title: Role of Selective Management of Penetrating Injuries in Mass Casualty Incidents.
abstract: Terrorist violence has emerged as an increasingly common cause of mass casualty incidents (MCI) due to the sequelae of explosive devices and shooting massacres. A proper emergency medical system disaster plan for dealing with an MCI is of paramount importance to salvage lives. Because the number of casualties following a MCI is likely to exceed the medical resources of the receiving health care facilities, patients must be appropriately sorted to establish treatment priorities. By necessity, clinical signs are likely to prove cornerstones of triage during MCI. An appropriate and effective application of experiences learned from the use of selective nonoperative management (SNOM) techniques may prove essential in this triage process. The present appraisal of the available literature strongly supports that the appropriate utilization of these clinical indicators to identify patients appropriate for SNOM is essential, critical, and readily applicable. We also review the initial emergent triage priorities for penetrating injuries to the head, neck, torso, and extremities in a mass casualty setting.
authors.affiliation: Division of Trauma Surgery and Surgical Critical Care, University of Southern California, USC + LAC Medical Center, 1200 North State Street, Room 9900, Los Angeles, CA, 90033, USA. peep.talving@karolinska.se.
authors.forename: Peep
authors.initials: P
authors.lastname: Talving
authors.forename: Joseph
authors.initials: J
authors.lastname: DuBose
authors.forename: Galinos
authors.initials: G
authors.lastname: Barmparas
authors.forename: Kenji
authors.initials: K
authors.lastname: Inaba
authors.affiliation: Division of Trauma Surgery and Surgical Critical Care, University of Southern California, USC + LAC Medical Center, Los Angeles, USA.
authors.forename: Demetrios
authors.initials: D
authors.lastname: Demetriades
keywords: Polytrauma management including pre-hospital and shock room
references.citation: J Trauma. 2005 Jul;59(1):217-22
references.pmid: 16096567
references.citation: J Trauma. 1997 Oct;43(4):624-6
references.pmid: 9356058
references.citation: Emerg Med Clin North Am. 2007 Aug;25(3):751-61, iv
references.pmid: 17826216
references.citation: Ann Surg. 1988 Jan;207(1):72-4
references.pmid: 3337565
references.citation: Br J Surg. 1986 Nov;73(11):888-90
references.pmid: 3790915
references.citation: J Trauma. 1996 May;40(5):758-60
references.pmid: 8614075
references.citation: J Bone Joint Surg Am. 1976 Jun;58(4):453-8
references.pmid: 773941
references.citation: Arch Surg. 1999 Feb;134(2):186-9
references.pmid: 10025461
references.citation: J Card Surg. 1997 Mar-Apr;12(2 Suppl):173-9; discussion 179-80
references.pmid: 9271743
references.citation: Clin Orthop Relat Res. 2003 May;(410):289-94
references.pmid: 12771843
references.citation: J Trauma. 1992 Jun;32(6):755-8; discussion 758-60
references.pmid: 1613835
references.citation: World J Surg. 2001 Aug;25(8):1028-35
references.pmid: 11571968
references.citation: Ann R Coll Surg Engl. 1994 May;76(3):147-9
references.pmid: 8017807
references.citation: J Vasc Surg. 2006 Jul;44(1):94-100
references.pmid: 16828431
references.citation: Ann Emerg Med. 2000 Mar;35(3):221-5
references.pmid: 10692187
references.citation: World J Surg. 1997 Mar-Apr;21(3):247-52; discussion 253
references.pmid: 9015166
references.citation: Am Surg. 2003 Oct;69(10):848-51
references.pmid: 14570361
references.citation: Br J Surg. 2005 Jul;92(7):890-5
references.pmid: 15918164
