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Active Shooter and Explosives
Topic Collection
September 17, 2024

Topic Collection: Active Shooter and Explosives

Terrorist attacks and mass shootings can be committed by “lone wolves” (who are likely connected to extremist communities), or by relatively small groups of attackers. As the nature of the incident impacts the type of response (e.g., field and hospital triage), healthcare emergency medical staff must also prepare to treat certain types of injuries (e.g., using tourniquets to stop bleeding related to blast injuries). ASPR TRACIE updated this Topic Collection in October 2021 to include recently released resources on lessons learned from actual incidents, 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 incidents.

Additional information can be found on ASPR TRACIE’s Mass Violence and Disaster Behavioral Health resource pages.

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.

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American College of Emergency Physicians. (2014). Bombings: Injury Patterns and Care.
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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ASPR TRACIE. (2019). Mass Casualty Trauma Triage: Paradigms and Pitfalls.
This ASPR TRACIE white paper (developed after a national expert roundtable) can help emergency medical system (EMS) medical directors and EMS systems planners to understand and plan for 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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Autrey, A., Hick, J., Bramer, K., et al. (2014). 3 Echo: Concept of Operations for Early Care and Evacuation of Victims of Mass Violence. (Abstract only.) Prehospital Disaster Medicine. 29(4):421-8.
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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Biddinger, P.D., Baggish, A., Harrington, L., et al. (2013). Be Prepared — The Boston Marathon and Mass-Casualty Events. New England Journal of Medicine. 368:1958-1960.
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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Bulger, E., Snyder, D., Schoelles, K., et al. (2014). An Evidence-Based Prehospital Guideline for External Hemorrhage Control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care. 18(2):163-173.
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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Burstein, J., Lacy, C., and Donovan, C. (eds.). (2017). Best Practices for Management of Explosive Incidents: Translating the US and Israeli Military and Civilian Experience for Use in US Civilian and Military Out-of-hospital and Hospital Health Care. (Abstracts only.) Annals of Emergency Medicine. 69(1): Supplement.
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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Callaway, D.W., Smith, E.R., Cain, J., et al. (2011). Tactical Emergency Casualty Care (TECC): Guidelines for the Provision of Prehospital Trauma Care in High Threat Environments. Journal of Special Operations Medicine. 11(3).
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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Healthcare and Public Health Sector Critical Infrastructure Protection Partnership. (2017). Active Shooter Planning and Response in a Healthcare Setting.
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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Hick, J., Nelson, J., Fildes, J., et al. (2020). Triage, Trauma, and Today’s Mass Violence Events. (References cited only.) Journal of the American College of Surgeons. 230(2): 251–256.
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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Hirsch, M., Carli, P., Nizard, R., et al. (2015). The Medical Response to the Multisite Terrorist Attacks in Paris. The Lancet.
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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Jacobs, L., McSwain, N., Rotondo, M., et al. (2013). Improving Survival from Active Shooter Events: The Hartford Consensus. The National Association of Emergency Medical Technicians.
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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King, D., Larentzakis, A., Ramly, A., et al. (2015). Tourniquet Use at the Boston Marathon Bombing: Lost in Translation. (Abstract only.) Journal of Trauma and Acute Care Surgery. 78(3):594-9.
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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Rozenfeld, M., Givon, A., Shenhar, G., et al. (2016). A New Paradigm of Injuries From Terrorist Explosions as a Function of Explosion Setting Type. (Abstract only.) Annals of Surgery. 263(6):1228-34.
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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Smith, E.R. and Shapiro, G. (2012). Changing the Paradigm: Tactical Emergency Casualty Care Guidelines for High Risk Scenarios. Committee for Tactical Emergency Casualty Care.
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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The National Association of Emergency Medical Technicians (2015). TCCC Guidelines and Curriculum.
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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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2017). Active Shooter Planning and Response in a Healthcare Setting.
This document provides active shooter guidance tailored specifically to the healthcare setting.
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Education and Training

American College of Emergency Physicians. (2014). Bombings: Injury Patterns and Care.
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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Association of Healthcare Emergency Preparedness Professionals. (2022). Threat Assessment Resources for Healthcare Facilities.
This webpage provides links to training videos, webinars, and other resources that can help healthcare facility staff prepare for, respond to, and recover from active shooter situations in their facilities and communities.
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Autrey, A., Hick, J., Bramer, K., et al. (2014). 3 Echo: Concept of Operations for Early Care and Evacuation of Victims of Mass Violence. (Abstract only.) Prehospital Disaster Medicine. 29(4):421-8.
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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Autrey, A., Hick, J., Bramer, K., et al. (2014). 3 Echo: Concept of Operations for Early Care and Evacuation of Victims of Mass Violence. (Abstract only.) Prehospital Disaster Medicine. 29(4):421-8.
The authors describe a three-phase approach to mass violence incidents used by their metro area and applied by responders during a mass shooting event in 2012: Enter, Evaluate, and Evacuate (or 3 Echo). 3 Echo stresses the same principles of the ‘rescue task force’ concept - early, multi-disciplinary coordination and teaches participants about unified command, swift victim evacuation, how to establish corridors of safety, and other critical skills.
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Blair, J.P. and Martaindale, M.H. (2013). United States Active Shooter Events from 2000 to 2010: Training and Equipment Implications.
In this summary of active shooter events, the authors share research findings (e.g., location, shooter and victim demographics) and emergency healthcare training and equipment implications for first responders (primarily law enforcement in these incidents).
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* California Hospital Association. (2017). Planning for Active Shooter Incidents.
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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Centers for Disease Control and Prevention. (2010). Blast Injuries: Crush Injuries and Crush Syndrome.
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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* Cybersecurity and Infrastructure Security Agency. (2022). What to Do-Bomb Threat.
This webpage includes information and links to resources that can help healthcare staff react if they receive a bomb threat or find a suspicious item. Guidance on planning and additional resources are also included.
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Doherty, M. (2016). From Protective Intelligence to Threat Assessment: Strategies Critical to Preventing Targeted Violence and the Active Shooter. Journal of Business Continuity & Emergency Planning, Volume 10 (1), 9-17.
This article aims to prevent active shooter incidents by discussing behavioral warning signs in individuals and barriers to prevention. It summarizes factors in individuals’ backgrounds which may lead to violence. The article also contains threat assessment tools and case studies.
