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Up Chemical agents Communication Epidemic Terrorism

Updated December 2006 by Charles Gomersall


There are no systematic data on which to base recommendations for the management of multiple casualty events. The content of this page is based on description of responses to terrorist attacks in Jerusalem, Madrid and New York.


  • thorough preparation is the key to successful management
  • each hospital should have its own disaster plan with plans to deal with failures in:
    • power supplies
    • telephone systems
      • not only may land phones fail but mobile networks are likely to be jammed
    • computer systems
    • water supply
    • transport to the hospital
      • this will make it difficult for staff to reach the hospital
      • may be exacerbated if the hospital lies within the police security cordon

    Note that these are not remote theoretical risks. St Vincent's Hospital in Manhattan suffered power, telephone, computer and water failures in the aftermath of the terrorist attack on the World Trade Centre

  • coordination between hospitals is vital, particularly to plan for the possibility of multiple simultaneous attacks. Many hospitals depend on transfer to other hospitals for surge capacity but this may be more difficult in the event of multiple attacks.
  • physical infrastructure
    • a "holding area" needs to be created
      • in terrorist incidents it is common for less severely injured patients to arrive in hospital before those with immediately life-threatening injuries. It is important that the operating theatres are not blocked by less severely ill patients by the time those with life-threatening injuries arrive
      • should be equipped to provide basic organ support and resuscitation


  • a system of alerting the appropriate staff should be devised with the relevant back-up systems to deal with the possibility of failure of communication systems. This is particularly important for incidents that occur outside normal working hours
  • extensive experience at Hadassah Medical Centre in Jerusalem suggests that the most appropriate response is to alert those who live close to the hospital first as the time between the incident and arrival of the first victims is usually short. Staff who live a considerable distance from the hospital are less likely to be able to arrive in time to deal with the initial response to the disaster and may be more usefully deployed as relief staff
  • at Hadassah a median of 9 additional staff (range 0-16) were required to supplement the 7 on-call staff to deal with out-of-hours incidents

Staff roles during an incident

  • the model reported by staff at Hadassah is one of "forward deployment" of anaesthesia and intensive care medical staff
    • senior anaesthesia/ICU staff are assigned to the Accident & Emergency department trauma rooms, holding area, CT and angiography suites as well the ICU and recovery room
    • an anaesthetist is assigned to care for each critically injured patient from the time of arrival in the trauma room until the time of admission to ICU. This anaesthetist is not only responsible for the anaesthetic management in the trauma room and the operating theatre but is also responsible for their care during transfers and investigations. In each area there is a senior anaesthetist who can supervise care. This system ensures continuity of care and minimizes the need for information transfer. It is particularly useful when the patient requires input from a variety of different surgical teams.
    • the whole operation and the allocation of staff is controlled centrally by a director who is based in the operating theatre
    • coordination of care for all critically injured patients is the responsibility of the most senior anaesthetist based in the Accident & Emergency department
  • the initial role of those doctors assigned to the ICU is to discharge all patients who can be safely discharged. This may involve transfer of patients to other hospitals which may require considerable staff and equipment resources.


  • the interval between the incident and arrival of the first casualties is variable but in urban areas is usually of the order of 20-30 minutes
    • the long delay between the attack on the World Trade Center and the arrival of the first casualty may reflect the difficulty of reaching the initial victims of the attack
  • an analysis of 14 incidents at Hadassah indicate that it is unusual for patients to need to be transferred immediately to the operating theatre and median time between the incident and the first patient being operated on was about 2 hours. The equivalent interval for admission to ICU was about 5 hours. However in the Madrid train bombing 7 of 27 critically ill patients admitted to one hospital required transfer directly from the Accident & Emergency department to the operating theatres
  • the possibility of blast and crush injury and toxin/dust inhalathion must be considered in addition to more usual patterns of injury
  • it is vital not to forget the usual structured approach to multiple trauma in the chaos of the multiple casualty event

Further reading

Shamir MY et al. Multiple casualty terror events: the anesthesiologist's perspective. Anesth Analg 2004;98:1746-52

Peral-Gutierrez de Ceballos J et al. 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. Crit Care, 2005; 9(1):104-111

Kirschenbaum L et al. The experience at St Vincent's Hospital, Manhattan, on September 11, 2001: preparedness, response, and lessons learned. Crit Care Med 2005; 33 [Suppl]:S48-S52



©Charles Gomersall, April, 2014 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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