Objective We discuss the strengths of the medical response to the Boston Marathon bombings that led to the excellent outcomes. Potential shortcomings were recognized, and lessons learned will provide a foundation for further improvements applicable to all institutions. Background Multiple casualty incidents from natural or man-made incidents remain a constant global threat. Adequate preparation and the appropriate alignment of resources with immediate needs remain the key to optimal outcomes. Methods A collaborative effort among Boston’s trauma centers (2 level I adult, 3 combined level I adult/pediatric, 1 freestanding level I pediatric) examined the details and outcomes of the initial response. Each center entered its respective data into a central database (REDCap), and the data were analyzed to determine various prehospital and early in-hospital clinical and logistical parameters that collectively define the citywide medical response to the terrorist attack. Results A total of 281 people were injured, and 127 patients received care at the participating trauma centers on that day. There were 3 (1%) immediate fatalities at the scene and no in-hospital mortality. A majority of the patients admitted (66.6%) suffered lower extremity soft tissue and bony injuries, and 31 had evidence for exsanguinating hemorrhage, with field tourniquets in place in 26 patients. Of the 75 patients admitted, 54 underwent urgent surgical intervention and 12 (22%) underwent amputation of a lower extremity. Conclusions Adequate preparation, rapid logistical response, short transport times, immediate access to operating rooms, methodical multidisciplinary care delivery, and good fortune contributed to excellent outcomes.

Introduction It is unknown whether the magnitude of rib fracture (RF) displacement predicts pain medication requirements in blunt chest trauma patients. Methods Adult blunt RF patients undergoing chest computed tomography (CT) admitted to an urban Level 1 trauma center (2007–2012) were retrospectively reviewed. Pain management in those with displaced RF (DRF), non-displaced RF (NDRF), or combined DRF and NDRF (CRF) was compared by univariate analysis. Linear regression models were developed to determine whether total opioids requirements [expressed as log morphine equianalgesic dose (MED)] could be predicted by the magnitude of RF displacement (expressed as the sum of the Euclidean distance of all displaced RF) or number of RF, after adjusting for patient and injury characteristics. Results There were 245 patients, of whom 39 (16%) had DRF only, 77 (31%) had NDRF only, and 129 (53%) had CRF. Opioids were given to 224 (91%) patients. Compared to DRF (mean1.7 RF/patient) and NDRF patients (2.4 RF/patient), those with CRF (6.8 RF/patient) were older and had more RF per patient and a higher ISS and MED (251 vs. 53 and 105 mg, respectively, p<0.0001 and p=0.0045). They also more frequently received patient controlled analgesia. DRF patients had a lower mean ISS and MED and received more epidural analgesia compared with patients with NDRF. Total MED was associated with both the magnitude of RF displacement (p<0.0001) and the number of RF (p<0.0001). Every 5 mm increase in total displacement predicted a 6.3% increase in mean MED (p=0.0035) while every additional RF predicted an 11.2% increase in MED (p=0.0001). These associations included adjustment for age, ISS, and presence of chest tubes. Conclusion The magnitude of RF displacement and the number of RF predicted opioids requirements. This information may assist in anticipating patients with blunt RF who might have higher analgesic requirements. Level of Evidence Prognostic study, level III.