BACKGROUND: The terrorist attacks in Norway on July 22, 2011, consisted of a bomb explosion in central Oslo, followed by a shooting spree in a youth camp. We describe the trauma center response, identifying possible success factors and suggesting improvements for institutional major incident plans., METHODS: The in-hospital response is analyzed. Data on triage, patient flow, injuries, treatment, resources, and outcome were collected., RESULTS: The explosion caused a total of 98 casualties and 8 died at scene. Ten patients were triaged to the trauma center, with the first patient arriving 18 minutes after the explosion and 7 patients within the next 19 minutes. The shooting caused 68 deaths at the scene and 61 injured. The trauma center received a total of 21 patients from the shooting incident.Surgical leadership was divided between emergency department triage with control of personnel and communication as well as control and supervision of treatment with retriage and optimal use of trauma surgical resources (dual command). Surge capacity was never exceeded in the emergency department, operating rooms, or intensive care units.Of the 31 patients treated at the trauma center, 20 had an Injury Severity Score of more than 15 and 25 required repeated operation, for a total of 125 operations during the first 4 weeks. One patient died, for a critical mortality of 5%., CONCLUSION: A trauma center can handle many patients with severe injury, with low critical mortality when protected from a large number of walking wounded. Limited specific trauma surgical competence was managed by the adoption of a dual surgical command model., LEVEL OF EVIDENCE: Therapeutic/care management study, level V.
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