On 7th July 2005 terrorists attacked the transportation system in London detonating four improvised explosive devices. 56 persons died and over 700 were injured, 45 of them critically. These bombings were unexpected and besides causing major injury and loss of life, longer term health effects were reported. A full major incident command structure was put in place led by the London UK Metropolitan Police, and involved other emergency services, the health system and central government. The transportation system of the capital was severely affected with major disruption of the city transportation system for 24 hours. Road traffic became completely gridlocked in the central area with all transport inside the M25 beltway suspended. Communications failures included the breakdown of the mobile phone system due to overload. Despite previous experience with the management of bombing incidents in the UK, the scale of the attacks was significant and caused considerable strains on the emergency response system and public health as well as on the infrastructure of the city.

The recent increase in incidents involving mass casualties has emphasized the need for a planned and coordinated prehospital emergency medical response, with medical teams on-site to provide advanced trauma life support. The special skills of the anesthesiologist make his/her contribution to prehospital emergency care particularly valuable. The United Kingdom's emergency medical services system is operated paramedically like that in the United States, and is based on rapid evacuation of casualties to hospital emergency medical facilities. In contrast, the French approach is based on the use of its emergency care system SAMU, where both structured dispatching and on-site medical care is provided by physicians, including anesthesiologists. In this article, the lessons learned from multiple casualty incidents in Europe during the past 2 decades are considered from the standpoint of the anesthesiologist.

There is an increasing risk of mass exposure of civil populations after release of toxic agents. These include military chemical warfare agents or industrial compounds, some of which have been used as a chemical. The traditional military divisions among chemical agents, toxins, and biologic agents may be viewed as a continuous spectrum of hazards. Each of these has four specific qualities (toxicity, latency, persistency, and transmissibility), which determine management of casualties and the toxic release. Toxic hazards may be released accidentally or deliberately, producing potentially large numbers of casualties. Previous incidents have shown that many of these require extended hospital care. This article reviews aspects of the nature of the toxic agents, the pathophysiology they produce, and therapeutic measures. The central and peripheral nervous systems and the respiratory systems are particularly vulnerable and may lead to fatal results unless early action is taken. Specific antidotes and life support care is required at all levels of prehospital and hospital management. Critical care management is required for severe cases, and this must combine continuing antidote, ventilatory and supportive therapy.

France has experienced two waves of major terrorist bombings since 1980. In the first wave (1985-1986), eight bombings occurred in Paris, killing 13 and injuring 281. In the second wave (1995-1996), six bombings occurred in Paris and Lyon, killing 10 and injuring 262. Based on lessons learned during these events, France has developed and improved a sophisticated national system for prehospital emergency response to conventional terrorist attacks based on its national emergency medical services (EMS) system, Service d'Aide Medicale Urgente (SAMU). According to the national plan for the emergency medical response to mass-casualty events (White Plan), the major phases of EMS response are: (1) alert; (2) search and rescue; (3) triage of victims and provision of critical care to first priority victims; (4) regulated dispatch of victims to hospitals; and (5) psychological assistance. Following the 1995 Tokyo subway sarin attack, a national plan for the emergency response to chemical and biological events (PIRATOX) was implemented. In 2002, the Ministries of Health and the Interior collaborated to produce a comprehensive national plan (BIOTOX) for the emergency response to chemical, biological, radiological, and nuclear events. Key aspects of BIOTOX are the prehospital provision of specialized advance life support for toxic injuries and the protection of responders in contaminated environments. BIOTOX was successfully used during the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak in France.

Anesthesiologists can be the ideal trauma life support physicians (Fig. 1). Unlike those in North America, anesthesiologists in European countries play an active role in the management of injured patients outside the hospital. This article provides anesthesiologists with a basic understanding of prehospital trauma management and present areas of controversy.