Active Shooter and Explosives
Topic Collection
December 1, 2020
Topic Collection: Active Shooter and Explosives
Research indicates that both the nature and outcome of terrorist attacks and mass shootings are shifting from incidents larger in scale committed by a group to smaller attacks committed by a "lone wolf" or a relatively smaller group of attackers. ASPR TRACIE updated this Topic Collection to include recently released resources on lessons learned from actual events in the U.S. and abroad, guidance documents, research, and links to curriculum. These resources can help emergency medical professionals plan for and respond to the changing nature of mass shootings or explosive events.
Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category.
Must Reads
This webpage contains resources to assist clinicians with treating victims of bombings and other explosive events. Included are fact sheets; training materials; and a link to a mobile application to assist in the response and clinical management of blast injuries.
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This ASPR TRACIE white paper can help emergency medical system (EMS) medical directors and EMS systems planners and hospital emergency planners to key differences between “conventional” MCIs and mass violence events when: the scene is dynamic; the number of patients far exceeds usual resources; and usual triage and treatment paradigms may fail.
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The authors describe a three-phase approach first responders can use when responding to a blast or active shooter event: Enter, Evaluate, and Evacuate, or 3 Echo.
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The authors describe how planning and training for mass-casualty events helped the Boston medical community successfully respond to the marathon bombing. The authors highlight the presence of medical tents, the mobilization of communications and additional resources, and the activation of hospital emergency plans as helpful contributing factors.
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This guideline is a culmination of an extensive literature review on the use of tourniquets and hemostatic agents for managing life-threatening extremity and junctional hemorrhage. An expert panel examined the results of the literature review, then provided recommendations for emergency medical services care.
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This supplemental issue of the Annals of Emergency Management highlights best practices in managing explosive incident scenes. This issue begins with an article featuring consensus statements and includes other pieces on blast physics, medical management of the scene, management in healthcare facilities, and the future of explosive scene management.
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These guidelines were developed based on the principles of Tactical Combat Casualty Care but take into account variations in the civilian environment (e.g., resources allocation, different patient populations). The authors list the goals of Tactical Emergency Casualty Care and strategies for achieving those goals.
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The author examines past terrorist bombing events and provides a summary of triage, treatment, and resource utilization differences.
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This guide provides a comprehensive overview of issues and response to active shooters in the healthcare environment and includes response plan templates in the appendix.
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The authors explain the difference between conventional mass casualty incidents and mass violence incidents and how triage needs to adjust accordingly. They highlight the three key planning elements hospitals must consider to prepare for mass violence (space, staff, and supplies) and define steps hospital providers should take under primary, secondary, and tertiary trauma phases.
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The authors describe the medical response to the attacks from the perspectives of three medical professionals: emergency physician, anesthesiologist, and trauma surgeon.
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The Hartford Consensus suggests that first responders to an active shooter scene should apply the actions in the acronym THREAT: 1) Threat suppression, 2) Hemorrhage control, 3) Rapid Extrication to safety, 4) Assessment by medical providers, and 5) Transport to definitive care.
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Every Boston Level 1 trauma center populated a database regarding specific injuries, extremities affected, prehospital interventions, and the like experienced by victims of the marathon bombings. The authors found that after the event, extremity exsanguination was either left alone or treated with an improvised tourniquet. The authors stress the need to share the military's approach to controlling severe extremity bleeding with "all civilian first responders."
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This article is a retrospective review of terrorist-related blast injuries from the Israeli national trauma registry over the time period of the second intifada 2000-2005, comparing injury patterns with the setting of the blast, specifically inside buildings, near buildings, inside buses, near buses, and in open spaces.
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This presentation takes participants through a blast injury scenario at a busy train station. The authors explain the differences between "traditional" attacks and the "new threat environment" (e.g., improvised explosives, lone wolf shooters) and strategies for related casualty care.
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This report emphasizes the importance of (and lists recommendations related to) having an integrated response to active shooter events by incorporating lessons learned from first responder agencies who have responded to these types of events.