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Federal Emergency Management Agency. (2015). IS-907: Active Shooter: What You Can Do.
This course was written for non-law enforcement employees and provides information on actions they can take should they be confronted with an active shooter situation.
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Hospital Association of Southern California. (2013). Active Shooter Drill Materials.
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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* Jorolemon, M., Lopez, R., and Krywko, D. (2021). Blast Injuries.
This article summarizes blast injuries, their effects on various body parts, and how to recognize, diagnose, and treat them.
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Los Angeles Sheriff's Department (2015). Surviving an Active Shooter.
This video depicts active shooter scenarios and shares strategies for responding and surviving such events.
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Los Angeles Sheriff's Department. (2015). Surviving an Active Shooter.
This video depicts active shooter scenarios and shares strategies for responding to and surviving such events.
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MESH Coalition. (2014). Responding to an Active Shooter in a Healthcare Setting.
This webpage contains several videos which provide information on preparing for and responding to an active shooter event in a healthcare setting.
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MESH Coalition. (2014). Responding to an Active Shooter in a Healthcare Setting.
This video provides information on preparing for and responding to an active shooter event in a healthcare setting.
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Mount Sinai (NY) Health System. (2020). Armed Intruder/Active Shooter Training Module.
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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National Association of Emergency Medical Technicians. (2015). TCCC-MP Guidelines and Curriculum.
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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Ready Houston. (2012). Run, Hide, Fight: Surviving an Active Shooter Event. The City of Houston Mayor’s Office of Public Safety and Homeland Security.
This short video depicts active shooter scenarios and demonstrates how those affected can increase their chances of survival. Though developed for Houston, it does not contain jurisdiction-specific information, allowing it to serve as a valuable resource for all.
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Texas State University San Marcos. (2015). Advanced Law Enforcement Rapid Response Training (ALERRT). Bureau of Justice Assistance, VALOR, Texas Office of the Governor, and the Federal Bureau of Investigation.
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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The City of Houston Mayor’s Office of Public Safety and Homeland Security, Ready Houston (2012). Run, Hide, Fight: Surviving an Active Shooter Event.
This video depicts active shooter scenarios and demonstrates how witnesses can increase their chances of survival.
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* The National Association of Emergency Medical Technicians (2015). TCCC Guidelines and Curriculum.
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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U.S. Department of Homeland Security. (n.d.). Enhanced Dynamic Geo-Social Environment (EDGE). (Accessed 6/29/2021.)
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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U.S. Department of Homeland Security. (2015). Active Shooter Preparedness.
This webpage includes information on the subject including tips for what to do in an active shooter situation, and links to webinars, reports, training events, and informational materials (e.g., pamphlets, posters and wallet cards) in English and Spanish.
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U.S. Department of Homeland Security. (2015). Stop the Bleed.
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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* U.S. Department of Homeland Security, Office of Health Affairs. (2015). First Responder Guide for Improving Survivability in Improvised Explosive Device and/or Active Shooter Incidents. U.S. Department of Homeland Security.
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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University of Iowa, College of Public Health, Upper Midwest Preparedness and Emergency Response Learning Center. (2007). Emergency Medical Services Operations and Planning for Weapons of Mass Destruction. (Requires free registration.)
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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Weston, B., Simpson, N., Hart, D., et al. (2015). Multiple Casualty Scenario from a Bomb/Blast Injury. MedEdPORTAL Publications. 2015;11:10065.
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

* American College of Emergency Physicians. (2021). Active Shooter Resources.
This webpage includes links to various ACEP and national resources on active shooter response, workplace violence, and general hospital disaster preparedness.
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American Hospital Association. (2023). Active Shooter Incidents in Health Care Settings.
This webpage includes links to various resources (e.g., webinars, podcasts, and case studies) on preparing for and responding to active shooter incidents in healthcare facilities.
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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 Exchange highlights lessons learned from two recent active shooter incidents in or near healthcare facilities and includes an article on how the new Health Care Preparedness and Response Capabilities emphasize response.
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* ASPR TRACIE. (2018). Healthcare Response to a No-Notice Incident: Las Vegas.
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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ASPR TRACIE. (2018). Mass Violence/Active Shooter Incident Tip Sheets.
ASPR TRACIE created these tip sheets for hospitals and other health care 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 health care needs resulting from no-notice incidents, these tip sheets focus on some of the identified challenges.
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* ASPR TRACIE. (2018). The Exchange, Issue 7: Providing Healthcare During No-Notice Incidents.
This issue covers the challenges associated with providing care during no-notice incidents (e.g., mass shootings) including EMS-related content.
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ASPR TRACIE. (2019). Mass Casualty Trauma Triage: Paradigms and Pitfalls.
This ASPR TRACIE white paper (developed after a national expert roundtable) can help emergency medical system (EMS) medical directors and EMS systems planners to understand and plan for 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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* ASPR TRACIE. (2024). On-Campus Health Care Facility Armed Assailant Planning Considerations.
Health care planners can use this checklist to help prepare their facilities to mitigate, respond to, and recover from an active shooter or armed assailant situation on campus.
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* Burstein, J., Lacy, C., and Donovan, C. (eds). (2017). Future Developments in the Management of Explosive Incidents. (Abstracts only.) Annals of Emergency Medicine. 69(1): Supplement.
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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* California Hospital Association. (2017). Planning for Active Shooter Incidents.
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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Callaway, D.W., Smith, E.R., Cain, J., et al. (2011). Tactical Emergency Casualty Care (TECC): Guidelines for the Provision of Prehospital Trauma Care in High Threat Environments. Journal of Special Operations Medicine. 11(3).
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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Committee for Tactical Emergency Casualty Care. (2015). Tactical Emergency Casualty Care (TECC) Guidelines.
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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Cybersecurity and Infrastructure Security Agency. (2020). Security and Resiliency Guide: Counter-Improvised Explosive Device (C-IED) Annex for Healthcare and Public Health Facility Stakeholders. U.S. Department of Homeland Security.
This guide can help healthcare staff and management understand, plan for, and respond to incidents involving improvised explosive devices.
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* Cybersecurity and Infrastructure Security Agency. (2022). What to Do-Bomb Threat.
This webpage includes information and links to resources that can help healthcare staff react if they receive a bomb threat or find a suspicious item. Guidance on planning and additional resources are also included.
