[Challenge of limb care after violence and war with a special focus on imaging procedures]. / Herausforderung der Extremitätenversorgung nach Gewalt und Krieg mit besonderer Betrachtung bildgebender Verfahren.

BACKGROUND: Injury patterns in the area of the extremities following violence and war harbor many special features and require special attention. Destructive and complex defect injuries are often present, which necessitate elaborate and special reconstruction approaches, predominantly as part of a staged and multistaged procedure. RESEARCH QUESTION: In this context, special attention must be paid to the diagnostic options as an essential aspect, as a clear diagnosis means that targeted treatment steps can be planned and implemented. MATERIAL AND METHOD: The authors' experience in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia, as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of interdisciplinary cooperation with radiological and, in particular, nuclear medicine disciplines are taken into account in the daily routine. RESULTS AND DISCUSSION: Extremity injuries in the context of violence and war are accompanied by complex bone and surrounding soft tissue defects due to the high energy impact. The principles of reconstruction familiar from everyday life can only be transferred one-to-one to a limited extent. The treatment pathways are often very long and complex and the questions of infection and tissue vitality must be answered again and again in stages. Interdisciplinary collaboration with the disciplines specialized in imaging procedures, particularly in the field of nuclear medicine, is one of the key building blocks for a successful treatment pathway.

[National challenges for trauma surgery in Germany due to violence and war]. / Nationale Herausforderungen für die Unfallchirurgie in Deutschland bei Gewalt und Krieg.

Due to the war in Ukraine and the treatment of patients with war wounds in the hospitals of the TraumaNetworks of the German Society for Trauma Surgery (TraumaNetzwerke DGU®), injuries from life-threatening mission situations (LebEL), terrorism, violence and war have become a matter of daily professional life. Furthermore, the societal and global feeling of security has fundamentally changed. The much-cited term "turning point in history", the reorientation of the Armed Forces and the investigation of the resilience of the healthcare system with respect to the "fitness for war", approximate to the description of the current challenges for trauma surgery (UCH) in Germany. Based on the developments following the terrorist attacks in Paris in 2015 and in Brussels in 2016, a clarification is given as to which adaptations have already been successful and how quickly an improvement could successfully be achieved. In this context, the concept of tactical care and the course on Terror and Disaster Surgical Care (TDSC), for example, have been game changing. The main challenge currently lies in overcoming the structural alterations in the German healthcare system and professionally in the treatment of war wounded personnel from Ukraine. The knowledge gained from these two national tasks must be analyzed for the future development and adaptation of established treatment structures, e.g., of the TraumaNetzwerke DGU®, under the requirements of the increased resilience against war, terrorism and violence. The aim is to name that which has already been achieved with respect to the national challenges for UCH and at the same time to outline or discuss further necessities for improvements and elimination of possible gaps in capabilities.

[Initial in-hospital treatment of patients with penetrating trauma due to violence and war]. / Innerklinische Erstversorgung von Patienten mit penetrierendem Trauma nach Gewalt und Krieg.

BACKGROUND: Current political and social developments have brought the topics of violence, in this context attributable to terrorism and sabotage, and since February 2022 awareness of war in particular has again greatly increased. This article aims to present the contextualized dealing with penetrating injuries in terms of initial in-hospital treatment. OBJECTIVE: The question remains to be answered as to what extent penetrating injuries require special attention and to what extent the treatment priorities, options and strategies as well as surgical treatment require adaptation of the usual approach in routine clinical practice in Germany. MATERIAL AND METHOD: The experience of the authors in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of a comprehensive systematic literature review and current data from a national evaluation on the topic of preparing hospitals in Germany for such scenarios are taken into account. RESULTS AND DISCUSSION: The clinical systems need to be well-prepared for such casualties, especially if they require treatment in large numbers. This is precisely so because the majority of patients are in a relevantly threatening situation (usually in the sense of a hemorrhage), treatment must be very urgently provided and in such scenarios a lack of resources must always be overcome, at least temporarily, especially for example for blood transfusions.

[Microbiological challenges in the treatment of war injuries]. / Mikrobiologische Herausforderungen bei der Versorgung von Kriegsverletzungen.