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The principles of Tactical Combat Casualty Care (TCCC) can also be applied by first responders when responding to bomb and mass shooting incidents. TCCC has three goals: 1) treat the casualty, 2) prevent additional casualties, and 3) complete the mission.
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Education and Training
This webpage contains resources to assist clinicians with treating victims of bombings and other explosive events. Included are fact sheets; training materials; and a link to a mobile application to assist in the response and clinical management of blast injuries.
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The authors describe a three-phase approach first responders can use when responding to a blast or active shooter event: Enter, Evaluate, and Evacuate, or 3 Echo.
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This resource is a detailed template that may be completed and used to conduct a tabletop exercise focused on active shooter/terrorism mass casualty incidents.
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This webpage provides two pages of links to resources that can help hospitals and other healthcare facilities plan for active shooter incidents. It includes a checklist, plans, guidelines, educational videos, and other materials. Note: On this webpage, please review the Active Shooter Planning and Response in a Health Care Setting Guidance 2017. Hostage situations are addressed throughout the document, and specific procedures are outlined starting on page 93.
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The speaker provides a brief overview for health care providers on how to respond and care for persons injured by an explosion or blast event.
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The authors define crush injury and crush syndrome, which are two injuries that could result from a bombing or explosion. Operational strategies for prehospital and hospital care settings are included.
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This course was designed for emergency responders caring for a large number patients after natural or human-caused incidents. Information on caring for patients exposed to chemical, biological, radiological, nuclear, or explosive (CBRNE) agents is also provided.
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The Hospital Association of Southern California developed several documents that can help a healthcare facility plan for active shooter incidents and carry out an active shooter drill (e.g., checklists, participant releases, and pocket cards).
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This video depicts active shooter scenarios and shares strategies for responding and surviving such events.
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This video provides information on preparing for and responding to an active shooter event in a healthcare setting.
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This free short training module provides healthcare providers and other staff with an overview of strategies and protocols for an armed intruder/active shooter incident. Speakers describe the "run-hide-fight" and "secure-preserve-fight" approaches and share "Stop the Bleed" basics, a video for how to apply a tourniquet, and resources for managing stress. Though this training was created by the Mount Sinai health system, it is applicable to other healthcare providers and healthcare systems.
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This presentation explains when and how to use tourniquets or hemostatic gauze to control severe hemorrhage.
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This webpage provides links to educational opportunities in various categories (e.g., bleeding control, Tactical Combat Casualty Care, and trauma first response) offered by the National Association of Emergency Medical Technicians.
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This webpage provides links to educational material and guidance on caring for victims of active shooters. Information is categorized by topic, such as guidelines, curriculum, skill sheets, instructor guides, and reference documents.
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This webpage includes information specific to the 2016 California statewide exercise, as well as training and exercise resources and templates to support an active shooter exercise. The “Sample Trainings and Drills” section includes a number of useful resources, including those for a “2-minute drill,” tabletop Situation Manual, sample scenarios, and facilitator guidance.
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This course can help healthcare professionals plan for and understand the terminology associated with explosive incidents. It also includes a section on pediatric patients.
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This webpage contains links to information on the ALERRT curriculum, developed to help law enforcement and other first responders increase survivability of and improve response to active shooter events.
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This video depicts active shooter scenarios and demonstrates how witnesses can increase their chances of survival.
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The principles of Tactical Combat Casualty Care (TCCC) can also be applied by first responders when responding to bomb and mass shooting incidents. TCCC has three goals: 1) treat the casualty, 2) prevent additional casualties, and 3) complete the mission.
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EDGE is a free (to U.S. agencies) multiplayer, scalable, online training program that allows first responders to role-play complex response scenarios. It can be used by single agencies or across agency, jurisdiction, or discipline. The first scenario features an active shooter incident at a local hotel.
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This webpage highlights the national campaign that provides individuals with the ability to “act quickly and save lives” before emergency medical providers arrive on the scene.
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This document incorporates lessons learned from the U.S. military experiences dealing with improvised explosive device and active shooter scenes and casualties. The guide includes a variety of scenarios and responses that can be used for tabletop exercises or general planning discussions.
