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Critical Care
Published in: Critical Care 1/2016

Open Access 01-12-2016 | Research

Pre-hospital management of mass casualty civilian shootings: a systematic literature review

Authors: Conor D. A. Turner, David J. Lockey, Marius Rehn

Published in: Critical Care | Issue 1/2016

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Abstract

Background

Mass casualty civilian shootings present an uncommon but recurring challenge to emergency services around the world and produce unique management demands. On the background of a rising threat of transnational terrorism worldwide, emergency response strategies are of critical importance. This study aims to systematically identify, describe and appraise the quality of indexed and non-indexed literature on the pre-hospital management of modern civilian mass shootings to guide future practice.

Methods

Systematic literature searches of PubMed, Cochrane Database of Systematic Reviews and Scopus were conducted in conjunction with simple searches of non-indexed databases; Web of Science, OpenDOAR and Evidence Search. The searches were last carried out on 20 April 2016 and only identified those papers published after the 1 January 1980. Included documents had to contain descriptions, discussions or experiences of the pre-hospital management of civilian mass shootings.

Results

From the 494 identified manuscripts, 73 were selected on abstract and title and after full text reading 47 were selected for inclusion in analysis. The search yielded reports of 17 mass shooting events, the majority from the USA with additions from France, Norway, the UK and Kenya. Between 1994 and 2015 the shooting of 1649 people with 578 deaths at 17 separate events are described. Quality appraisal demonstrated considerable heterogeneity in reporting and revealed limited data on mass shootings globally.