The treatment of war injuries represents a continuing and recurrent challenge in modern reconstructive surgery. Previously, tumor resections and sepsis-related resections were mainly responsible for lengthy bone defects in Germany. In recent years another picture has increasingly emerged, particularly caused by the medical support of Ukraine. Aspects of military surgery are also becoming more important in civil hospitals, especially in the treatment of gunshot and explosion injuries. In Germany, war injuries are currently secondarily treated, as the distribution of patients is carried out according to the cloverleaf principle, weeks or months after the occurrence of the primary injury. In addition to complex bone and soft tissue defects of the extremities following such injuries, which often affect neural and vascular structures, reconstruction is often complicated by an increasing spectrum of multidrug-resistant pathogens. The definition of microbiological terms, such as contamination, colonization, critical colonization, local and systemic infections are important in the clinical routine in order to initiate a targeted treatment, especially in treatment with antibiotics. Wound swabs for determination of the spectrum of pathogens and the optimal testing of resistance are important for selecting the appropriate antibiotic agents. The concept of antibiotic stewardship (ABS) is established in many hospitals to improve the quality of antibiotic treatment and to minimize the formation of resistance. The selection of the method of reconstruction depends on the condition of the patient, the overall clinical constellation and the function to be expected after completion of treatment. The treatment of injuries due to violence and terrorism necessitates clear concepts and an interdisciplinary approach, especially with respect to microbiological challenges and increasing resistance situations.

[Stress fractures in the military context]. / Stressfrakturen im militärischen Kontext.

BACKGROUND: Soldiers, especially as recruits, are exposed to significantly elevated stress patterns of the foot due to occupation-related marching and excessive running. This can lead to military-specific stress fractures of the metatarsals, i.e., marching fractures. The treatment and prevention of stress fractures are of particular importance in the military context due to the impact on operational capability and treatment costs. A uniform classification of these fractures does not yet exist. OBJECTIVE: Review of stress fractures in the military setting with presentation of the incidence, risk factors, classification, treatment and prevention possibilities. MATERIAL AND METHODS: A PubMed®-based review of the current literature on stress fractures in the military context was conducted and the results were discussed with a focus on specific military medical treatment options. RESULTS: There are several possibilities to classify stress fractures, the most well-known being a 4-level magnetic resonance imaging (MRI)-based classification. Prevention and treatment possibilities are multifaceted but so far insufficiently validated. CONCLUSION: Military-specific stress fractures should be grouped according to a 4-level and MRI-based classification. The treatment options include both conservative and surgical measures and should be implemented taking the patient's individual requirements into account. Preventive measures play a key role in the military context. They include the adaptation of screening tools, training and equipment and require continuous evaluation and development.

[Keeping the big picture in Terror-MASCAL-A new hospital concept]. / Überblick im Terror-MANV ­ ein neues Klinikkonzept.

BACKGROUND: Two key positions have been defined for the in-house management of patients in the context of a terrorism-related mass casualty incident (Terror-MASCAL). The senior triage coordinator (LArS) categorizes the injured according to injury severity using algorithms. The central operational and medical coordinator (ZONK) disposes and prioritizes the injured for treatment measures, considering the injury severity and the available treatment capacities. The dynamics and complexity of a Terror-MASCAL combined with the high number of patients requires comprehensible documentation. MATERIAL AND METHODS: The evaluation of an incident exercise of a Terror-MASCAL revealed deficits in its documentation. Based on the deficits identified, requirements have been defined. The article presents the management and documentation aids of a German national trauma center. RESULTS: The hospital with its currently available resources is abstractly represented via the Trauma Tactics Board (TTB). Patients with their individual injuries are represented by identification cards on the TTB. The ZONK can prioritize and dispose further treatment based on the information about the available resources and the patient-specific injury pattern. The patient registry continues to document the patient's other medical findings. Important external and internal information is noted in an event register. The entire documentation process on the TTB is documented by camera. CONCLUSION: Documentation aids are required to fulfil the core tasks of the ZONK. By using the documentation aids, a hospital can prepare for a Terror-MASCAL within a short time. Lack of daily practical application of the documentation aids should be compensated for by regular practice and interdisciplinary exchange of experience.

[Care of the severely injured in mass casualty incidents : What is the difference compared to emergency room management?] / Schwerstverletztenversorgung beim Massenanfall von Verletzten : Worin besteht der Unterschied zum Schockraummanagement?