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This course is geared towards emergency medical service personnel and features modules on biological, radiological, incendiary, and explosive weapons. Modules on pre- and hospital decontamination are also included.
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This article describes in detail the simulation plan for a blast-related mass casualty incident exercise targeted to emergency medicine residents. All of the associated materials may be downloaded for free. All the supporting materials are available for free download.
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Guidance Documents
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ASPR TRACIE. (2016).
The Exchange, Issue 3.
U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This issue of the newsletter focuses on preparing for and responding to no-notice events.
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In this ASPR TRACIE webinar, healthcare providers who responded to the mass shooting incident in Las Vegas share their experiences and recommendations that can help others prepare for similar incidents.
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This issue covers the challenges associated with providing care during no-notice incidents (e.g., mass shootings).
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ASPR TRACIE created these tip sheets for hospitals and other healthcare facilities planning for no-notice incident response. The series is based on discussions ASPR NHPP and ASPR TRACIE had with healthcare personnel who were involved in the October 2017 mass shooting response in Las Vegas and supplemented with information from other recent no-notice incidents. While there is great variance in the scope and healthcare needs resulting from no-notice incidents, these tip sheets focus on some of the identified challenges.
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This ASPR TRACIE white paper can help emergency medical system (EMS) medical directors and EMS systems planners and hospital emergency planners to key differences between “conventional” MCIs and mass violence events when: the scene is dynamic; the number of patients far exceeds usual resources; and usual triage and treatment paradigms may fail.
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This supplemental issue includes articles on various types of management (organization, operations, and medical) of explosive incidents, based on a summary of expert panel consensus statements and lessons learned.
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This webpage provides two pages of links to resources that can help hospitals and other healthcare facilities plan for active shooter incidents. It includes a checklist, plans, guidelines, educational videos, and other materials. Note: On this webpage, please review the Active Shooter Planning and Response in a Health Care Setting Guidance 2017. Hostage situations are addressed throughout the document, and specific procedures are outlined starting on page 93.
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These guidelines were developed based on the principles of Tactical Combat Casualty Care but take into account variations in the civilian environment (e.g., resources allocation, different patient populations). The authors list the goals of Tactical Emergency Casualty Care and strategies for achieving those goals.
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These guidelines were adapted from evidence-based studies from the battlefield and are applicable to high threat events such as active shooter situations.
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This guide can help healthcare staff and management understand, plan for, and respond to incidents involving improvised explosive devices.
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This website provides guidance and general information on active shooter incidents from the Federal Bureau of Investigation.
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This guide provides a comprehensive overview of issues and response to active shooters in the healthcare environment and includes response plan templates in the appendix.
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This discussion paper examines some of the issues and potential best practices during responses to terrorist incidents, including mass shootings and bombings. Response coordination and planning considerations are also discussed which could optimize patient outcomes.
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The authors explain the difference between conventional mass casualty incidents and mass violence incidents and how triage needs to adjust accordingly. They highlight the three key planning elements hospitals must consider to prepare for mass violence (space, staff, and supplies) and define steps hospital providers should take under primary, secondary, and tertiary trauma phases.
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This guide sets forth a new active shooter policy requirement for all nonmilitary federal facilities within the executive branch of the government and a set of recommendations to assist with implementing this policy.
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The Hartford Consensus suggests that first responders to an active shooter scene should apply the actions in the acronym THREAT: 1) Threat suppression, 2) Hemorrhage control, 3) Rapid Extrication to safety, 4) Assessment by medical providers, and 5) Transport to definitive care.
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The NFPA 3000™ (PS): Standard for an Active Shooter/Hostile Event Response (ASHER) Program identifies the minimum program elements needed to organize, manage, and sustain an active shooter and/or hostile event response program that helps mitigate the risks, effect, and impact on an organization or community affected by these events. Chapter 19 applies to medical facilities who are preparing to receive patients from an active shooter/hostile event, while Chapter 20 addresses comprehensive recovery including the Family Assistance Center.