references.citation: Injury. 2007 Sep;38(9):1084-90
references.pmid: 17544428
references.citation: S Afr J Surg. 2007 Nov;45(4):128-30, 132
references.pmid: 18069579
references.citation: Am Surg. 1999 Apr;65(4):360-5
references.pmid: 10190364
references.citation: J Trauma. 2001 Aug;51(2 Suppl):S16-25
references.pmid: 11505195
references.citation: Prehosp Disaster Med. 2008 Jan-Feb;23(1):3-8
references.pmid: 18491654
references.citation: J Am Coll Surg. 1999 Mar;188(3):290-5
references.pmid: 10065818
references.citation: J Bone Joint Surg Am. 2005 Jan;87(1):8-12
references.pmid: 15634809
references.citation: J Trauma. 2003 May;54(5 Suppl):S7-12
references.pmid: 12768095
references.citation: Eur J Radiol. 2007 Oct;64(1):92-102
references.pmid: 17869471
references.citation: J Trauma. 2008 Feb;64(2 Suppl):S28-37; discussion S37
references.pmid: 18376169
references.citation: Am Surg. 1995 Aug;61(8):647-53; discussion 653-4
references.pmid: 7618800
references.citation: J Trauma. 1992 Mar;32(3):398-400
references.pmid: 1548730
references.citation: Neurosurgery. 1990 Nov;27(5):696-700; discussion 700
references.pmid: 2259398
references.citation: J Am Coll Surg. 2000 Mar;190(3):288-98
references.pmid: 10703853
references.citation: J Trauma. 1998 Jun;44(6):1073-82
references.pmid: 9637165
references.citation: Ann Otol Rhinol Laryngol. 1994 Nov;103(11):863-71
references.pmid: 7979000
references.citation: J Trauma. 1975 Aug;15(8):663-9
references.pmid: 1152088
references.citation: Ann R Coll Surg Engl. 2005 Sep;87(5):348-52
references.pmid: 16176694
references.citation: Am J Surg. 1997 Sep;174(3):342-6
references.pmid: 9324151
references.citation: J Trauma. 2006 Nov;61(5):1166-70
references.pmid: 17099524
references.citation: AJR Am J Roentgenol. 2000 May;174(5):1269-78
references.pmid: 10789775
references.citation: Ann Surg. 2001 Sep;234(3):395-402; discussion 402-3
references.pmid: 11524592
references.citation: Scand J Surg. 2002;91(1):41-5
references.pmid: 12075833
references.citation: J Ultrasound Med. 2008 Jan;27(1):95-107
references.pmid: 18096735
references.citation: Injury. 2006 Jan;37(1):1-19
references.pmid: 16410079
references.citation: J Trauma. 2001 Aug;51(2 Suppl):S44-86
references.pmid: 11505200
references.citation: J Trauma. 2006 Oct;61(4):868-72
references.pmid: 17033553
references.citation: World J Emerg Surg. 2006 Mar 24;1:4
references.pmid: 16759407
references.citation: J Trauma. 2000 Oct;49(4):689-94; discussion 694-5
references.pmid: 11038087
references.citation: Injury. 2005 Mar;36(3):400-6
references.pmid: 15710157
references.citation: J Trauma. 2006 Mar;60(3):502-6; discussion 506-7
references.pmid: 16531846
references.citation: J Trauma. 1987 May;27(5):483-5
references.pmid: 3573102
references.citation: Injury. 2008 May;39(5):554-60
references.pmid: 18054014
references.citation: Curr Opin Anaesthesiol. 2001 Apr;14(2):197-209
references.pmid: 17016402
references.citation: J Coll Physicians Surg Pak. 2006 Apr;16(4):253-6
references.pmid: 16624186
references.citation: Arch Surg. 1997 Feb;132(2):178-83
references.pmid: 9041923
references.citation: J Cardiovasc Surg (Torino). 2007 Oct;48(5):581-6
references.pmid: 17989627
references.citation: J Trauma. 2001 Aug;51(2 Suppl):S34-40
references.pmid: 11505198
references.citation: J Orthop Trauma. 1994;8(2):81-7
references.pmid: 8207579
references.citation: Am J Surg. 1994 Mar;167(3):309-12
references.pmid: 8160903
references.citation: J Bone Joint Surg Am. 1996 Aug;78(8):1167-71
references.pmid: 8753708
references.citation: Cochrane Database Syst Rev. 2004;(1):CD003764
references.pmid: 14974035