The management of a severely injured patient according to the standards and principles of individualized trauma care is a well-established procedure in many hospitals. The process is structured and standardized by the content of several course formats. In contrast, a mass casualty incident (MCI, MANV) is a rare and exceptional situation. In this case the treatment priorities and approaches are changed. The main aim in this situation is to ensure the best possible chance of survival for every casualty by organizational measures to mobilize rooms, personnel and material and to temporarily abandon the standards of individualized trauma care. To be prepared for a MCl situation it is necessary to know the realistic scenarios, to update the hospital emergency plan and to adapt all treatment procedures to the transient lack of resources. This article gives an overview of this process and summarizes the current clinical concepts to cope with a MCl situation and the current principles for the care of the severely injured involving many casualties.

Education and training as a key enabler of successful patient care in mass-casualty terrorist incidents.

BACKGROUND AND PURPOSE: The increase in terrorist attacks with sometimes devastating numbers of victims has become a reality in Europe and has led to a fundamental change in thinking and a reorientation in many fields including health policy. The purpose of this original work was to improve the preparedness of hospitals and to provide recommendations for training. MATERIAL AND METHODS: We conducted a retrospective literature search based on the Global Terrorism Database (GTD) for the period 2000 to 2017. Using defined search strategies, we were able to identify 203 articles. We grouped relevant findings into main categories with 47 statements and recommendations on education and training. In addition, we included data from a prospective questionnaire-based survey on this topic that we conducted at the 3rd Emergency Conference of the German Trauma Society (DGU) in 2019. RESULTS: Our systematic review identified recurrent statements and recommendations. A key recommendation was that regular training should take place on scenarios that should be as realistic as possible and should include all hospital staff. Military expertise and competence in the management of gunshot and blast injuries should be integrated. In addition, medical leaders from German hospitals considered current surgical education and training to be insufficient for preparing junior surgeons to manage patients who have sustained severe injuries by terrorist events. CONCLUSION: A number of recommendations and lessons learned on education and training were repeatedly identified. They should be included in hospital preparations for mass-casualty terrorist incidents. There appear to be deficits in current surgical training which may be offset by establishing courses and exercises.

Evaluation of the decision-making process within the table-top exercise of the Terror and Disaster Surgical Care (TDSC®) course.

PURPOSE: The threat of terror is omnipresent in Europe and the number of attacks worldwide is increasing. The target of attacks in Europe is usually the civilian population. Incalculable dangerous situations at the scene of the event and severe injury patterns such as complex gunshot and explosion injuries with a high number of highly life-threatening people present rescue forces, emergency physicians and subsequently hospitals with medical, organizational as well as tactical and strategic challenges. The Terror and Disaster Surgical Care (TDSC®) course trains clinical decision-makers to meet these challenges of a TerrorMASCAL in the first 24-48 h. METHODS: A table-top exercise was developed for the TDSC® course as a decision training tool, which was prospectively evaluated in six courses. The evaluation took place in 3 courses of the version 1.0, in 3 courses in the further developed version 2.0 to different target values like, e.g., the accuracy of the in-hospital triage. Furthermore, 16 TDSC® course instructors were evaluated. RESULTS: For the evaluation, n = 360 patient charts for version 1.0 and n = 369 for version 2.0 could be evaluated. Overall, the table-top exercise was found to be suitable for training of internal clinical decision makers. Version 2.0 was also able to depict the action and decision-making paths in a stable and valid manner compared to the previous version 1.0. The evaluation of the instructors also confirmed the further value and improvement of version 2.0. CONCLUSION: With this prospective study, the table-top exercise of the TDSC® course was tested for decision stability and consistency of the participants' decision paths. This could be proven for the selected target variables, it further showed an improvement of the training situation. A further development of the table-top exercise, in particular also using digital modules, will allow a further optimization. http://www.bundeswehrkrankenhaus-ulm.de.

Early total care or damage control orthopaedics for major fractures ? Results of propensity score matching for early definitive versus early temporary fixation based on data from the trauma registry of the German Trauma Society (TraumaRegister DGU®).