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This study highlights these commonalities in shooter pre-attack behavior: planning, access to firearms, stressors, mental health, concerning behaviors, primary grievances, targeting specific people, suicide ideation, and concerning communications. The authors emphasize the importance of collaborative community engagement in preventing future incidents.
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The authors emphasize the need for a paradigm shift in the emergency medical services field to accompany the changing nature of active shooter events.
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This presentation takes participants through a blast injury scenario at a busy train station. The authors explain the differences between "traditional" attacks and the "new threat environment" (e.g., improvised explosives, lone wolf shooters) and strategies for related casualty care.
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This report emphasizes the importance of (and lists recommendations related to) having an integrated response to active shooter events by incorporating lessons learned from first responder agencies who have responded to these types of events.
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This factsheet provides information about active shooter/ hostile events and provides some general guidelines that can assist organizations plan for and respond to this threat.
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The principles of Tactical Combat Casualty Care (TCCC) can also be applied by first responders when responding to bomb and mass shooting incidents. TCCC has three goals: 1) treat the casualty, 2) prevent additional casualties, and 3) complete the mission.
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This document gives healthcare facility emergency planners, executive leadership, and others involved in emergency operations planning assistance with planning for active shooter incidents.
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This webpage includes links to resources geared towards first responders who may be called to an active shooter situation. Users can access "how to respond" resources (e.g., booklets, pamphlets, fact sheets--in several languages), videos, reports, and other items that can be helpful in developing plans for and responding to these types of incidents.
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This document incorporates lessons learned from the U.S. military experiences dealing with improvised explosive device and active shooter scenes and casualties. The guide includes a variety of scenarios and responses that can be used for tabletop exercises or general planning discussions.
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This document highlights guidelines and concepts that can be incorporated into standard operating procedures to enhance the fire and emergency medical response to an active shooter/ mass casualty incident.
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Lessons Learned
The authors combined an analysis of data contained in the Israeli National Trauma Registry with their firsthand experience caring for suicide bomb victims at the Hadassah University Hospital to provide an overview of lessons learned.
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*
ASPR TRACIE. (2016).
The Exchange, Issue 3.
U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This issue of the newsletter focuses on preparing for and responding to no-notice events.
Login to rate, favorite, and comments on the article
In this ASPR TRACIE webinar, healthcare providers who responded to the mass shooting incident in Las Vegas share their experiences and recommendations that can help others prepare for similar incidents.
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This issue covers the challenges associated with providing care during no-notice incidents (e.g., mass shootings).
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The authors synthesized comments from a series of expert panel meetings on identifying innovative strategies hospitals could adopt to address terrorism-related surge issues.
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This article uses interactive graphics to illustrate the history of mass shootings in the U.S. in which four or more people were killed by a lone shooter (or two shooters in three cases).
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The authors describe how planning and training for mass-casualty events helped the Boston medical community successfully respond to the marathon bombing. The authors highlight the presence of medical tents, the mobilization of communications and additional resources, and the activation of hospital emergency plans as helpful contributing factors.
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In 2014, the Federal Bureau of Investigation initiated a review of active shooter incidents. This report includes data that can help law enforcement and other first responders plan for and respond to these events.
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This after action report provides an overview of the Boston Marathon bombing and the collaborative planning between public health and healthcare that occurred before and in the weeks just after the incident. The report focuses on 10 specific public health and healthcare capabilities and lists related observations, strengths, areas for improvement, and recommendations. There is “a particular emphasis on the recovery efforts and public health's role as it relates to mass care and human service efforts.”
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This supplemental issue includes articles on various types of management (organization, operations, and medical) of explosive incidents, based on a summary of expert panel consensus statements and lessons learned.
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This supplemental issue of the Annals of Emergency Management highlights best practices in managing explosive incident scenes. This issue begins with an article featuring consensus statements and includes other pieces on blast physics, medical management of the scene, management in healthcare facilities, and the future of explosive scene management.
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The authors compared the timing of social media reports against information shared through official emergency response channels after the Boston Marathon bombing. They suggest that first response agencies and healthcare providers can monitor social media to better tailor their response to an incident.