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Federal Bureau of Investigation. (n.d.). Active Shooter Incidents. (Accessed 6/29/2021.) U.S. Department of Justice.
This webpage describes the incidents and the agency’s efforts at prevention. The page provides links to in-depth reports, statistics, guides, after-action reports of recent incidents (including the school shooting at Sandy Hook Elementary), planning guides, and the video geared towards the general public: “Run, Hide, Fight.”
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Federal Bureau of Investigation. (n.d.). Active Shooter Resources. (Accessed 6/29/2021.)
This website provides guidance and general information on active shooter incidents from the Federal Bureau of Investigation.
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Federal Bureau of Investigation. (2020). Making Prevention a Reality. Behavioral Threat Assessment Center National Center for the Analysis of Violent Crime Critical Incident Response Group, Federal Bureau of Investigation.
This guide from industry experts examines threat assessment and management with the goal of preventing violence through knowledge, experience and cooperation. It can be used by professionals of any level of expertise.
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Federal Bureau of Investigation. (2022). Active Shooter Safety Resources.
This Federal Bureau of Investigation webpage includes links to educational videos and other resources specific to active shooter incidents.
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French, L. (2020). EMS World Expo Quick Take: This is Not a Drill — Active Shooter in the ED. EMS1.
This article summarizes a presentation on an active shooter incident that took place in the parking lot and inside of Mercy Hospital’s (Chicago) emergency department. The author lists five takeaways and provides links to related resources.
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* Healthcare and Public Health Sector Critical Infrastructure Protection Partnership. (2017). Active Shooter Planning and Response in a Healthcare Setting.
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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Hick, J., Hanfling, D., Evans, B. et al. (2016). Health and Medical Response to Active Shooter and Bombing Events.
This National Academies of Medicine perspective 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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* Hick, J., Nelson, J., Fildes, J., et al. (2020). Triage, Trauma, and Today’s Mass Violence Events. (References cited only.) Journal of the American College of Surgeons. 230(2): 251–256.
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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Huddy, J. (2021). Violence in the Emergency Department: Strategies for Prevention and Response.
Violence in healthcare facilities presents a growing and significant challenge to patients, providers, support staff, and visitors. Hospital emergency departments (EDs)—where doors are always “open”—are frequently the site of violence, which is either carried over from external conflict or perpetrated by patients (and/or their loved ones) against healthcare workers. This article highlights variables that contribute to challenging situations and strategies hospitals can use to prevent them, keeping patients and staff as safe as possible.
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Interagency Security Committee Active Shooter Working Group. (2015). Planning and Response to an Active Shooter: An Interagency Security Committee Policy and Best Practices Guide.
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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Jacobs, L., McSwain, N., Rotondo, M., et al. (2013). Improving Survival from Active Shooter Events: The Hartford Consensus. The National Association of Emergency Medical Technicians.
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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Kelley, K., Toscano, N., Gestring, M., et al. (2023). Disaster Planning for a Surgical Surge: When Mass Trauma Threatens to Overwhelm Your Operating Rooms. Trauma Surgery & Acute Care Open. 8. .
The authors encourage hospitals to develop emergency plans to help staff prepare for conducting multiple surgeries simultaneously post-incident. They list specific plan components (e.g., activation criteria, communication, space, staffing, and supplies) and suggest key stakeholders from both the surgery and anesthesia departments and operating room be part of the committee responsible for hospital incident command.
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LaBuff, P. (2021). Active-Shooter Incidents: Basic Strategies for Hospitals. EMSWorld.
The author briefly lists considerations hospital planners can incorporate into their planning, exercises, and infrastructure to mitigate active shooter incidents at their facility.
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Motzer, E. and Smock, W. (2010). “Active Shooter” Safety Guidelines For Healthcare Campuses.
The authors provide active shooter planning guidance under five main categories: Pre-Incident Prevention and Preparation, Management During and Incident, Post Event Management, Safety Tips for Personnel and Additional Resources.
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National Fire Protection Agency. (2018). NFPA 3000™ (PS): Standard for an Active Shooter/Hostile Event Response (ASHER) Program.
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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Schwerin D., Thurman, J., and Goldstein, S. (2021). Active Shooter Response. StatPearls.
The authors provide comprehensive overviews of active shooter incidents and these incidents in healthcare facilities. They highlight response options, training considerations, and other considerations healthcare emergency planners can incorporate.
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Silver, J., Simons, A., and Craun, S. (2018). A Study of the Pre-Attack Behaviors of Active Shooters in the United States Between 2000 and 2013. Federal Bureau of Investigation.
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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Smith, E.R. and Delaney, J.B. (2013). A New Response: Supporting Paradigm Change in EMS’ Operational Medical Response to Active Shooter Events. Journal of Emergency Medical Services. 38(12): 48-50, 52, 54-5.
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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* Smith, E.R. and Shapiro, G. (2012). Changing the Paradigm: Tactical Emergency Casualty Care Guidelines for High Risk Scenarios. Committee for Tactical Emergency Casualty Care.
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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The Interagency Board. (2016). Training Trigger: Integrated Response Operations in Active Shooter/Hostile Events (ASHE).
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 Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events. (2013). Active Shooter and Intentional Mass-Casualty Events: The Hartford Consensus II. Bulletin of the American College of Surgeons.
The author 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 National Association of Emergency Medical Technicians (2015). TCCC Guidelines and Curriculum.
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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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2017). Active Shooter Planning and Response in a Healthcare Setting.
This document provides active shooter guidance tailored specifically to the healthcare setting.
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U.S. Department of Health and Human Services, U.S. Department of Homeland Security, U.S. Department of Justice, Federal Bureau of Investigation, and Federal Emergency Management Agency. (2014). Incorporating Active Shooter Incident Planning into Health Care Facility Emergency Operations Plans.
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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* U.S. Department of Homeland Security. (n.d.). First Responder.
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U.S. Department of Homeland Security. (2017). First Responder.
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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U.S. Department of Homeland Security, CISA. (2019). Hospitals & Healthcare Facilities: Security Awareness for Soft Targets and Crowded Places.
This brief action guide highlights potential warning signs and response and mitigation strategies specific to an active shooter situation in a healthcare facility.