PURPOSE: Damage control orthopaedics (DCO) und early total care (ETC) are well-established strategies for managing severely injured patients. There is no definitive evidence of the superiority of DCO over ETC in polytrauma patients. We conducted this study to assess the probability of a polytraumatised patient undergoing DCO. In addition, the effect of DCO on complications and mortality was investigated. METHODS: We analysed data from 12,569 patients with severe trauma (Injury Severity Score ≥ 16) who were enrolled in the trauma registry of the German Trauma Society (TraumaRegister DGU®) from 2009 to 2016 and had undergone surgery for extremity or pelvic fractures. These patients were allocated to a DCO or an ETC group. We used the propensity score to identify factors supporting the use of DCO. For a comparison of mortality rates, the groups were stratified and matched on the propensity score. RESULTS: We identified relevant differences between DCO and ETC. DCO was considerably more often associated with packed red blood cell (pRBC) transfusions (33.9% vs. 13.4%), catecholamine therapy (14.1% vs. 6.8%), lower extremity injuries (72.4% vs. 53.5%), unstable pelvic fractures (41.0% vs. 25.9%), penetrating injuries (2.8% vs. 1.5%), and shock (20.5% vs. 10.8%) and unconsciousness (23.7% vs. 16.3%) on admission. Based on the propensity score, patients with penetrating trauma, pRBC transfusions, unstable pelvic fractures, and lower extremity injuries were more likely to undergo DCO. A benefit of DCO such as reduced complications or reduced mortality was not detected. CONCLUSION: We could identify some parameters of polytrauma patients used in the trauma registry (Traumaregister DGU®), which led more likely to a DCO therapy. The propensity score did not demonstrate the superiority of DCO over ETC in terms of outcome or complications. It did not appear to adequately adjust for the variables used here. Definitive evidence for or against the use of DCO remains unavailable.

Education, training and technological innovation, key components of the ESTES-NIGHTINGALE project cooperation for Mass Casualty Incident preparedness in Europe.

Disasters induced by extreme weather events and terrorism-related activities, causing mass casualty incidents (MCIs) in Europe, are expected to increase in the upcoming years. This challenging scenario demands a high level of readiness and coordinated multi-disciplinary response to reduce morbidity and mortality. The European Society of Trauma and Emergency Surgery (ESTES) is one of the 23 partners of the European-funded project Novel Integrated Toolkit for Enhanced Pre-Hospital Life Support and Triage in Challenging and Large Emergencies (NIGHTINGALE), whose primary objective is to promote the exchange in experiences and define the best practices among first responders. Additionally, the project promotes multi-disciplinary and multi-institutional efforts to achieve technological innovation that will enhance preparedness in MCI management. This manuscript aims to describe the challenges of MCI triage, the education and training programs for MCI response in Europe, and the technological innovation that may aid optimal response. These three elements were discussed by ESTES Disaster and Military Surgery Section members during the German Society for Trauma Surgery session at the ECTES 2022 in Oslo "TDSC® and beyond: ideas and concepts for education and training in Terror Preparedness", additionally the manuscript describes the first steps of the cooperation between ESTES and the rest of the NIGHTINGALE consortium.

Diagnostic options for blunt abdominal trauma.

PURPOSE: Physical examination, laboratory tests, ultrasound, conventional radiography, multislice computed tomography (MSCT), and diagnostic laparoscopy are used for diagnosing blunt abdominal trauma. In this article, we investigate and evaluate the usefulness and limitations of various diagnostic modalities on the basis of a comprehensive review of the literature. METHODS: We searched commonly used databases in order to obtain information about the aforementioned diagnostic modalities. Relevant articles were included in the literature review. On the basis of the results of our comprehensive analysis of the literature and a current case, we offer a diagnostic algorithm. RESULTS: A total of 86 studies were included in the review. Ecchymosis of the abdominal wall (seat belt sign) is a clinical sign that has a high predictive value. Laboratory values such as those for haematocrit, haemoglobin, base excess or deficit, and international normalised ratio (INR) are prognostic parameters that are useful in guiding therapy. Extended focused assessment with sonography for trauma (eFAST) has become a well established component of the trauma room algorithm but is of limited usefulness in the diagnosis of blunt abdominal trauma. Compared with all other diagnostic modalities, MSCT has the highest sensitivity and specificity. Diagnostic laparoscopy is an invasive technique that may also serve as a therapeutic tool and is particularly suited for haemodynamically stable patients with suspected hollow viscus injuries. CONCLUSIONS: MSCT is the gold standard diagnostic modality for blunt abdominal trauma because of its high sensitivity and specificity in detecting relevant intra-abdominal injuries. In many cases, however, clinical, laboratory and imaging findings must be interpreted jointly for an adequate evaluation of a patient's injuries and for treatment planning since these data supplement and complement one another. Patients with blunt abdominal trauma should be admitted for clinical observation over a minimum period of 24 h since there is no investigation that can reliably rule out intra-abdominal injuries.

