Franke et al. succinctly and skillfully deal with a broad theme that is very relevant, but more clarity is required with respect to two areas of the prehospital care described.

Firstly, the authors’ proposition that, “There is a lack of uniform treatment recommendations in the sense of standards or guidelines for the prehospital [...] treatment of gunshot or blast injuries [...] especially for major events,” is misleading. Two British physicians developed a rigorous Major Incident Medical Management System (MIMMS) in 1995 and it is now an established and well-tested civilian course used internationally (1). Its guidelines are applicable and adaptable for all major incidents, which include blast or ballistic injury, or a combination. Treatment options during the first response (triage sieve) in a major incident are application of a tourniquet (‘C’) and putting the patient in the recovery position (‘A’).

Secondly, resuscitation guidelines need to be standardized, extremely clear, and easily communicated. The authors agree with that sentiment, but the message as to which algorithm should be used in a pre-hospital context could be clearer. C-ABC was developed by the British military following a stark lesson learnt on the battlefield; catastrophic hemorrhage (‘C’) kills before an airway (‘A’) can be secured, and thus the paradigm has shifted to C-ABC during prehospital trauma resuscitation (2, 3) . If ‘C’ (active and massive bleeding) is subjectively ruled out then ‘A’ is by default the priority but it is important to clearly communicate that C-ABC should be the cognitive flow of the first responder in a trauma situation.

DOI: 10.3238/arztebl.2017.0561a

Andrew Dickinson

The Institute of General Practice and Multi-Disciplinary Healthcare

Universitätsklinikum Tübingen, Germany

andykdickinson@icloud.com

Matt Gunning

Netcare Umhlanga Hospital, Durban, South Africa

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
2.
Hodgetts TJ, Mackway-Jones K (eds): Major incident medical
management and support. The practical approach. Plymouth: BMJ 1995.
3.
Hodgetts TJ, Mahoney PF, Russell MQ, Byers M: ABC to CABC: redefining the military trauma paradigm. Emerg Med J 2006; 23: 745–6 CrossRef MEDLINE PubMed Central
4.
Lee C, Porter KM, Hodgetts TJ: Tourniquet use in the civilian prehospital setting. Emerg Med J 2007; 24: 584–7 CrossRef MEDLINE PubMed Central
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
2. Hodgetts TJ, Mackway-Jones K (eds): Major incident medical
management and support. The practical approach. Plymouth: BMJ 1995.
3. Hodgetts TJ, Mahoney PF, Russell MQ, Byers M: ABC to CABC: redefining the military trauma paradigm. Emerg Med J 2006; 23: 745–6 CrossRef MEDLINE PubMed Central
4. Lee C, Porter KM, Hodgetts TJ: Tourniquet use in the civilian prehospital setting. Emerg Med J 2007; 24: 584–7 CrossRef MEDLINE PubMed Central

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