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* U.S. Department of Homeland Security, Office of Health Affairs. (2015). First Responder Guide for Improving Survivability in Improvised Explosive Device and/or Active Shooter Incidents. U.S. Department of Homeland Security.
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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U.S. Fire Administration. (2013). Fire/ Emergency Medical Services Department Operational Considerations and Guide for Active Shooter and Mass Casualty Incidents.
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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Injuries and Treatment

* Almogy, G. and Rivkind, A. (2005). Surgical Lessons Learned from Suicide Bombing Attacks. (Abstract only.) Journal of the American College of Surgeons. 202(2):313-319.
In this landmark article, 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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American College of Surgeons. (2015). See Something, Do Something: Improving Survival Strategies to Enhance Survival in Active Shooter and Intentional Mass Casualty Events: A Compendium. Bulletin of the American College of Surgeons. 100(15).
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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  • Meghan Treber test
    9/21/2019 2:21:41 PM
Bulger, E., Snyder, D., Schoelles, K., et al. (2014). An Evidence-Based Prehospital Guideline for External Hemorrhage Control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care. 18(2):163-173.
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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* Burstein, J., Lacy, C., and Donovan, C. (eds.). (2017). Best Practices for Management of Explosive Incidents: Translating the US and Israeli Military and Civilian Experience for Use in US Civilian and Military Out-of-hospital and Hospital Health Care. (Abstracts only.) Annals of Emergency Medicine. 69(1): Supplement.
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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* Centers for Disease Control and Prevention. (n.d.). Blast Injuries: Fact Sheets for Professional. (Accessed 8/2/2021.)
These fact sheets (originally developed by CDC) are designed to help healthcare providers identify and treat an array of blast injuries (e.g., crush, abdominal, ear, eye, extremity, and lung).
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Duncan, E. Colver, K., Dougall, N., et al. (2014). Consensus on Items and Quantities of Clinical Equipment Required to Deal with Mass Casualties Big Bang Incident: A National Delphi Study. BMC Emergency Medicine. 14: 5.
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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Frykberg, E. (2004). Principles of Mass Casualty Management Following Terrorist Disasters. Annals of Surgery. 239(3): 319–321.
The author presents an overview of three studies on mass casualty terrorist attacks in Israel in this landmark article. 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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Hart, A., Nammour, E., Mangolds, V., and Broach, J.. (2018). Intuitive Versus Algorithmic Triage. (Abstract only.) Journal of Prehospital Disaster Medicine. 33(4): 355-361.
The authors compared the traditional START triage model to one where an experienced responder used instinct to determine victims’ triage category based on first impression assessments. Based on a staged active shooter simulation, the authors found intuitive triage to be faster, potentially saving lives and money in the long run.
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* Hick, J., Nelson, J., Fildes, J., et al. (2020). Triage, Trauma, and Today’s Mass Violence Events. (References cited only.) Journal of the American College of Surgeons. 230(2): 251–256.
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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* Jorolemon, M., Lopez, R., and Krywko, D. (2021). Blast Injuries.
This article summarizes blast injuries, their effects on various body parts, and how to recognize, diagnose, and treat them.
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Kalayci, M., Er, S., and Tahtabasi, M. (2020). Bomb Explosion: Ocular Effects of Primary, Secondary and Tertiary Mechanisms. Clinical Opthamology. 28(14):1145-1151.
This study examines twenty-two patients who had ocular injuries due to a bombing in Somalia in 2019 (32 eyes in total were included in the study). The bulk of ocular injuries were “open globe” (and most of them were lacerations). The authors suggest that ocular blast injuries will increase along with the “widespread use of highly explosive fragmentary munitions.”
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Kearns, R.D., Myers, B., Cairns, C.B., et al. (2014). Hospital Bioterrorism Planning and Burn Surge. Biosecurity Bioterrorism. 12(1):20-8.
This article discusses how using an all-hazards approach to bioterrorism response planning helped to prepare hospitals in the Raleigh/Durham, NC area to care for casualties from a plant explosion in June 2009. The rescue, response, and resuscitation of survivors by first responders and first receivers, as well as efforts to develop burn surge, are described.
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* King, D., Larentzakis, A., Ramly, A., et al. (2015). Tourniquet Use at the Boston Marathon Bombing: Lost in Translation. (Abstract only.) Journal of Trauma and Acute Care Surgery. 78(3):594-9.
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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Klassen, A., Marshall, M., Dai, M., et al. (2019). Emergency Medical Services Response to Mass Shooting and Active Shooter Incidents, United States, 2014-2015. (Abstract only.) Prehospital Emergency Care. 23(2): 159-166 .
The authors examined data from 34 emergency medical services (EMS) responses to mass shooting incidents to gain a better understanding of injury types and other variables. Overall, 76% of the victims were male (80% African American); wounds were found in extremities (49%), chest (12%), and head/neck (13%). While extremity wounds were common, tourniquets were used in only 6% of cases. This finding, combined with the fact that dispatch did not notify responders of shooting incidents in nearly 16% of the cases, contributed to a call for more action and research to protect EMS.
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Levy, M., Pasley, J., Remick, K., et al. (2021). Removal of the Prehospital Tourniquet in the Emergency Department. The Journal of Emergency Medicine. 60(1): 98-102.
Early tourniquet use controls severe hemorrhage and increases survival when applied in a pre-hospital setting. The authors describe a stepwise approach to the assessment and removal of a tourniquet in the emergency department.
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* Mutafchiyski, V., Popivanov, G., and Kjossev, K. (2014). Medical Aspects of Terrorist Bombings - A Focus on DCS and DCR. Military Medical Research. 11;1:13.
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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Office for Victims of Crime. (2016). Helping Victims of Mass Violence and Terrorism: Planning, Response, Recovery, and Resources. U.S. Department of Justice, Office of Justice Programs, National Institute of Justice.
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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Scott, T., Kirkman, E., Haque, M., et al. (2017). Primary Blast Lung Injury - A Review. The British Journal of Anaesthesia. 118(3):311-316.
The authors reviewed literature from 2000 on to better understand the nature of lung injuries after bomb and explosion-blasts. They also highlighted treatment options geared towards anesthetists and intensive care providers.
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Sever, M. and Vanholder, R. (2013). Management of Crush Victims in Mass Disasters: Highlights from Recently Published Recommendations. Clinical Journal of the American Society of Nephrology. 8(2): 328-335.