[Safety aspects, emergency preparedness and hazard prevention in hospitals concerning mass casualty incidents (MCI)/terror-related MCI : Prospects on future challenges based on survey results from the 3rd emergency conference of the DGU]. / Sicherheitsaspekte und Vorbereitung zur Notfallvorsorge und Gefahrenabwehr in Kliniken bei MANV/TerrorMANV : Ausblick auf zukünftige Herausforderungen anhand von Umfrageergebnissen zur 3. Notfallkonferenz der DGU.

BACKGROUND: Worldwide terrorist activities since "9/11" and subsequently also in the European region have led to a rethinking in the context of the evaluation of critical infrastructure in Germany, also with respect to security at and in hospitals. OBJECTIVE: This publication deals with the evaluation of existing concepts on topics such as "alerting", "security", "communication" and "preparation" in the aforementioned context. MATERIAL AND METHODS: Based on a literature review as well as a survey among participants of the 3rd emergency conference of the DGU (German Society for Trauma Surgery), this topic and the currently existing situation are further analyzed and presented. RESULTS: The data obtained illustrate that while the majority of hospitals have a hospital alert and response planning, the frequency of updates and intrahospital communication to increase awareness show significant variation. Furthermore, the results illustrate a heterogeneity of the existing intrahospital alerting concepts as well as a lack of security concepts and cooperation with security and guard services. Furthermore, it is evident that the topic of a possible CBRN (chemical, biological, radiological, nuclear) threat is not yet adequately perceived or implemented in the risk analysis. DISCUSSION: The latent threat of terrorist activities appears to have led German hospitals to address the issue of hospital alarm and response planning in their assessment as critical infrastructure and to have implemented this for the most part; however, the subordinated areas and the consequences that can be derived from alarm planning do not yet show the necessary stringency to ultimately ensure adequate responses in these special scenarios with respect to security in and at German hospitals.

Surgical Reconstruction Options in Chronic Distal Biceps Tendon Ruptures - Case Report and Literature Review. / Operative Rekonstruktionsmöglichkeiten chronisch distaler Bizepssehnenrupturen ­ Fallbeispiel und Literaturrecherche.

INTRODUCTION: Chronic distal biceps tendon ruptures are rare and conservative or operative treatment options are suitable. There is a consensus in the literature in case of acute traumatic ruptures the operative refixation should be preferred. Disagreement exists in the best way of care of old ruptures (> 4 weeks) of distal biceps tendon. Several kinds of refixation possibilities up to tendon grafts are described. Aim of this publication is showing an overview of the literature of the approved methods in reconstruction of the distal biceps tendon using autogenous and allogenic grafts, comparing the outcomes and transferring them on an own case. MATERIAL AND METHODS: A literature research was carried out using the online medical database "PubMed" with the following keywords "chronic rupture distal biceps tendon, surgical techniques". 59 citations were found concerning the topic, 37 publications were relevant for this work. RESULTS: There is consensus that even in chronic ruptures the operative management of the distal biceps tendon generates the best results. Consistently the experiences and results of only little patient collectives are reported. Numerous techniques of surgery are described without predominance of one method. Reinsertions of the tendon butts are reported in different techniques: with achilles, palmaris longus, fascia lata, triceps, quadriceps and semitendinosus tendon grafts. All together they showed postoperative satisfactory results. CONCLUSION: With surgical treatment of chronic ruptured distal biceps tendons comparable outcomes can be achieved by primary refixation and graft augmentations. In case of graft augmentations several tissue options are available which showed in all cases satisfactory functional results in the end.

Evaluation of the Terror and Disaster Surgical Care course.

