were similarly distributed across both severity groups, suggesting their limited utility in predicting disease severity despite being the most common injury overall. These findings are consistent with previous earthquake reports, where central body traumas were also more commonly associated with poor outcomes [5; 18; 20; 25; 26].\u003c/p\u003e\u003cp\u003eCompartment syndrome, a critical complication of crush injuries, was significantly more frequent in patients with severe-critical crush syndrome in our study. Consistent with previous reports, it is strongly associated with increased mortality and morbidity in disaster settings. While fasciotomy is essential, timely intervention is crucial to prevent irreversible damage. However, routine fasciotomy is not recommended, as it increases the risk of sepsis and death [26; 27]. In this present study, patients with severe crush syndrome had a statistically significant greater number of amputations, even though fasciotomy rates were comparable in the mild-to-moderate and severe crush syndrome groups.\u003c/p\u003e\u003cp\u003eComplications such as ARDS, sepsis, DIC, arrhythmias, and hypotension were significantly more frequent in severe-critical crush syndrome patients, highlighting their role in poor outcomes. Hypotension (38.8%) was a key determinant of mortality, worsening perfusion and multiorgan dysfunction, consistent with prior studies emphasizing the importance of early resuscitation [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Sepsis (31.7%) and ARDS (10.2%) reflected severe systemic inflammation and pulmonary injury, while DIC (8.5%) led to microvascular thrombosis and haemorrhagic complications, all of which have been strongly linked to poor prognosis in disaster settings [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. These findings reinforce the need for rapid intervention and multidisciplinary care to manage life-threatening complications.\u003c/p\u003e\u003cp\u003eKaplan-Meier analysis further demonstrated a significant association between crush syndrome severity and survival outcomes. The severe-critical group had a lower survival rate (67.7%) and a median survival time of 58.0 days, while the mild-moderate group had a 97.7% survival rate (Log-rank χ\u0026sup2; = 188.468, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eSevere crush patients had significantly higher levels of inflammatory markers, muscle enzymes, renal dysfunction markers, and systemic complications, reinforcing the impact of prolonged entrapment, metabolic derangements, and multiorgan failure. The higher mortality rate in the severe-critical group likely reflects extensive muscle damage and systemic complications such as hypotension, sepsis, ARDS, and arrhythmias. Despite advancements in disaster preparedness and healthcare infrastructure, these findings emphasize the need for early intervention, optimized fluid resuscitation, and aggressive management to improve survival in disaster victims.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study proves that the severity of crush syndrome at admission is a reliable predictor of clinical outcome and mortality in earthquake survivors. Mild-moderate group experienced fewer complications and demonstrated significantly better outcomes, whereas severe-critical group had increased complications, multi-organ dysfunction and higher mortality. These findings highlight the importance of early triage, early intervention, and aggressive treatment to improve survival and minimize complications in future disasters.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eALT\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAlanine Aminotransferase\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eARDS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAcute Respiratory Distress Syndrome\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eAST\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAspartate Aminotransferase\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eBUN\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBlood Urea Nitrogen\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCK\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCreatine Kinase\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCKD\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eChronic Kidney Disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCRP\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eC-reactive Protein\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eDBP\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDiastolic Blood Pressure\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSBP\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSystolic Blood Pressure\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eDIC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDisseminated Intravascular Coagulation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eDM\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDiabetes Mellitus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eHT\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHypertension\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eICU\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntensive Care Unit\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eLDH\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLactate Dehydrogenase\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConflict of interest:\u003c/h2\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical approval:\u003c/strong\u003e\u003cp\u003e Approval for the study was obtained from the Istanbul University Ethics Committee dated 17.02.2023 with the approval number 04.