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The authors examined emergency psychiatric treatment-seeking emergency room visits in the weeks after four events (the Oklahoma City Bombing, the Columbine High School shooting, the Wedgewood Baptist Church shooting, and the 9/11 terrorist attacks). They found that in the week following each event, there was minimal change in the number of visits.
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The speakers in this hour-long webinar discuss the West, TX public health and hospital communities’ response to the April 2013 fertilizer plant explosion. In particular, they share how emergency preparedness program capabilities were successfully operationalized during the response, and list lessons learned.
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The authors of this study compared medical response capabilities for critical incidents in Newark (New Jersey's largest city), with those in Boston. The authors found significant disparities between the two locations, but concluded that because medical personnel in both sites had conducted exercises together often, Newark would likely be able to carry out an effective response to an incident like the Boston Marathon bombing.
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This infographic includes general statistics and depicts how emergency medical services effectively distributed patients after the Boston Marathon bombing.
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This factsheet summarizes data as a result of a study into 160 active shooter incidents between 2000 and 2013.
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The author examines past terrorist bombing events and provides a summary of triage, treatment, and resource utilization differences.
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The author presents an overview of three studies on mass casualty terrorist attacks in Israel. He notes several distinctive characteristics of these incidents that go "far beyond the standard surgical training and experience:" the large number of victims; young victims; and the severity of injury.
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The authors provide an overview of the medical response to the Boston Marathon bombing, and list the factors that contributed to positive outcomes. They note that 10% of patients required immediate transfusion of packed red blood cells in the emergency department.
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In 2004, 10 bombs exploded in four commuter trains in Madrid, Spain. The authors provide an in-depth overview of the 250 patients with severe injuries and found the following injuries in patients: soft tissue and musculoskeletal injuries (85%), ear blast injury (67%), blast lung injury (63%), and head trauma (52%).
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The author recounts an interview with several emergency medical care providers from Hôpital Saint Louis after the coordinated terrorist attack in Paris on November 13, 2015. They discussed their response and lessons learned from the attack, emphasizing the importance of planning and coordination.
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Vascular casualties from Improvised Explosive Devices are more complex and have a poorer prognosis. This has implications for victim triage with such injuries and selection of receiving hospitals.
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The authors describe the medical response to the attacks from the perspectives of three medical professionals: emergency physician, anesthesiologist, and trauma surgeon.
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This white paper describes some foundational principals related to implementing the concepts of integrated emergency services response to high-threat events, based on current best-practice operational models from Arlington, VA; Los Angeles, CA; and New York, NY.
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The author describes the paradigm shift associated with the emergency medical response to an active shooter situation and other lessons learned from large mass casualty events.
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The authors analyzed reports on acute care hospital shooting events in the U.S. from 2000-2011 and found 154 incidents in 40 states, resulting in 235 injured or dead victims. They provide additional demographic data (e.g., perpetrator characteristics, location of shooting).
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Kellerman, A. and Peleg, K. (2013).
Lessons from Boston.
New England Journal of Medicine. 368:1956-1957.
The authors summarize three key points from the Boston bombing incident: the low mortality rate and related factors; the vital role played by bystanders who offered on-scene medical care; and the role the well-exercised disaster plan played in the successful response
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Every Boston Level 1 trauma center populated a database regarding specific injuries, extremities affected, prehospital interventions, and the like experienced by victims of the marathon bombings. The authors found that after the event, extremity exsanguination was either left alone or treated with an improvised tourniquet. The authors stress the need to share the military's approach to controlling severe extremity bleeding with "all civilian first responders."
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The authors examined how psychiatric advanced practice nurses helped care for patients and their loved ones in the aftermath of the Boston Marathon bombing.
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This report was written to help hospital, healthcare coalition, and emergency management planners learn more about the actions taken, lessons learned, observations and hospital experiences that occurred after the Las Vegas mass shooting. Information was collected through interviews, facilitated discussions, field trips and the state's InfoXChange program. The author also highlights planning, exercises, and updated assumptions "based on the changing world and social environment in which we now live."
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The authors explain that many victims of blast trauma will require significant blood transfusions. They then highlight the differences between damage control surgery and damage control resuscitation.