references.citation: Tex Heart Inst J. 2006;33(1):31-4
references.pmid: 16572866
references.citation: J Vasc Surg. 1993 Jan;17 (1):116-22; discussion 122-4
references.pmid: 8421327
references.citation: J Trauma. 2005 Nov;59(5):1155-60; discussion 1160-1
references.pmid: 16385294
references.citation: Am Surg. 2008 Feb;74(2):103-7
references.pmid: 18306857
references.citation: Ortop Traumatol Rehabil. 2005 Dec 30;7(6):651-5
references.pmid: 17611430
references.citation: Am Surg. 2005 Dec;71(12):1009-14
references.pmid: 16447469
references.citation: World J Surg. 1997 Jan;21(1):41-7; discussion 47-8
references.pmid: 8943176
references.citation: J Trauma. 2008 Jun;64(6):1466-71
references.pmid: 18545110
references.citation: Curr Probl Surg. 2007 Jan;44(1):13-85
references.pmid: 17317418
references.citation: Eur J Vasc Endovasc Surg. 2002 Oct;24(4):349-55
references.pmid: 12323179
references.citation: Br J Surg. 1991 Feb;78(2):220-2
references.pmid: 2015480
references.citation: Prehosp Disaster Med. 2007 Mar-Apr;22(2):106-8
references.pmid: 17591182
references.citation: Scand J Surg. 2002;91(1):62-6
references.pmid: 12075838
references.citation: Adv Surg. 2007;41:51-62
references.pmid: 17972556
references.citation: Lancet. 2000 May 20;355(9217):1813-7
references.pmid: 10832851
references.citation: Surg Neurol. 1992 Dec;38(6):418-23
references.pmid: 1298106
references.citation: Dis Colon Rectum. 1997 Mar;40(3):307-11
references.pmid: 9118745
references.citation: Ann Surg. 2006 Oct;244(4):620-8
references.pmid: 16998371
references.citation: Ann Surg. 1987 Feb;205(2):129-32
references.pmid: 3813686
references.citation: Ann Surg. 2004 Mar;239(3):311-8
references.pmid: 15075646
references.citation: Radiographics. 2005 Oct;25 Suppl 1:S133-42
references.pmid: 16227487
references.citation: J Trauma. 1996 May;40(5):761-3
references.pmid: 8614076
references.citation: Injury. 2005 Jun;36(6):745-50
references.pmid: 15910827
references.citation: World J Surg. 1998 Oct;22(10):1034-8
references.pmid: 9747162
references.citation: Am J Surg. 1970 Aug;120(2):210-4
references.pmid: 5456407
references.citation: Am J Surg. 1984 Dec;148(6):782-5
references.pmid: 6439065
references.citation: J Trauma. 2005 Mar;58(3):526-32
references.pmid: 15761347
references.citation: Am Surg. 1995 Feb;61(2):139-45
references.pmid: 7856974
references.citation: J Ultrasound Med. 2003 Jun;22(6):625-30
references.pmid: 12795558
references.citation: Injury. 2003 Dec;34(12):912-4
references.pmid: 14636733
references.citation: J Trauma. 2007 May;62(5):1234-9
references.pmid: 17495730
references.citation: J Trauma. 1993 Feb;34(2):216-22
references.pmid: 8459458
references.citation: Neurosurgery. 1985 Jun;16(6):754-8
references.pmid: 2409471
references.citation: Br J Surg. 2000 Aug;87(8):1030-4
references.pmid: 10931046
references.citation: Surg Clin North Am. 1991 Apr;71(2):267-96
references.pmid: 2003250
references.citation: Surgery. 1974 Dec;76(6):955-62
references.pmid: 4479695
references.citation: Arch Surg. 2001 May;136(5):513-8
references.pmid: 11343541
references.citation: Emerg Med Australas. 2007 Jun;19(3):269-75
references.pmid: 17564696
references.citation: Surg Clin North Am. 1996 Aug;76(4):661-83
references.pmid: 8782468
references.citation: Am J Emerg Med. 1996 Mar;14 (2):151-6
references.pmid: 8924136
references.citation: J Trauma. 2007 Nov;63(5):1010-3
references.pmid: 17993944
references.citation: Surg Neurol. 2003 Aug;60(2):98-104; discussion 104
references.pmid: 12900108
references.citation: J Trauma. 1994 Nov;37(5):737-44
references.pmid: 7966470