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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Smith, E., Shapiro, G, and Sarani, B. (2018). Fatal Wounding Pattern and Causes of Potentially Preventable Death Following the Pulse Night Club Shooting Event. (Abstract only.) Prehospital Emergency Care. 22(6): 662-668 .
This retrospective study of autopsy reports for victims of the Pulse Night Club shooting found that there were 6.9 wounds per patient (90% to an extremity, 78% to the chest, 47% to the abdomen/pelvis, and 39% to the head). Sixteen patients (32%) had potentially survivable wounds; no tourniquets or wound packing materials were documented. The authors concluded that civilian care provided on scene and a more coordinated evacuation approach could increase survival in future incidents.
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Smith, E., Shapiro, G., and Sarani, B. (2016). The Profile of Wounding in Civilian Public Mass Shooting Fatalities. (Abstract only.) Journal of Trauma and Acute Care Surgery. 81(1): 86-92.
The authors reviewed autopsy reports from 12 civilian public mass shootings to determine the site of injury, “probable site of fatal injury, and presence of potentially survivable injury (i.e., if prehospital care is provided within 10 minutes and trauma center care within 60 minutes of injury).” They found that only 7% head survivable wounds, no head injury was potentially survivable, and the probable site of fatal injury was either the head or the chest (77%).
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Sylvester, K., Rocchio, M., Belisle, C., et al. (2014). Pharmacy Response to the Boston Marathon Bombings at a Tertiary Academic Medical Center. (Abstract only.) The Annals of Pharmacotherapy. 19;48(8):1082-1085.
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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Tahtabasi, M., Er, S., Karasu, R., and Ucaroglu, E. (2021). Bomb Blast: Imaging Findings, Treatment and Clinical Course of Extremity Traumas. BMC Emergency Medicine. 21: 28.
A review of 101 patients with injuries caused by bomb explosions was conducted to determine severity and types of injury. Three quarters presented with at least one fracture; 91.2% were open and 8.8% were closed. Open fractures were more likely to affect the femur and tibia. These findings can help hospitals better prepare to treat victims of bomb blasts.
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Lessons Learned

* Almogy, G. and Rivkind, A. (2005). Surgical Lessons Learned from Suicide Bombing Attacks. (Abstract only.) Journal of the American College of Surgeons. 202(2):313-319.
In this landmark article, 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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* American College of Emergency Physicians. (2021). Active Shooter Resources.
This webpage includes links to various ACEP and national resources on active shooter response, workplace violence, and general hospital disaster preparedness.
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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 Exchange highlights lessons learned from two recent active shooter incidents in or near healthcare facilities and includes an article on how the new Health Care Preparedness and Response Capabilities emphasize response.
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* ASPR TRACIE. (2018). Healthcare Response to a No-Notice Incident: Las Vegas.
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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* ASPR TRACIE. (2018). The Exchange, Issue 7: Providing Healthcare During No-Notice Incidents.
This issue covers the challenges associated with providing care during no-notice incidents (e.g., mass shootings) including EMS-related content.
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ASPR TRACIE. (2019). Lessons Learned from the Pulse Nightclub Shooting: An Interview with Staff from Orlando Regional Medical Center.
ASPR TRACIE interviewed staff from Orlando Regional Medical Center three months after a gunman opened fire at the Pulse nightclub, killing 49 people and wounding at least 66. Trauma surgeons and the director of the hospital’s emergency preparedness program shared a comprehensive overview of the attack, including challenges encountered during the response and lessons learned.
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Association of Healthcare Emergency Preparedness Professionals. (2024). After the Echo: Hospital Recovery After an Active Shooter Event.
In this webinar, Donald Denson shares considerations for recovery after a shooting at a hospital. He covers how to handle the aftermath of workplace violence, leadership thoughts and actions, interactions with law enforcement, impacts to the facility, returning to normal operations, and mental health concerns for survivors.
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Bachman, M., Anzalone, B., Williams, J., et al. (2019). Evaluation of an Integrated Rescue Task Force Model for Active Threat Response. (Abstract only.) Prehospital Emergency Care. 23(3): 309-318.
Following didactic training involving law enforcement and emergency medical services, the authors evaluated scenarios that called for rescue task forces to treat and triage 11 simulated casualties over 13,000 square feet. Over 18 days, and 69 scenarios, the authors concluded that clinical care was appropriate and improvement in task execution was possible.
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Basavaraju, S.V., Hunt, R.C., Vikas, K., et al. (2010). In A Moment's Notice: Surge Capacity for Terrorist Bombings: Challenges and Proposed Solutions. Centers for Disease Control and Prevention.
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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Berkowitz, B. and Alcantara, C. (2021). The Terrible Numbers that Grow with Each Mass Shooting. The Washington Post.
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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Biddinger, P.D., Baggish, A., Harrington, L., et al. (2013). Be Prepared — The Boston Marathon and Mass-Casualty Events. New England Journal of Medicine. 368:1958-1960.
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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Blair, J.P. and Schweit, K.W. (2014). A Study of Active Shooter Incidents in the United States Between 2000 and 2013. Texas State University and Federal Bureau of Investigation, U.S. Department of Justice.
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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Boston Public Health Commission. (2013). 2013 Boston Marathon Emergency Support Function 8 (ESF-8) Public Health and Medical Planning, Response, and Recovery Operations (April 15-April 26): Final After Action Report.
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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* Burstein, J., Lacy, C., and Donovan, C. (eds.). (2017). Best Practices for Management of Explosive Incidents: Translating the US and Israeli Military and Civilian Experience for Use in US Civilian and Military Out-of-hospital and Hospital Health Care. (Abstracts only.) Annals of Emergency Medicine. 69(1): Supplement.
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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* Burstein, J., Lacy, C., and Donovan, C. (eds). (2017). Future Developments in the Management of Explosive Incidents. (Abstracts only.) Annals of Emergency Medicine. 69(1): Supplement.
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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Cassa, C., Chunara, R., Mandl, K., and Brownstein, J. (2013). Twitter as a Sentinel in Emergency Situations: Lessons from the Boston Marathon Explosions. PLoS Currents. (Revised 2013 Jul 2.).