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The authors examined an academic medical center's Department of Psychiatry's response during the week after the Boston marathon bombings and share lessons learned.
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The authors share information on strategies used by the U.S. military to reduce morbidity and discuss possible implications for improving care in non-military/combat settings.
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This article is a retrospective review of terrorist-related blast injuries from the Israeli national trauma registry over the time period of the second intifada 2000-2005, comparing injury patterns with the setting of the blast, specifically inside buildings, near buildings, inside buses, near buses, and in open spaces.
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This after-action report was requested by the City of Orlando and the Orlando Fire Department (OFD). It describes OFD's level of preparedness for an incident such as this, and details the response and recovery from the incident. The report also offers guidance and recommendations for fire and emergency medical service providers to take into consideration.
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The authors (from a tertiary academic medical center) discuss the pharmaceutical response to the Boston Marathon bombing, which focused on staffing, supplies, and communication.
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This resource summarizes findings from a meeting of The Hartford Consensus on active shooter and mass casualty events. The group emphasizes the need for on-scene collaboration between emergency medical services and law enforcement, and highlights the supportive role that uninjured bystanders can also play in the response effort.
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The authors describe the hospital response to the mass shooting at the Westgate mall in Nairobi, Kenya.
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This book features chapters on a variety of emergency medical topics related to preparing for the 2004 Olympics, including the following: epidemiological surveillance; preparedness for deliberate use of biological or chemical agents, or radionuclear materials; food and water safety; and emergency medical services preparedness.
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Pediatric Resources
The authors discuss the results of an anonymous survey of American Pediatric Surgical Association members in 2007, which found that while 77% felt "definitely responsible" for assisting after a disaster, only 24% felt "definitely prepared" to do so. The authors listed factors associated with higher levels of preparedness and emphasized the need for more training.
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This resource provides guidelines for the immediate on-scene stabilization of victims, depending on whether or not there is an ongoing threat to safety.
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The authors review the presentation, pathophysiology, and treatment of pediatric victims of blast injury, chemical weapons, and biological weapons, with a focus on those injuries not commonly encountered in critical care practice.
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In this podcast, Dr. Michael Frogel, Co-Principal Investigator for the New York City Pediatric Disaster Coalition shares his experience planning for a pediatric mass casualty event after the failed bombing attempt on Times Square in 2010.
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This course can help healthcare professionals plan for and understand the terminology associated with explosive incidents. It also includes a section on pediatric patients.
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Plans, Tools, and Templates
Pathology departments throughout the Boston area received amputated limbs and other specimens from trauma surgeries, which were not accompanied by clear examination guidelines. The authors of this study developed a protocol (reviewed and approved by experts in forensic evidence collection) that can be used by pathology departments in the aftermath of a disaster.
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This webpage provides two pages of links to resources that can help hospitals and other healthcare facilities plan for active shooter incidents. It includes a checklist, plans, guidelines, educational videos, and other materials. Note: On this webpage, please review the Active Shooter Planning and Response in a Health Care Setting Guidance 2017. Hostage situations are addressed throughout the document, and specific procedures are outlined starting on page 93.
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This template was developed to help hospitals in New York prepare for and respond to explosive and mass casualty events. The templates can help facilitate coordination between various hospital departments and can be customized by healthcare facility emergency planners across the country.
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This questionnaire can be used in two ways: 1) by states, localities, and multi-hospital systems to determine overall hospital emergency preparedness, or 2) by individual hospitals or healthcare facilities as a checklist of areas to consider as a facility creates or updates emergency preparedness and response plans.
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This guide provides a comprehensive overview of issues and response to active shooters in the healthcare environment and includes response plan templates in the appendix.
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Healthcare emergency managers can use this sample bomb threat policy as a template for creating or updating their facility's plans.
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This white paper can help healthcare facility emergency planners plan for and better support non-resident/foreign patients in general and after a mass casualty/mass fatality incident.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2019).
National Health Security Strategy.
U.S. Department of Health and Human Services.