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eK.T, S.C.K wrote the main manuscript text and S.O. prepared figure, All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eVanholder R, Sever MS, Erek E, Lameire N. 2000. Rhabdomyolysis. \u003cem\u003eJ Am Soc Nephrol\u003c/em\u003e 11:1553\u0026ndash;61\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTurgutalp K, Kıykım AA, Oto \u0026Ouml;A, Demir S, \u0026Ccedil;obanoğlu D, et al. 2024. Analysis of crush syndrome patients with and without acute kidney injury during the 2023 Kahramanmaraş earthquake: experience of a tertiary referral center from T\u0026uuml;rkiye. \u003cem\u003eTurk J Nephrol\u003c/em\u003e 33:161\u0026ndash;72\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSever MS, Vanholder R, Lameire N. 2006. Management of crush-related injuries after disasters. \u003cem\u003eN Engl J Med\u003c/em\u003e 354:1052\u0026ndash;63\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSlater MS, Mullins RJ. 1998. Rhabdomyolysis and myoglobinuric renal failure in trauma and surgical patients: a review. \u003cem\u003eJ Am Coll Surg\u003c/em\u003e 186:693\u0026ndash;716\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eErek E, Sever MS, Serdenge\u0026ccedil;ti K, Vanholder R, Akoğlu E, et al. 2002. An overview of morbidity and mortality in patients with acute renal failure due to crush syndrome: the Marmara earthquake experience. \u003cem\u003eNephrol Dial Transplant\u003c/em\u003e 17:33\u0026ndash;40\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLameire N, Kellum J, Aspelin P. 2012. Kidney disease: Improving global outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury. \u003cem\u003eKidney International Supplements\u003c/em\u003e 2:1\u0026ndash;138\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRajagopalan S. 2010. Crush Injuries and the Crush Syndrome. \u003cem\u003eMed J Armed Forces India\u003c/em\u003e 66:317\u0026ndash;20\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNates JL, Nunnally M, Kleinpell R, Blosser S, Goldner J, et al. 2016. ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research. \u003cem\u003eCrit Care Med\u003c/em\u003e 44:1553\u0026ndash;602\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOzturk S, Tuglular S, Olmaz R, Kocyigit I, Kibar MU, et al. 2024. Patients with crush syndrome and kidney disease: lessons learned from the earthquake in Kahramanmaraş, T\u0026uuml;rkiye. \u003cem\u003eKidney Int\u003c/em\u003e 106:771\u0026ndash;6\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSever MS, Erek E, Vanholder R, Akoğlu E, Yavuz M, et al. 2001. The Marmara earthquake: epidemiological analysis of the victims with nephrological problems. \u003cem\u003eKidney Int\u003c/em\u003e 60:1114\u0026ndash;23\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVanholder R, van der Tol A, De Smet M, Hoste E, Ko\u0026ccedil; M, et al. 2007. Earthquakes and crush syndrome casualties: lessons learned from the Kashmir disaster. \u003cem\u003eKidney Int\u003c/em\u003e 71:17\u0026ndash;23\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAydin K, Ozel Yesilyurt A, Cetinkaya F, Gok MG, Dogan O, Ozcengiz D. 2024. Earthquake victims in focus: a cross-sectional examination of trauma and management in intensive care unit. \u003cem\u003eBMC Emerg Med\u003c/em\u003e 24:30\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEpstein D, Shavit I, Peretz L, Almog O, Romain M, et al. 2023. Survival Under the Rubble After the 2023 Earthquake in Turkey. \u003cem\u003ePediatrics\u003c/em\u003e 152\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOzturk I, Gungor O, Ozturk S, Olmaz R, Keskin AJG, et al. 2024. Epidemiological analysis of the victıms wıth crush syndrome in earthquakes of southeastern Turkey. \u003cem\u003eJ Nephrol\u003c/em\u003e 37:2589\u0026ndash;99\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSever MS, Erek E, Vanholder R, Ozener C, Yavuz M, et al. 2002. Lessons learned from the Marmara disaster: Time period under the rubble. \u003cem\u003eCrit Care Med\u003c/em\u003e 30:2443\u0026ndash;9\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAğan FZ, Cindoğlu \u0026Ccedil;. 2024. Earthquake in Turkey: The Triangle of Life and Disaster Kits Saves Lives. \u003cem\u003eDisaster Med Public Health Prep\u003c/em\u003e 18:e74\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOh MS. 1993. Does serum creatinine rise faster in rhabdomyolysis? \u003cem\u003eNephron\u003c/em\u003e 63:255\u0026ndash;7\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOda J, Tanaka H, Yoshioka T, Iwai A, Yamamura H, et al. 1997. Analysis of 372 patients with Crush syndrome caused by the Hanshin-Awaji earthquake. \u003cem\u003eJ Trauma\u003c/em\u003e 42:470\u0026ndash;5; discussion 5\u0026ndash;6\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSever MS, Luyckx V, Tonelli M, Kazancioglu R, Rodgers D, et al. 2023. Disasters and kidney care: pitfalls and solutions. \u003cem\u003eNat Rev Nephrol\u003c/em\u003e 19:672\u0026ndash;86\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSever MS, Erek E, Vanholder R, Ozener C, Yavuz M, et al. 2002. The Marmara earthquake: admission laboratory features of patients with nephrological problems. \u003cem\u003eNephrol Dial Transplant\u003c/em\u003e 17:1025\u0026ndash;31\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSafari S, Eshaghzade M, Najafi I, Baratloo A, Hashemi B, et al. 2017. Trends of Serum Electrolyte Changes