Conclusion

Key themes were identified to improve future practice: tactical emergency medical support may harmonise inner cordon interventions, a need for inter-service education on effective haemorrhage control, the value of senior triage operators and the need for regular mass casualty incident simulation.
Literature
1.
Blair JP, Schweit K. A study of active shooter incidents, 2000-2013. Washington DC: Texas State University and Federal Bureau of Investigation, US Department of Justice; 2014.
2.
3.
Kelleher MD. Flash point: The American mass murderer. Westport: Praeger; 1997.
4.
Aitken L, Oosthuizen P, Emsley R, Seedat S. Mass murders: implications for mental health professionals. Int J Psychiatry Med. 2008;38(3):261–9.CrossRefPubMed
5.
Fattah S, Rehn M, Lockey D, Thompson J, Lossius HM, Wisborg T. A consensus based template for reporting of pre-hospital major incident medical management. Scand J Trauma Resusc Emerg Med. 2014;22(1):1.CrossRef
6.
Sandler T, Arce DG, Enders W. The challenge of terrorism. Lowell: Report, Copenhagen Consensus Center; 2008.
7.
Farace DJ, Frantzen J, Schöpfel J, Stock C, Boekhorst AK. Access to grey content: an analysis of grey literature based on citation and survey data. In: Seventh International Conference on Grey Literature: Open Access to Grey Resources. GL7 Conference Proceedings, Nancy, France. Amsterdam: TextRelease; 2006.
8.
Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151:264–9. W264.CrossRefPubMed
9.
10.
Augustine JJ. Target audience. A mass shooting requires cooperative response. EMS World. 2012;41(4):26.
11.
Autrey AW, Hick JL, Bramer K, Berndt J, Bundt J. 3 Echo: Concept of Operations for Early Care and Evacuation of Victims of Mass Violence. Prehosp Disaster Med. 2014;29:421–8.CrossRefPubMed
12.
Barr P. In the wake of tragedy, Tucson hospitals lauded for deft handling of victims. Mod Healthc. 2011;41(3):10.
13.
Beyersdorf SR, Nania JN, Luna GK. Community medical response to the Fairchild mass casualty event. Am J Surg. 1996;171(5):467–70.CrossRefPubMed
14.
Careless J. High-tech training preps agency: simulation assists Northwest Fire/Rescue District with emergency response. EMS World. 2012;41(2):33.PubMed
15.
Carhart ED. How to develop tactical EMS protocols. EMS World. 2012;41(2):26–31.PubMed
16.
17.
Cicero MX, Brown L, Overly F, Yarzebski J, Meckler G, Fuchs S, Tomassoni A, Aghababian R, Chung S, Garrett A, Fagbuyi D, Adelgais K, Goldman R, Parker J, Auerbach M, Riera A, Cone D, Baum CR. Creation and Delphi-method refinement of pediatric disaster triage simulations. Prehosp Emerg Care. 2013;18:282–9.CrossRef
18.
Coupland RM, Meddings DR. Mortality associated with use of weapons in armed conflicts, wartime atrocities, and civilian mass shootings: literature review. BMJ. 1999;319:407–10.CrossRefPubMedPubMedCentral
19.
Moffat R. The public inquiry into the shootings at Dunblane Primary School on 13th March 1996: The Hon. Lord Cullen. London: HMSO; 1996.
20.
Elster EA, Butler FK, Rasmussen TE. Implications of combat casualty care for mass casualty events. Jama. 2013;310:475–6.CrossRefPubMed
21.
Fabbri WP. Improving survival in active shooter events. The FBI’s view two years after Sandy Hook. JEMS. 2014;Suppl:4-9.
22.
23.
Hirsch M, Carli P, Nizard R, Riou B, Baroudjian B, Baubet T, Chhor V, Chollet-Xemard C, Dantchev N, Fleury N, Fontaine JP. The medical response to multisite terrorist attacks in Paris. Lancet. 2015;386(10012):2535–8.CrossRefPubMed
24.
Jacobs LM, McSwain NE, Rotondo MF, Wade D, Fabbri W, Eastman AL, Butler FK, Sinclair J. Improving survival from active shooter events: the Hartford Consensus. J Trauma Acute Care Surg. 2013;74:1399–400.CrossRefPubMed
25.
Jacobs LM, Burns KJ. Improving survival from intentional mass casualty incidents: the need for a national curriculum. JAMA Surg. 2014;149(9):891–2.CrossRefPubMed
26.
Jacobs LM. Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events: Hartford Consensus II. J Am Coll Surg. 2014;218(3):476–8.CrossRefPubMed