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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Claassen, C., Kashner, T., Kashner, T., et al. (2011). Psychiatric Emergency "Surge Capacity" Following Acts of Terrorism and Mass Violence with High Media Impact: What is Required? (Abstract only.) General Hospital Psychiatry. 33(3):287-93.
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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Clements, B. (2013). Public Health Response to the Fertilizer Plant Explosion in West, Texas. University of Washington, Northwest Center for Public Health Practice.
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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Cole, L., Scott, S., Feravolo, M., and Lamba, S. (2014). Preparedness in America's Prime Danger Zone and at the Boston Marathon Bombing Site. (Abstract only.) American Journal of Disaster Medicine. 9(1):17-24.
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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de Jager E., Goralnick, E., McCarty, J., et al. (2018). Lethality of Civilian Active Shooter Incidents With and Without Semiautomatic Rifles in the United States. Journal of the American Medical Association. 11;320(10):1034-1035.
The authors compared 248 active shooter incidents through 2017 to determine differences in lethality based on type of firearm used. The use of semiautomatic rifle was associated with an increase in lethality.
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DelValle Institute for Emergency Preparedness. (2014). 2013 Boston Bombings: Response and Recovery. Boston Public Health Commission, Office of Public Health Preparedness.
This infographic includes general statistics and depicts how emergency medical services effectively distributed patients after the Boston Marathon bombing.
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Federal Bureau of Investigation. (2014). Active Shooter Study: Quick Reference Guide.
This factsheet summarizes data as a result of a study into 160 active shooter incidents between 2000 and 2013.
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Federal Bureau of Investigation and the Advanced Law Enforcement Rapid Response Training (ALERRT) Center at Texas State University. (2024). Active Shooter Incidents in the United States in 2023.
This report provides an analysis of data on 48 active shooter incidents in 2023. While this total indicates a 4% decrease from 2022, the number of incidents (defined by the Federal Bureau of Investigation as "one or more individuals actively engaged in killing or attempting to kill people in a populated area") has increased by 60% since 2019.
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Frykberg, E. (2002). Medical Management of Disasters and Mass Casualties From Terrorist Bombings: How Can We Cope? Journal of Trauma. 53(2): 201-212.
The author examines past terrorist bombing events and provides a summary of triage, treatment, and resource utilization differences.
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Gao, H. and Adashi, E. (2015). An Analysis of Active Shooters in the Hospital Setting, 2000-2015. Alpert School of Medicine at Brown University.
This infographic illustrates the frequency of active shooter incidents and lists location demographics and motive and disposition of perpetrators. The authors found that more shootings are happening inside of healthcare facilities, the most common motive is a “grudge,” and incidents are often perpetrated by inmates trying to escape.
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Gates, J., Arabian, S., Biddinger, P., et al. (2014). The Initial Response to the Boston Marathon Bombing: Lessons Learned to Prepare for the Next Disaster. (Abstract only.) Annals of Surgery. 260(6):960-6.
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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Gutierrez de Ceballos, J., Turégano-Fuentes, F., Perez-Diaz, D., et al. (2005). 11 March 2004: The Terrorist Bomb Explosions in Madrid, Spain– An Analysis of the Logistics, Injuries Sustained and Clinical Management of Casualties Treated at the Closest Hospital. Critical Care. 9(1):104-111.
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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Haug, C. (2015). Report from Paris. The New England Journal of Medicine.
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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Heldenberg, E., Givon, A., Simon, D., et al. (2016). Civilian Casualties of Terror-Related Explosions: The Impact of Vascular Trauma on Treatment and Prognosis. (Abstract only.) The Journal of Trauma and Acute Care Surgery. 81(3):435-40.
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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Hirsch, M., Carli, P., Nizard, R., et al. (2015). The Medical Response to the Multisite Terrorist Attacks in Paris. The Lancet.
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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InterAgency Board for Equipment Standardization and Interoperability (IAB). (2015). Integrating Law Enforcement, Fire, and Emergency Medical Services During Active Shooter/Hybrid Targeted Violence Incidents.
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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Kelen, G.D., Catlett, C.L., Kubit, J.G., and Hsieh, Y.H. (2012). Hospital-Based Shootings in the United States: 2000 to 2011. (Abstract only.) Annals of Emergency Medicine. 60(6):790-798.
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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Kelly, R. (2012). Active Shooter Recommendations and Analysis for Risk Mitigation. New York City Police Department.
This report provides summary and detailed information for 281 active shooter events and includes related policy and other recommendations.
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* King, D., Larentzakis, A., Ramly, A., et al. (2015). Tourniquet Use at the Boston Marathon Bombing: Lost in Translation. (Abstract only.) Journal of Trauma and Acute Care Surgery. 78(3):594-9.
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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Lakatos, B., Delisle, L., Mitchell, M., and Etheredge, M. (2014). Psychiatric Advanced Practice Nurses Contributions to Supporting Survivors and Caregivers Affected by the Boston Marathon Bombings. (Abstract only.) Clinical Nurse Specialist. 28(2): 92-96.
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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Lake, C. (2018). A Day Like No Other – Case Study of the Las Vegas Mass Shooting. Nevada Hospital Association.
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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Lee, C., Walters, E., Borger, R., et al. (2016). The San Bernardino, California, Terror Attack: Two Emergency Departments’ Response. The Western Journal of Emergency Medicine. 17(1): 1-7.
This article provides a comprehensive overview of how two emergency departments-- Loma Linda University Medical Center and Children’s Hospital and Arrowhead Regional Medical Center—managed the influx of injured patients after the 2015 San Bernardino (CA) terror attack that left 14 dead and 22 injured.
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Lenz, A., Shelton, R., Ryznar, R., et al. (2020). The Next Nine Minutes: Lessons Learned from the Large-Scale Active Shooter Training Prior to the STEM School Shooting. (Abstract only.) American Journal of Disaster Medicine. 15(4): 241-249.
"The Next Nine Minutes,” a large active shooter drill, involved 904 personnel and 126 “patients” who wore “Cut Suits.” Those patients received 479 procedures (e.g., wound packs, needle decompressions, and tourniquets). Law enforcement established a “warm zone” and emergency medical services was able to extract and transport the first patient within 12 minutes. The lessons learned during this exercise were incorporated into several real-world responses, emphasizing the benefit of “in situ immersion training.”
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Leppert, J., Wren, S., and Bergman, J. (2019). Operating Room Preparedness for Active Shooter Events. Surgery. 167(2):510-511.
