1.Abdelhakim T. Elkholy MBBCH,FACS ATLS CHAIRPERSON EGYPT

2. Aknowlegement Dr.Mohamed Alasmar MBBCH, MRCS National coordinator and Instructor ATLS- Egypt General Surgery Resident, Ahmed Maher Teaching Hospital Visitor Resident, KasrAlainy Hospital Cairo University 3. All pictures and cases are real and taken from the scene of events . 4. 25 January 2011 Low velocity shot-gun injuries. Multiple casualty event. 5. Police officers were attending in the resuscitation rooms. All pictures were taken secretly by mobile phone camera ! 6. 28 January 2011 Fatal injuries (shooting to kill !). Mass casualty incidents. No disaster management plan was present or applied. All doctors from all specialties worked in the casualty reception and all on-call consultants came to the hospital All elective surgeries stopped. Collapse of medical service, communication and security. 7. - Cairo University Hospital. - The biggest hospital with a 5200-beds capacity. - It is tertiary ,referral center for all hospitals in Egypt . - It is the closest hospital to Tahrir Square. 8. Evidence of an Emerging Pattern of Regimes Organized Escalating Violence During 10 Hours on the Night of January 28, 2011 Published Article in Annals of Surgery, 2012 Mohamed D. Sarhan, MD, MRCS, Ashraf A. Dahaba, MD, MSc, PhD, Michael Marco, MD, MSc, and Ayman Salah, MD 9. Published Article in Annals of Surgery Of 3012 casualties, 453 were triaged as immediate care patients. On arrival, 339 of 453 patients (74.8%) needed surgical intervention within 6 hours of arrival whereas 74 of 453 patients (16.3%) were managed conservatively. Forty of 453 (8.8%) of patients did not survive their injuries. Most of the inpatients (302/453, 66.6%) were admitted within 10 hours on January 28, 2011, during which evidence of a pattern of regimes organized escalating violence emerged. 10. Patterns of injuries Firearms resulted in the majority of injuries (93.1%) Stab wounds (3.5%) Blunt trauma from stone throwing (2.6%) Tear gas inhalation (0.4%) 11. Sites of injuries The most common sites of injury were the head and neck (52.9%). the upper and lower extremities (18.1%). abdominal area (13.6%). chest (9%). multiple firearm injuries (6.1%) 12. Case scenarios Some Cases presented during the revolution. 13. Gunshot: entrance Rt. Lower chest and exitLt. neck . Presented hemodynamically unstable and unfortunately died due to extension of the vascular injury to major vessels. 14. Shotgun left hemi-thorax and left upper quadrant of the abdomen. Patient presented hemodynamicaly unstable and Splenectomy was done but patient died due to extensive hematemesis. 15. Shotgun to the back. Patient presented with hematuria. Admitted under observation. Patient discharged. 16. Shotgun to the back. Presented with right pneumothorax and paraplegia. 17. Shotgun umbilical region presented 24 hours after the injury. Multiple small bowel perforation. Patient died after 2 weeks due to septicemia. It was noticed that the effect of small pellet may be delayed and this issue is under research now. 18. Gunshot to the chest ; 19. Patient presented toAhmed Maher Teaching Hospital without cardiothoracic surgeons !! Hemodinamicaly stable middle-aged male patient. Gunshot to the chest. no communication method as the government cut all methods of communication. You can not transfer patients as there is no way of communication. Conflict between people and police increased the problem of security. 20. How can we solve the security problem?? 21. Not only physicians, nurses and hospital workers but also patients relatives and even some patients share in securing the hospitals and protecting medical staff. 22. Thank you..