27.
Jacobs LM, Wade DS, McSwain NE, Butler FK, Fabbri WP, Eastman AL, Rotondo M, Sinclair J, Burns KJ. The Hartford Consensus: THREAT, A Medical Disaster Preparedness Concept. J Am Coll Surg. 2013;217:947–53.CrossRefPubMed
28.
Johnson C. Prepared for the worst: the Aurora, Colorado, shootings. Physician Exec. 2012;38:6–10.
29.
Jones J, Kue R, Mitchell P, Eblan SG, Dyer KS. Emergency Medical Services response to active shooter incidents: provider comfort level and attitudes before and after participation in a focused response training program. Prehosp Disaster Med. 2014;29:350–7.CrossRefPubMed
30.
Kaplowitz L, Reece M, Hershey JH, Gilbert CM, Subbarao I. Regional health system response to the Virginia Tech mass casualty incident. Disaster Med Public Heal Prep. 2007;1:S9–13.CrossRef
31.
Kelley RL. EMS response to mass shootings. EMS Mag. 2008;37(10):86.PubMed
32.
Koehler A, Scott RA, Davis R. Surviving the Dark Night: The Aurora, Colorado, Mass Shootings. J Emerg Nurs. 2014;40:440–5.CrossRefPubMed
33.
Lawerence D. Tactical emergency medicine: lessons from Paris marauding terrorist attack. Crit Care. 2016;20:37.CrossRef
34.
Levy MJ. The Columbia Mall shooting: reflections of a physician responder. Prehosp Disaster Med. 2014;29(April):113–4.CrossRefPubMed
35.
Lockey DJ. The shootings in Oslo and Utøya island July 22, 2011: Lessons for the International EMS community. Scand J Trauma Resusc Emerg Med. 2012;20:4.CrossRefPubMedPubMedCentral
36.
Mell H, Sztajnkrycer M. EMS response to Columbine: lessons learned. Int J Rescue Dis Med. 2005;5(1).
37.
38.
NA. Mass shooting in Colorado: Practice drills, disaster preparations key to successful emergency response. ED Managment. 2012;24(10):109-12.
39.
Peleg K, Aharonson-Daniel L, Stein M, Michaelson M, Kluger Y, Simon D, Noji EK. Gunshot and explosion injuries: characteristics, outcomes, and implications for care of terror-related injuries in Israel. Ann Surg. 2004;239:311–8.CrossRefPubMedPubMedCentral
40.
Peleg K, Rozenfeld M, Stein M. Poorer outcomes for mass casualty events victims: is it evidence based? J Trauma. 2010;69:653–8. discussion 659.CrossRefPubMed
41.
Philippe JM, Brahic O, Carli P, Tourtier JP, Riou B, Vallet B. French Ministry of Health’s response to Paris attacks of 13 November 2015. Crit Care. 2016;20(1):1.CrossRef
42.
Pons PT, Jerome J, McMullen J, Manson J, Robinson J, Chapleau W. The hartford consensus on active shooters: Implementing the continuum of prehospital trauma response. J Emerg Med. 2015;49:878–85.CrossRefPubMed
43.
Ramasamy A, Midwinter M, Mahoney P, Clasper J. Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma. Injury. 2009;40:1342–5.CrossRefPubMed
44.
Ressel R, Reihart M, Brown S, Hinkle R, Wireback S, Gilger A. West Nickel Mines School shooting: how a rural MCI was successfully managed. JEMS. 2008;33(5):48–56.PubMed
45.
Rivkind AI, Blum R, Gershenstein I, Stein Y, Coleman S, Mintz Y, Zamir G, Richter ED. Trauma care and case fatality during a period of frequent, violent terror attacks and thereafter. World J Surg. 2012;36:2108–18.CrossRefPubMed
46.
Roy N, Kapil V, Subbarao I, Ashkenazi I. Mass casualty response in the 2008 Mumbai terrorist attacks. Disaster Med Public Health Prep. 2011:273–279.
47.
Aberle SJ, Lohse CM, Sztajnkrycer MD. A descriptive analysis of United States out-of-hospital care response to law enforcement tactical incidents. Ann Emerg Med. 2014;64:S30.CrossRef
48.
Sollid SJ, Rimstad R, Rehn M, Nakstad AR, Tomlinson A-E, Strand T, Heimdal H, Nilsen J, Sandberg M. Oslo government district bombing and Utøya island shooting July 22, 2011: the immediate prehospital emergency medical service response. Scand J Trauma Resusc Emerg Med. 2012;20:3.CrossRefPubMedPubMedCentral
49.
Strommen JJ, Waterman SM, Mitchell CA, Grogan BF. Fort Hood, Texas, mass casualty incident: reviews and perspectives. Curr Rev Musculoskelet Med. 2014;2015(8):298–303.
50.
