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



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.


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.


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.


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.


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.

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Correspondence to Gerhard Achatz.

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Conflict of interest

Achatz G, Bieler D and Paffrath Th are active as instructors of the TDSC—Course, Friemert B and Franke A are active as directors and instructors of the TDSC—course. Achatz G., Bieler D, Franke A and Friemert B developed the TDSC®—course concept. Hoth P confirms that there is no conflict of interest.

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For this study, there were no test or experiments to humans or animals.

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Friemert, B., Achatz, G., Hoth, P. et al. Specificities of terrorist attacks: organisation of the in-hospital patient-flow and treatment strategies . Eur J Trauma Emerg Surg 46, 673–682 (2020).

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  • Mass-casualty incident
  • Terrorism
  • Preparedness
  • Treatment priorities
  • Treatment approaches
  • Tactical abbreviated surgical care