in Crush syndrome patients of Bam Earthquake; a Cross sectional Study. \u003cem\u003eEmerg (Tehran)\u003c/em\u003e 5:e7\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang L, Fu P, Wang L, Cai G, Zhang L, et al. 2013. Hyponatraemia in patients with crush syndrome during the Wenchuan earthquake. \u003cem\u003eEmerg Med J\u003c/em\u003e 30:745\u0026ndash;8\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWard MM. 1988. Factors predictive of acute renal failure in rhabdomyolysis. \u003cem\u003eArch Intern Med\u003c/em\u003e 148:1553\u0026ndash;7\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNehring SM, Goyal A, Patel BC. 2025. C Reactive Protein. In \u003cem\u003eStatPearls\u003c/em\u003e. Treasure Island (FL) ineligible companies. Disclosure: Amandeep Goyal declares no relevant financial relationships with ineligible companies. Disclosure: Bhupendra Patel declares no relevant financial relationships with ineligible companies.: StatPearls Publishing Copyright \u0026copy; 2025, StatPearls Publishing LLC. Number of.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSever MS, Erek E, Vanholder R, Akoglu E, Yavuz M, et al. 2002. Clinical findings in the renal victims of a catastrophic disaster: the Marmara earthquake. \u003cem\u003eNephrol Dial Transplant\u003c/em\u003e 17:1942\u0026ndash;9\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSever MS, Erek E, Vanholder R, Koc M, Yavuz M, et al. 2004. Lessons learned from the catastrophic Marmara earthquake: factors influencing the final outcome of renal victims. \u003cem\u003eClin Nephrol\u003c/em\u003e 61:413\u0026ndash;21\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evon Keudell AG, Weaver MJ, Appleton PT, Bae DS, Dyer GSM, et al. 2015. Diagnosis and treatment of acute extremity compartment syndrome. \u003cem\u003eLancet\u003c/em\u003e 386:1299\u0026ndash;310\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline laboratory findings and complications observed during hospitalization according to the admission-based classification of crush syndrome severity.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild-moderate crush syndrome\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;730)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSevere-critical\u003c/p\u003e\u003cp\u003ecrush syndrome\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;232)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender, Male, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e351 (48.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e122 (52.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (year)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (28\u0026ndash;53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39 (28\u0026ndash;49)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSBP (mmHg)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e120 (110\u0026ndash;135)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e119.5 (97.5\u0026ndash;134)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDBP (mmHg)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e73 (66\u0026ndash;80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67 (60\u0026ndash;80)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHeart rate (minute)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e89 (80\u0026ndash;100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e104 (89\u0026ndash;116)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFever (\u003c/b\u003e\u003csup\u003e\u003cb\u003e0\u003c/b\u003e\u003c/sup\u003e\u003cb\u003eC)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36.5 (36-36.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36.5 (36.1\u0026ndash;37)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eOxygen saturation (%)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;95%*\u003c/p\u003e\u003cp\u003e90\u0026ndash;95%\u003c/p\u003e\u003cp\u003e\u0026lt;\u0026thinsp;90%*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e280 (57.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (20.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e178(36.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53 (39.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28 (5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54 (40)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBUN (mg/dL)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37 (19.5\u0026ndash;62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48.6 (34\u0026ndash;77)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCreatinine (mg/dL)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.6 (0.8\u0026ndash;3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.82 (1.9\u0026ndash;4.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSodium (mmol/L)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e136 (132\u0026ndash;139)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e136 (132\u0026ndash;140)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePotassium (mmol/L)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.795 (4.2\u0026ndash;5.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.95 (4.9\u0026ndash;6.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCalcium (mg/dL)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.8 (7.3\u0026ndash;8.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.3 (6.6-8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePhosphorus (mg/dL)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.3 (3-6.