The authors describe hearing an alarm for an active shooter while they were in the middle of performing a robotic partial nephrectomy for a patient with renal cell carcinoma. They listed some of the ethical dilemmas the faced regarding next steps (i.e., abort or continue the surgery).
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Melmer. P., Carlin, M., Castater, C., et al. (2019). Mass Casualty Shootings and Emergency Preparedness: A Multidisciplinary Approach for an Unpredictable Event. Journal of Multidisciplinary Healthcare. 12: 1013-1021.
The authors review mass casualty shootings in the U.S. and abroad and emphasize the value of multi-disciplinary teams (MDT) in incident response and the delivery of life-saving care. They also highlight the importance of blood bank preparedness, incorporating lessons learned into plans, simulation exercises, and the “Stop the Bleed” campaign in MDT preparedness and response efforts.
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* Mutafchiyski, V., Popivanov, G., and Kjossev, K. (2014). Medical Aspects of Terrorist Bombings - A Focus on DCS and DCR. Military Medical Research. 11;1:13.
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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Myers, S., DeSimone, J., Lorch, S., et al. (2020). US Hospital Type and Proximity to Mass Shooting Events. JAMA Surgery. 155(5): 446-447.
The authors examined the location of mass shooting incidents for calendar year 2019 relative to closest trauma centers and hospitals. Out of the 187 incidents in 38 states, a non-trauma center was closer to the scene more than 70% of the time; more than 50% of incidents took place more than 10 miles from a pediatric trauma center. The authors emphasize the need for all types of hospitals to prepare to treat adult and pediatric patients wounded in mass violence incidents.
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National Academies of Sciences, Engineering, and Medicine. (2016). A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.
Due to advances in trauma care, the case fatality rate for U.S. service members injured in Afghanistan decreased by almost half. The authors discuss applying these advances to trauma care in defense and civilian settings in response to mass casualty events.
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National Threat Assessment Center. (2023). New Secret Service Research Examines for the First Time Five Years of Mass Violence Data. U.S. Secret Service.
The authors analyzed 173 incidents of mass violence from 2016 to 2020. The report provides an overview of the attacks (e.g., timing, location, motives, weapons involved) and another section on characteristics of the attackers (e.g., criminal behavior, substance use, mental health, and belief systems). Findings indicate that most attackers exhibited concerning behavior prior to the incident, and that behavioral threat assessment programs are a helpful tool in identifying and addressing this type of behavior, potentially preventing future mass violence incidents.
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Orlando Health. (2016). Orlando Health Disaster Response Project. (Free registration required.)
This free, online book includes chapters that detail how several departments (administration, nursing, physicians, support) responded to the Pulse shooting. It also includes a comprehensive timeline of events.
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Oser, M., Shah, S., and Gitlin, D. (2015). Psychiatry Department Response to the Boston Marathon Bombings Within a Level-1 Trauma Center. (Abstract only.) Harvard Review of Psychiatry. 23(3):195-200.
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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Pepper, M., Archer, F., and Moloney, J. (2019). Triage in Complex, Coordinated Terrorist Attacks. (Abstract only.) Prehospital and Disaster Medicine. 34(4)442-448.
The authors reviewed literature on the 2011 Oslo/Utoya Island (Norway), 2015 Paris (France), and 2015 San Bernardino (California USA) terrorist attacks and found there were “significant barriers to the implementation of triage systems designed around flow charts, physiological variables, and the use of tags.”
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Redhead, J., Ward, P., and Batrick, N. (2005). The London Attacks--Response: Prehospital and Hospital Care. The New England Journal of Medicine. 353:546-547.
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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Rozenfeld, M., Givon, A., Shenhar, G., et al. (2016). A New Paradigm of Injuries From Terrorist Explosions as a Function of Explosion Setting Type. (Abstract only.) Annals of Surgery. 263(6):1228-34.
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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Simons, T., Richter, A., and Wollman, L. (2020). Two Teams, One Mission: A Study Using EMS Units in Hospital Triage During Active-Shooter and Other Mass-Casualty Events. (Abstract only.) American Journal of Disaster Medicine. 15(1):33-41.
The authors review the assumption that patients wounded in a mass casualty incident will have gone through some sort of on-site triage and been transported via emergency medical services (EMS) vehicles. Upon observation of an exercise in Utah, the authors found that this may not be the case, and stress the value of having EMS crews on site at the hospital to assist with triage and overall response.
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Skryabina, E., Betts, N., Reedy, G., et al. (2020). The Role of Emergency Preparedness Exercises in the Response to a Mass Casualty Terrorist Incident: A Mixed Methods Study. International Journal of Disaster Risk Reduction. 46.
Responders to the 2017 Manchester (U.K.) Arena bombing participated in in-depth interviews designed to study the impact of health emergency preparedness scenarios on the response to an actual incident. Overall, participants reported feeling more aware of existing incident plans, and those who had participated in exercise felt more prepared and confident when it came time to respond than those who did not.
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Straub, F., Jennings, C., and Gorban, B. (2018). After-Action Review of the Orlando Fire Department Response to the Attack at Pulse Nightclub. The National Police Foundation.
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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Sylvester, K., Rocchio, M., Belisle, C., et al. (2014). Pharmacy Response to the Boston Marathon Bombings at a Tertiary Academic Medical Center. The Annals of Pharmacotherapy. 19;48(8):1082-1085.
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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Tallach, R. Einav, S., Brohi, K., et al. (2021). Learning from Terrorist Mass Casualty Incidents: A Global Survey. British Journal of Anaesthesia. 128(2): E168-E179.
The authors surveyed physicians who had played a leadership role in their hospital's response to a terrorist mass casualty incident (MCI). The first survey was open ended and revealed that human resources (and not space or supplies) were respondents' primary strengths and concerns during these incidents. In a follow up quantitative survey, participants ranked the following as top areas for improvement: re-triage at hospital (90% agreement), coordination roles (85% agreement), flexibility (100% agreement), and large-scale exercises (95% agreement).
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The Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events. (2013). Active Shooter and Intentional Mass-Casualty Events: The Hartford Consensus II. Bulletin of the American College of Surgeons.