The goal of the National Health Security Strategy (NHSS) is to strengthen and sustain communities’ abilities to prevent, protect against, mitigate the effects of, respond to, and recover from disasters and emergencies. This webpage includes links to the full text of the plan, an overview, the NHSS Implementation Plan, the NHSS Evaluation of Progress, and an NHSS Archive.
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Treatment
The authors combined an analysis of data contained in the Israeli National Trauma Registry with their firsthand experience caring for suicide bomb victims at the Hadassah University Hospital to provide an overview of lessons learned.
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This document was developed by the Hartford Consensus (a team of healthcare leaders) and is a comprehensive compendium of resources and supporting documents that first responders can use to facilitate planning and training and enhance survivability from mass casualty and active shooter events.
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This guideline is a culmination of an extensive literature review on the use of tourniquets and hemostatic agents for managing life-threatening extremity and junctional hemorrhage. An expert panel examined the results of the literature review, then provided recommendations for emergency medical services care.
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This supplemental issue of the Annals of Emergency Management highlights best practices in managing explosive incident scenes. This issue begins with an article featuring consensus statements and includes other pieces on blast physics, medical management of the scene, management in healthcare facilities, and the future of explosive scene management.
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DePalma, R.G., Burris, D., Champion, H.R., and Hodgson, M.J. (2005).
Blast Injuries.
(Abstract only.)New England Journal of Medicine. 352:1335-42.
The authors explain the nature of blast injuries, highlight strategies for stabilizing patients and determining the severity of injury, and discuss treatment approaches.
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British researchers developed an expert consensus regarding the essential items and minimum quantities of clinical equipment necessary to care for 100 patients on the scene of a mass casualty explosion event.
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The author presents an overview of three studies on mass casualty terrorist attacks in Israel. He notes several distinctive characteristics of these incidents that go "far beyond the standard surgical training and experience:" the large number of victims; young victims; and the severity of injury.
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In 2004, 10 bombs exploded in four commuter trains in Madrid, Spain. The authors provide an in-depth overview of the 250 patients with severe injuries and found the following injuries in patients: soft tissue and musculoskeletal injuries (85%), ear blast injury (67%), blast lung injury (63%), and head trauma (52%).
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The authors explain the difference between conventional mass casualty incidents and mass violence incidents and how triage needs to adjust accordingly. They highlight the three key planning elements hospitals must consider to prepare for mass violence (space, staff, and supplies) and define steps hospital providers should take under primary, secondary, and tertiary trauma phases.
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The authors discuss injuries suffered as a result of an explosion at a manufacturing plant in North Carolina, and how pre-event preparedness and planning influenced the medical response.
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Every Boston Level 1 trauma center populated a database regarding specific injuries, extremities affected, prehospital interventions, and the like experienced by victims of the marathon bombings. The authors found that after the event, extremity exsanguination was either left alone or treated with an improvised tourniquet. The authors stress the need to share the military's approach to controlling severe extremity bleeding with "all civilian first responders."
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The authors explain that many victims of blast trauma will require significant blood transfusions. They then highlight the differences between damage control surgery and damage control resuscitation.
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This presentation explains when and how to use tourniquets or hemostatic gauze to control severe hemorrhage.
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This toolkit provides victim assistance resources for communities to include in their emergency response plans. There are links to resources on creating and maintaining partnerships, developing victim assistance protocols, and tools such as checklists, samples, a glossary, and a compendium of victim assistance resources.
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The authors detail the medical response to the 2005 London public transportation bombing. They discuss the nature of injuries, how a treatment center was set up in a nearby hotel, and the process of handing burn patients over to a regional burn center.
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The authors discuss best practices regarding the treatment of crush victims, both at the disaster field and upon admission to hospitals.
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The authors (from a tertiary academic medical center) discuss the pharmaceutical response to the Boston Marathon bombing, which focused on staffing, supplies, and communication.
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Agencies and Organizations
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U.S. Department of Homeland Security.
TRIPwire.
This government website offers resources on bombings and related incidents. Additional information including list-serves are available to qualified subscribers (referred for a membership and in public safety/response).
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