We would like to thank the overall positive reactions to our work (1). Due to reasons of space, it was not possible to address this complex topic to its full extent.

Dickinson et al. criticize, among other things, the fact that we did not recommend a clearly structured approach to first aid for injured persons in a mass casualty incident, such as a terrorist attack with numerous gunshot and blast injuries. Here, we deliberately tried to highlight only the medical priorities.

Within our German federal system, preparation is the responsibility of the local authorities and federal states. Thus, the establishment of management, observation, and treatment structures adequate for terrorist situations, and the adaptation of existing emergency care algorithms, are currently being discussed. Local solutions adapted to the existing care structures are currently being developed. It is correct and important to emphasize that the C–ABC algorithm, for instance, must be prioritized in these considerations.

These preparations include, as correctly pointed out by Dolscheid-Pommerich et al., a clear allocation of roles and definitions of responsibilities and command hierarchy. They also include predestinated triage and documentation areas immediately outside the hospital, as well as the adaptation and testing of the Hospital Emergency Operations Plan (Krankenhaus Alarm- und Einsatzplan, KAEP). These intrahospital organizational structures have to become hospital-specific and must be trained at each hospital with realistic resource usage. Such training exercises are essential for identifying ways to improve both the pre-hospital and hospital treatment, yet the cost burden means that hospitals, local authorities, and federal states face both technical and political challenges.

We deliberately did not include recommendations for individual hemostyptics, since we consider that the scientific discussion about the advantages and disadvantages of individual preparations has not yet been finalized. Nevertheless, the procurement and stocking of these supplies are recommended. The explanation of Kiesewetter for differentiated volume therapy during life-threatening (perforating) bleeding represents a possible procedure and includes key elements of the current S3 guideline on treatment of polytrauma injuries. These are part of the individualized emergency room procedures and are established, for example, in regional and supra-regional trauma centers. For resource planning and storage in the event of mass casualties due to gunshot and blast injuries, these valuable recommendations must be taken into account.

The aim of our article (1) was to provide an overview and to sensitize all those involved in treatment in an emergency situation to the importance of rapidly stopping bleeding and of identifying injured persons who are bleeding from the trunk or into body cavities. In the case of the latter, mortality can only be reduced by timely transportation to allow bleeding to be stopped surgically and the additional administration of differentiated volume therapy.

Zack et al. rightly point out that obtaining forensic evidence is an important aspect for all parties concerned. This is easier to do with individual cases than with mass casualties. However, all practitioners should be aware of this commitment and take this into account when treating patients, even though ensuring the survival of as many people as possible must initially be given priority at the beginning of a mass attack or a local emergency situation.

Our work focused specifically on providing the basic information about gunshot and blast injuries that are required for a coordinated action from all parties in the different levels involved in the emergency response and supply chain. This required us to limit our work to the essentials. Thus, the compromises and limitations of this article should be evaluated within this framework.

DOI: 10.3238/arztebl.2017.0563

On behalf of the authors

PD Dr. med. Axel Franke

Klinik für Unfallchirurgie, Orthopädie, Rekonstruktive- und Handchirurgie, Verbrennungsmedizin

Bundeswehrzentralkrankenhaus Koblenz, Germany


Conflict of interest statement

The authors of the contributions declare that no conflict of interest exists.

Franke A, Bieler D, Friemert B, Schwab R, Kollig E, Güsgen C: The first aid and hospital treatment of gunshot and blast injuries. Dtsch Arztebl Int 2017; 114: 237–43 VOLLTEXT
1.Franke A, Bieler D, Friemert B, Schwab R, Kollig E, Güsgen C: The first aid and hospital treatment of gunshot and blast injuries. Dtsch Arztebl Int 2017; 114: 237–43 VOLLTEXT

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