Suicide bombing attacks have emerged as a lethal weapon in the hands of terrorist groups. Our aim was to review the medical experience acquired in Israel, Spain, the United Kingdom and the United States in managing terrorist attacks, and prepare medical systems for the difficult task of managing these events. EMS protocols are amended to deal with a large number of victims in an urban setting who must be rapidly evacuated to a medical center where resuscitative as well as definitive care is delivered. A combination of extensive soft tissue damage caused by penetrating injuries, blast injury to the lungs and tympanic membranes, and burns are common among survivors. Preparation must include establishment of a clear chain-of-command lead by a general surgeon who manages the event and is responsible for decisions regarding OR preferences and ICU admissions. The emergency department is re-organized to handle the influx of numerous severely injured casualties. Professional personnel and resources are recruited and re-directed away from routine tasks towards treating the victims. This is achieved by deferring non-urgent operations, procedures and imaging studies. Victims are frequently re-assessed and re-evaluated to control chaos, minimize missed injuries and ensure delivery of an adequate level of care.