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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Wachira, B., Abdalla, R., and Wallis, L. (2014). Westgate Shootings: An Emergency Department Approach to a Mass-Casualty Incident. (Free registration required.) Prehospital and Disaster Medicine. 29(05):1-4.
The authors describe the hospital response to the mass shooting at the Westgate mall in Nairobi, Kenya.
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Pediatric Resources

Committee for Tactical Emergency Casualty Care. (2023). Pediatric Tactical Emergency Casualty Care.
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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Hamele, M., Poss, W.B., and Sweney, J. (2014). Disaster Preparedness, Pediatric Considerations in Primary Blast Injury, Chemical, and Biological Terrorism. World Journal of Critical Care Medicine. 3(1):15-23.
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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National Association of County and City Health Officials. (2016). Summit Podcast Series: Lessons Learned from the Attempted Times Square Bombing.
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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Plans, Tools, and Templates

Arizona Department of Health Services. (2014). Code Silver/Active Shooter Tabletop Exercise for Community Health Centers: Situation Manual (SitMan).
This Situation Manual (SitMan) is intended for participants of a tabletop exercise that focuses on emergency response plans, policies, and procedures as they pertain to an active shooter event at a community health center.
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ASPR TRACIE. (2020). Bomb Threat Policies for Hospitals.
This ASPR TRACIE TA response includes comments from ASPR TRACIE Subject Matter Expert Cadre members and resources related to hospital bomb threats.
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ASPR TRACIE. (2023). Mass Casualty Hospital Capacity Expansion Toolkit (PDF).
Mass casualty incidents (MCIs) generally occur without warning. A concise, scalable surge response template can be a helpful quick reference to the hospital personnel tasked with expanding care capacity in the first hours of an MCI and can minimize ad hoc and potentially conflicting decisions about prioritization of space and strategies. This optional toolkit includes four sections to guide emergency department, general inpatient, and critical care space expansion and basic additional staffing needs in the event of patient surge. Access the Word version of this toolkit here: https://files.asprtracie.hhs.gov/documents/mass-casualty-hospital-capacity-expansion-toolkit---word-version.docx
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ASPR TRACIE. (2024). ASPR TRACIE Hospital Mass Casualty Response Plan Considerations.
The term “mass casualty incident” (MCI) refers to the combination of patients and care requirements that require mobilization of additional resources to meet the demand. MCIs generally occur without warning and a concise plan is needed to ensure rapid and efficient response. The considerations in this document can assist hospitals in developing a new—or vetting an existing— MCI plan.
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* ASPR TRACIE. (2024). On-Campus Health Care Facility Armed Assailant Planning Considerations.
Health care planners can use this checklist to help prepare their facilities to mitigate, respond to, and recover from an active shooter or armed assailant situation on campus.
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California Hospital Association. (2017). Active Shooter Event Response: Interactive Tabletop Exercise.
This webpage includes links to various components of an active shooter tabletop exercise (e.g., master scenario events list, injects, roles for actors, and printable signs).
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* California Hospital Association. (2017). Planning for Active Shooter Incidents.
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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* Centers for Disease Control and Prevention. (n.d.). Blast Injuries: Fact Sheets for Professional. (Accessed 8/2/2021.)
These fact sheets (originally developed by CDC) are designed to help healthcare providers identify and treat an array of blast injuries (e.g., crush, abdominal, ear, eye, extremity, and lung).
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Florida Department of Health. (2012). Hospital Mass Casualty Incident Planning Checklist.
This checklist is rooted in the “whole community approach” and provides step-by-step guidance for those planning for significant increases in demand as a result of a critical incident.
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Greater New York Hospital Association. (2013). Integrated Explosive Event and Mass Casualty Event: Response Plan Template.
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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* Healthcare and Public Health Sector Critical Infrastructure Protection Partnership. (2017). Active Shooter Planning and Response in a Healthcare Setting.
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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Jacobs, L., McSwain, N., Rotondo, M., et al. (2013). Improving Survival from Active Shooter Events: The Hartford Consensus. The National Association of Emergency Medical Technicians.
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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Kaiser Permanente. (2020). Kaiser Sample Code Yellow Bomb Threat Policy.
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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Orlando Health. (2018). Questions Every Hospital Must Ask About Whether They’re Supporting Their Non-resident/Foreign Citizen Patients.
This white paper is based on the significant experience Orlando Regional Medical Center had after the Pulse Nightclub shooting and can help health care 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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The National Association of Emergency Medical Technicians. (2015). TCCC Guidelines and Curriculum.
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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Agencies and Organizations

American College of Emergency Physicians. Bombings: Injury Patterns and Care.
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American Hospital Association. Active Shooter Incidents in Health Care Settings.
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Committee for Tactical Emergency Casualty Care.
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NAEMT Education.
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U.S. Department of Homeland Security. Active Shooter Preparedness.
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* U.S. Department of Homeland Security. First Responder.
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U.S. Department of Homeland Security. TRIPwire.
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This ASPR TRACIE Topic Collection was updated and comprehensively reviewed in October 2021 by the following subject matter experts (listed in alphabetical order): Eric Alberts, BS, CEM, CHPP, CEDP, CCMC, CHEP, FPEM, FPEM-HC, SEM, Corporate Director, Emergency Preparedness, Orlando Health, Inc.; Scott Cormier, Vice President, Emergency Management, EC and Safety, Medxcel; John Hick, MD, Hennepin Healthcare; Mark P. Jarrett, MD, MBA, MS, SVP & Chief Quality Officer, Deputy Chief Medical Officer, Northwell Health, and Professor of Medicine, Zucker School of Medicine at Hofstra/Northwell; James Paturas, Director, Center for Emergency Preparedness and Disaster Response, Yale New Haven Heath System; and Mary Russell, EdD, MSN, Healthcare Emergency Response Coalition of Palm Beach County Florida. 

It was updated by ASPR TRACIE in January 2017 and originally comprehensively reviewed in June 2015 by: Scott Cormier, Vice President, Emergency Management, EC and Safety, Medxcel; Robert Dunne, MD FACEP, Program Director, EMS Fellowship, Medical Director, Detroit East Medical Control Authority, Associate Professor, Wayne State University; and John Hick, MD, HHS ASPR and Hennepin County Medical Center. Additional assistance was provided by James Paturas, Director, Center for Emergency Preparedness and Disaster Response, Yale New Haven Heath System.

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