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Primary Prevention References
Prevention should be aimed at educating the population to be 1. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield
aware of what actions should be carried out during an active (2001–2011). J Trauma Acute Care Surg. 2012;73:S431–437.
shooter situation or terrorist attack. This formative strategy is 2. Haus-Cheymol R, Bouguerra C, Mayorg E, et al. Blessures par
where the so called chain of survival in IMCIs starts. arme à feu et engins explosifs dans les armées. Résultats de la sur-
veillance épidémiologique de 2004 à 2008. Médecine et Armées.
2011;39(1): 89–96.
Secondary Action 3. Bellamy RF. The causes of death in conventional land warfare:
Early activation of the competent local or regional IMCI plans implications for combat casualty care research. Mil Med. 1984;
is the key to rapid suppression and response to these kinds 149:55–62.
of threats. In the way that the Hartford Consensus uses the 4. Eastridge BJ, Hardin M, Cantrell J, et al. Died of wounds on
THREAT acronym (Threat suppression, Hemorrhage con- the battlefield: causation and implications for improving combat
casualty care. J Trauma. 2011;71:S4–8.
trol, Rapid Extrication to safety, Assessment by medical pro- 5. US Department of Homeland Security. Active Shooter. How
viders and Transport to definitive care) to refer to the need to Respond. Washington, DC: US Department of Homeland Se-
to respond to active shooter events and IMCIs, the Victoria curity; 2008. https://www.dhs.gov/xlibrary/assets/active_shooter
I proposes the Spanish adaptation: AMHENAZA (approxi- _booklet.pdf. Accessed 26 February 2018.
mately translated as Annul Menace, HEmorrhage control, No 6. Real Academia Española. Diccionario de la Lengua Española.
extraction delays, Assistance in the Zone, Activate Trauma 2017. http://dle.rae.es/?id=DgIqVCc. Accessed 20 February 2018.
Code). 17-28 It is important to highlight that the adapted acro- 7. North Atlantic Treaty Organization. Glossary of Terms and
Definitions. 2014. http://wcnjk.wp.mil.pl/plik/file/N_20130808
nym in Spanish comes from the word amenaza, which literally _AAP6EN.pdf. Accessed 25 February 2018.
means “threat.” 8. Giménez Mediavilla JJ, Castillo Ruiz de Apodaca M del C,
González Rodríguez D. Actuación Sanitaria en Incidentes NRBQ.
During secondary action, responders will divide the scene into Madrid, Spain: AWWE Editorial Médica; 2016.
safety zone for further rapid medical response according to the 9. Jacobs LM, Joint Committee to Create a National Policy to En-
threat risk. It is important to note that advanced medical re- hance Survivability from Intentional Mass-Casualty and Active
Shooter Events. The Hartford Consensus III: Implementation of
sponse will always be subordinate to the security zoning. This bleeding control—if you see something do something. Bull Am
response zoning can be stratified into three safety levels: (1) Coll Surg. 2015;100:20–26.
care under direct threat, where there is a direct hostile situation 10. American College of Surgeons. Hartford Consensus III focuses on
and only security forces, assault teams, or armed forces should empowering the public to serve as first responders. Bull Am Coll
be involved to avoid further victims and minimize hemorrhage Surg. 2015;100:52.
control, if possible; (2) care under indirect threat, where peo- 11. Callaway D, Bobko J, Smith ER, et al. Building community resil-
ience to dynamic mass casualty incidents. J Trauma Acute Care
ple usually are within a safer area but are still at high risk, and Surg. 2016;80:665–669.
victim prioritization and limited stabilization management are 12. Martín L, Pérez J, Zamora D, et al. Consenso Victoria I: la cadena
performed, if possible; and (3) low risk for responders and de supervivencia táctica—civil ante incidentes de múltiples victi-
victims, and evacuation and further patient management are mas intencionados. Emergencias. In press.
performed until arrival at a definitive trauma center. 13. Usero-Pérez C, González Alonso V, Orbañanos Peiro L, et al.
Implementation of the Hartford Consensus and Tactical Combat
Casualty Care recommendations in emergency services: a review
Tertiary Action of the literature. Emergencias. 2017;29:416–421.
Tertiary action involves the definitive treatment of victims 14. Federal Bureau of Investigation. Active Shooter Event Quick
in receiving hospitals. These hospitals must undergo an offi- Reference Guide. 2015. https://www.fbi.gov/file-repository/active
cial trauma level accreditation. It is essential that the refer- -shooter-event-quick-reference-guide_2015.pdf/view. Accessed 27
ence healthcare facilities also adopt the standard trauma code January 2018.
used by the EMS and dispatch centers so that coordination is 15. American College of Surgeons. Homepage. 2018. https://www
.bleedingcontrol.org/. Accessed 12 February.
smooth and hospitals are optimally alerted of specific victim 16. Committee for Tactical Emergency Casualty Care. Homepage.
arrivals. http://www.c-tecc.org/. Accessed 12 February 2018.
17. Bulger EM, Snyder D, Schoelles K, et al. An evidence-based pre-
hospital guideline for external hemorrhage control: American
Conclusion College of Surgeons Committee on Trauma. Prehosp Emerg Care.
IMCI response requires a multidisciplinary coordination and 2014;18:163–173.
the ability and capacity to adapt to dynamic threat environ- 18. Ramly E, Runyan G, King DR. The state of the union. J Trauma
Acute Care Surg. 2016;80:787–791.
ments. In the face of a growing global threat, and inspired 19. National Registry of Emergency Medical Technicians. National
by the spirit of the Hartford Consensus, the Victoria I docu- Continued Competency Program. 2018. https://www.nremt.org
ment establishes an integrated, seamless response within a new /rwd/public/document/nccp. Accessed 12 February 2018.
framework of the tactical–civilian chain of survival. 20. Real Decreto 836/2012, de 25 de mayo, por el que se establecen
las características técnicas, el equipamiento sanitario y la dotación
de personal de los vehículos de transporte sanitario por car retera.
Disclosures Boletin Oficial del Estado, núm. 137, de 8 de junio de 2012,
The authors have indicated they have no financial relation- 41589–41595.
ships relevant to this article to disclose. 21. Real Decreto 22/2014, de 17 de enero, por el que se modifica
el Real Decreto 836/2012, de 25 de mayo, por el que se esta-
Author Contributions blecen las características técnicas, el equipamiento sanitario y la
All authors contributed to writing the manuscript. BL trans- dotación de personal de los vehículos de transporte sanitario por
lated the manuscript from Spanish to English. All authors read carretera. Boletin Oficial del Estado, núm. 22, de 25 de enero de
and approved the final manuscript. 2014, 4700–4701. https://www.boe.es/boe/dias/2014/01/25/pdfs
/BOE-A-2014-749.pdf.

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