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.6 (4.8-9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAST (IU/L)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e336 (108\u0026ndash;758)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e712.5 (308\u0026ndash;1374)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eALT (IU/L)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e154.5 (58\u0026ndash;309)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e303 (134\u0026ndash;594)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLDH (IU/L)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e852 (460\u0026ndash;1533)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1509 (750\u0026ndash;3148)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCK (IU/L)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9500 (2246\u0026ndash;46506)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27634.5 (2834\u0026ndash;88049)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e\u003cb\u003eCRP (mg/dL)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eNormal, (n)\u003c/p\u003e\u003cp\u003e1\u0026ndash;5 times upper, (n)*\u003c/p\u003e\u003cp\u003e5\u0026ndash;10 times upper, (n)*\u003c/p\u003e\u003cp\u003e10\u0026ndash;20 times upper, (n)\u003c/p\u003e\u003cp\u003e\u0026gt;\u0026thinsp;20 times upper, (n)*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e132\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e190\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e261\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e124\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAlbumin (gr/dL)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.1 (2.6\u0026ndash;3.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.7 (2.2\u0026ndash;3.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLeukocyte (103/mm3)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14575 (10640\u0026ndash;20010)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17420 (11640\u0026ndash;24570)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHemoglobin (gr/dL)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12.45 (10.4\u0026ndash;14.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.4 (9.3\u0026ndash;15.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThrombocyte (103/mm3)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e237.5 (180\u0026ndash;300)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e211 (152\u0026ndash;279)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAmount of parenteral fluid given in the first three days (ml/hour)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (3\u0026ndash;8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (4\u0026ndash;6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDischarge creatinine (mg/dL)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.7 (0.5-1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.265 (0.6\u0026ndash;2.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHypotension, n (%)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e73 (38.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eARDS, n (%)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (1.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (10.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDIC, n (%)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (1.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (8.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSepsis, n (%)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60 (9.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58 (31.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eArrythmia, n (%)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (0.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (11.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eICU need, n (%)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e296 (40.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e219 (95.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eComorbidity, n (%)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCKD\u003c/p\u003e\u003cp\u003eHT\u003c/p\u003e\u003cp\u003eDM*\u003c/p\u003e\u003cp\u003eIschemic heart disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (2.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e95 (14.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (9.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e63 (9.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (6.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (5.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTime under the rubble (hours)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (6\u0026ndash;33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (8\u0026ndash;40)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLength of hospital stays (days)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (6\u0026ndash;27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.5 (3\u0026ndash;30)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCranial trauma, n (%)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e68 (9.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43 (22.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAbdominal trauma, n (%)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 (7.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45 (23.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThoracic trauma, n (%)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e170 (24.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e98 (48)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eExtremity fractur, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e224 (31.