Responding to mass casualty incidents in a tunnel environment is problematic not least from a prehospital emergency medical services (EMS) perspective. The aim of this review was to 1) categorize preconditions for emergency response in tunnel environments based on Haddon’s matrix and 2) identify specific EMS knowledge of providing prehospital care. Twenty eight articles, reports and book chapters were selected for further analysis. Firstly, sorting the data from each included article was done according to Haddon’s matrix. The result covers human factors, technical factors, physical environmental factors and socioeconomic environmental factors all related to preconditions for emergency response. To describe the EMS’s knowledge the data was also sorted according to command and safety, communication, assessment, and triage treatment and transport, also known as CSCATT. Few studies, especially of high quality, actually provide detailed information regarding emergency response to tunnel incidents and those that do, often have a main focus on management by the rescue service. While many incidents studied were caused by fires in tunnels, thus requiring rescue service in action, the subsequent EMS response issues that have taken place appear to have been given limited attention. To optimize the survival rates and health of the injured, as well as to provide a safe and effective work environment for the emergency services, there is a need to explore the event phase.