BACKGROUND: Mass-casualty terrorist incidents are a medical and organisational challenge for every hospital. The Terror and Disaster Surgical Care (TDSC®) course was developed because such incidents are associated with special injury patterns, escalating situations, and surges of casualties and haemodynamically unstable patients requiring treatment and can overwhelm the resources of hospitals. MATERIALS AND METHODS: The course currently lasts two-and-a -half days and is designed for 18-21 experienced surgeons, anaesthetists and clinical emergency physicians (who form groups of three for the tabletop simulation game). From 2017 to 2019, a total of 20 courses with 437 participants were conducted. The data in this study were collected from these 437 participants. RESULTS: Most of the participants were male (82%); 64% of participants specialised in a major field of surgery (general surgery, visceral surgery, vascular surgery, trauma surgery and orthopaedics). At the time of the course, most participants (86%) were department heads, senior physicians or specialists. The tabletop simulation game, which was specifically developed for the course, as well as the presentations were rated good to very good. The result of the overall course evaluation, which included aspects such as organisation, professionalism, content and teaching, was on average 1.34 and thus very good. DISCUSSION: The TDSC course complements already established courses and provides training in tactical surgical care after hospital admission. The TDSC course integrates and builds on elements of individualised trauma care such as the primary survey and the extended focused assessment with sonography in trauma (eFAST). This underlines again that it complements and does not replace other course formats. We can conclude that the presentations and the tabletop simulation game were well suited to the target group and that the participants were able to increase their knowledge of this complex subject.

Terror and disaster surgical care: training experienced trauma surgeons in decision making for a MASCAL situation with a tabletop simulation game.

BACKGROUND: Mass-casualty incidents, especially in connection with a terrorist attack, can quickly overwhelm the capacities of receiving hospitals. After a mass-casualty terrorist incident, patients often arrive at hospitals in an uncoordinated manner on account of the chaotic situation. Many patients leave the incident site and refer themselves to hospitals independently. Hospital decision makers must, therefore, be able to make quick decisions on diagnostic procedures and treatment for every individual patient and, at the same time, take into consideration available resources. They require decision criteria and aids to properly manage such scenarios. MATERIALS AND METHODS: As part of the preparation of the Terror and Disaster Surgical Care (TDSC®) course, we developed a tabletop simulation game based on a comprehensive and structured review of the literature, the opinions of renowned experts, and the results of specialised conferences. This tabletop simulation game is played four times during each TDSC® course. RESULTS: Our analysis involved 264 of 465 course-participants from 2017 to 2019 and showed that the overall evaluation was very good and that participants grew more positive about the tabletop simulation game during the course. The tabletop simulation game received an average rating of 1.53 (1 = very good, 6 = insufficient). This rating remained consistently high over 19 courses. DISCUSSION: Hospital decision makers must respond to mass-casualty terrorist situations in a defined tactical and strategic approach. Rapid decisions must be made that take into account the special situation and available capacities and resources to maximise the number of survivors even though individual patients may have a poorer functional outcome. As part of the TDSC® course, the tabletop simulation game teaches high-level decision-making algorithms and prepares key hospital personnel for such situations.

Specificities of terrorist attacks: organisation of the in-hospital patient-flow and treatment strategies.

BACKGROUND: Mass-casualty incidents are always a particular challenge not only for healthcare providers and other emergency service responders at the scene but also for receiving hospitals. Terrorism-related mass-casualty incidents can result in a wide variety of different scenarios so that hospitals and their personnel must prepare for far more complex and demanding requirements. PURPOSE: In this article, we describe and discuss in-hospital aspects of mass-casualty terrorist incidents and focus on the special medical and in particular surgical care that is required in this setting. METHODS: The overview presented here is based on the Terror and Disaster Surgical Care (TDSC®) course. The TDSC® course was mainly developed from a comprehensive and structured analysis of the literature, single expert opinions, and expert consensus conferences. The objective of this course is to train clinical decision-makers in how to manage major incidents. RESULTS: The management of a mass-casualty terrorist incident and the care of victims present multiple and unique challenges to hospitals. This applies in particular to the number and distribution of patients arriving at the hospital, injury patterns, infrastructural aspects, and personnel resources. Particular attention must be given to the surgical approach to caring for these patients, e.g., early total care, damage control surgery, or tactical abbreviated surgical care. CONCLUSION: Mass-casualty terrorist incidents are different from other mass-casualty events in many respects that require special attention. The provision of appropriate public services requires in particular that the preparation and training of personnel as well as the organisation of the in-hospital response be tailored to the incident.