Kaine M. Mass Shootings at Virginia Tech: Addendum to the Report of the Review Panel. Arlignton: TriData Division, System Planning Corporation; 2009.
51.
Tourtier JP, Pelloux P, Minh PD, Klein I, Marx JS, Carli P. Charlie Hebdo attacks: lessons from the military milieu. Am J Emerg Med. 2015;33:843.CrossRefPubMed
52.
Waage S, Poole JC, Thorgersen EB. Rural hospital mass casualty response to a terrorist shooting spree. Br J Surg. 2013;100:1198–204.CrossRefPubMed
53.
Wachira BW, Abdalla RO, Wallis LA. Westgate shootings: an emergency department approach to a mass-casualty incident. Prehosp Disaster Med. 2014;29(05):538–41.CrossRefPubMed
54.
Wild J, Maher J, Frazee RC, Craun ML, Davis ML, Childs EW, Smith RW. The Fort Hood massacre. J Trauma Acute Care Surg. 2012;72:1709–13.CrossRefPubMed
55.
56.
Jacobs LM, Wade D, Mcswain NE, Butler FK, Fabbri W, Eastman A, Conn A, Burns KJ. Hartford consensus: a call to action for THREAT, a medical disaster preparedness concept. J Am Coll Surg. 2014;218:467–75.CrossRefPubMed
57.
58.
Rinnert KJ, Hall WL. Tactical emergency medical support. Emerg Med Clin North Am. 2002;20:929–52.CrossRefPubMed
59.
60.
Vainionpää T, Peräjoki K, Hiltunen T, Porthan K, Taskinen A, Boyd J, Kuisma M. Integrated model for providing tactical emergency medicine support (TEMS): analysis of 120 tactical situations. Acta Anaesthesiol Scand. 2012;56:158–63.CrossRefPubMed
61.
Tieu BH, Holcomb JB, Schreiber MA. Coagulopathy: its pathophysiology and treatment in the injured patient. World J Surg. 2007;31(5):1055–65.CrossRefPubMed
62.
Duchesne JC, McSwain Jr NE, Cotton BA, Hunt JP, Dellavolpe J, Lafaro K, Marr AB, Gonzalez EA, Phelan HA, Bilski T, Greiffenstein P. Damage control resuscitation: the new face of damage control. J Trauma Acute Care Surg. 2010;69(4):976–90.CrossRef
63.
Tourtier JP, Palmier B, Tazarourte K, Raux M, Meaudre E, Ausset S, Sailliol A, Vivien B, Domanski L, Carli P. The concept of damage control: extending the paradigm in the prehospital setting. Ann Fr Anesth Reanim. 2013;32(7):520–6. Elsevier Masson.CrossRefPubMed
64.
Smith IM, James RH, Dretzke J, Midwinter MJ. Prehospital Blood Product Resuscitation for Trauma: A Systematic Review. Shock (Augusta, Ga). 2016;46(1):3-16.
65.
Mackway-Jones KE. Major Incident Medical Management and support: The practical approach to pre-hospital incident command. New York City: Wiley-Blackwell; 2012.
66.
Kahn CA, Schultz CH, Miller KT, Anderson CL. Does START triage work? An outcomes assessment after a disaster. Ann Emerg Med. 2009;54(3):424–30.CrossRefPubMed
67.
Merin O, Miskin IN, Lin G, Wiser I, Kreiss Y. Triage in mass-casualty events: the Haitian experience. Prehosp Disaster Med. 2011;26:386–90.CrossRefPubMed
68.
69.
Rehn M, Sollid SJ. Guidelines for mass casualty triage have been established. Tidsskrift for den Norske lægeforen. 2013;133(19):2029.CrossRef
70.
MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, Salkever DS, Scharfstein DO. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4):366–78.CrossRefPubMed
71.
Rehn M, Vigerust T, Andersen JE, Krüger AJ, Lossius HM. Major incident patient evacuation: full-scale field exercise feasibility study. Air Med J. 2011;30:153–7.CrossRefPubMed
72.
Stephenson J, Andrews L, Moore F. Developing and introducing a new triage sieve for UK civilian practice. Trauma. 2014;17:140–1.CrossRef
73.
74.
Shultz JM, Thoresen S, Flynn BW, Muschert GW, Shaw JA, Espinel Z, Walter FG, Gaither JB, Garcia-Barcena Y, O’Keefe K, Cohen AM. Multiple vantage points on the mental health effects of mass shootings. Curr Psychiatry Rep. 2014;16(9):1–7.CrossRef
Metadata
Title
Pre-hospital management of mass casualty civilian shootings: a systematic literature review
Authors
Conor D. A. Turner
David J. Lockey
Marius Rehn
Publication date
01-12-2016
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2016
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-016-1543-7

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