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65 (32)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCompartment syndrome, n (%)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e263 (36.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e115 (53.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFasciotomy, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e201 (77.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e79 (71.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAmputation, n (%)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62 (23.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41 (36.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSurvival, n (%)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e713 (97.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e157 (67.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNon-survival n (%)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (2.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75 (32.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eNote\u003c/b\u003e: * p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAbbreviations: ALT:\u0026nbsp;\u003c/strong\u003eAlanine Aminotransferase,\u003cstrong\u003e\u0026nbsp;ARDS:\u0026nbsp;\u003c/strong\u003eAcute Respiratory Distress Syndrome,\u003cstrong\u003e\u0026nbsp;AST:\u0026nbsp;\u003c/strong\u003eAspartate Aminotransferase,\u003cstrong\u003e\u0026nbsp;BUN:\u0026nbsp;\u003c/strong\u003eBlood Urea Nitrogen,\u003cstrong\u003e\u0026nbsp;CK:\u0026nbsp;\u003c/strong\u003eCreatine Kinase, \u003cstrong\u003eCKD:\u0026nbsp;\u003c/strong\u003eChronic Kidney Disease,\u003cstrong\u003e\u0026nbsp;CRP:\u0026nbsp;\u003c/strong\u003eC-reactive Protein,\u003cstrong\u003e\u0026nbsp;DBP:\u0026nbsp;\u003c/strong\u003eDiastolic Blood Pressure, \u003cstrong\u003eSBP:\u003c/strong\u003e Systolic Blood Pressure, \u003cstrong\u003eDIC:\u0026nbsp;\u003c/strong\u003eDisseminated Intravascular Coagulation,\u003cstrong\u003e\u0026nbsp;DM:\u0026nbsp;\u003c/strong\u003eDiabetes Mellitus,\u003cstrong\u003e\u0026nbsp;HT:\u0026nbsp;\u003c/strong\u003eHypertension,\u003cstrong\u003e\u0026nbsp;ICU:\u0026nbsp;\u003c/strong\u003eIntensive Care Unit,\u003cstrong\u003e\u0026nbsp;LDH:\u0026nbsp;\u003c/strong\u003eLactate Dehydrogenase\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Crush Syndrome, earthquakes, acute kidney injury, rhabdomyolysis, Southeastern Türkiye","lastPublishedDoi":"10.21203/rs.3.rs-7030768/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7030768/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eCrush syndrome is a potentially life-threatening complication of prolonged compression injuries, frequently encountered after earthquakes. The 2023 Kahramanmaraş earthquakes in T\u0026uuml;rkiye caused extensive crush-related trauma. The objective of this study was to assess the effect of baseline crush syndrome severity on hospitalization outcomes and complications.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eIn this multicentre, retrospective observational study, 962 crush syndrome patients hospitalized after the earthquakes were evaluated. Patients were grouped as mild-moderate vs. severe-critical based on clinical presentation. Demographics, laboratory results, comorbidities, trauma types, complications, and outcomes were assessed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOf 962 patients, 232 (24.1%) were classified as severe-critical and 730 (75.9%) as mild-moderate. Severe-critical patients had significantly higher rates of hypotension, ARDS, sepsis, DIC, arrhythmias, compartment syndrome, and ICU requirement (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Laboratory markers including BUN, creatinine, potassium, phosphorus, liver enzymes, CK, and CRP were all significantly elevated, while calcium and albumin levels were lower in the severe-critical group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Kaplan\u0026ndash;Meier analysis revealed a significantly lower survival rate in the severe-critical group (67.7% vs. 97.7%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Trauma types such as cranial, abdominal, and thoracic injuries were more frequent in this group, and prolonged entrapment time (median 24 vs. 11 hours, p\u0026thinsp;=\u0026thinsp;0.031) was associated with increased severity.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eCrush syndrome severity at admission is strongly associated with clinical outcomes, complication rates, and in-hospital survival. Prolonged time under the rubble, systemic complications, and elevated muscle and renal injury markers contribute to worse prognosis. These findings highlight the need for rapid triage, timely fluid resuscitation, and organized multidisciplinary intervention in future disaster scenarios.\u003c/p\u003e","manuscriptTitle":"Effect of Crush Syndrome Severity on Clinical Outcomes and Complications After the Earthquakes in Southeastern Türkiye","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-14 08:34:44","doi":"10.21203/rs.3.rs-7030768/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"04b3c2e6-e689-4bae-9061-f8e7bf2426f5","owner":[],"postedDate":"July 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-02T02:53:22+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-14 08:34:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7030768","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7030768","identity":"rs-7030768","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}