Supplement A (Triage in TCCC) to TCCC Guidelines
JTS/CoTCCC
Triage in Tactical Combat Casualty Care
Triage
1. Conduct first pass triage to provide immediate lifesaving care and identify urgent and nonurgent categories.
a. Urgent category: Casualties that are dying now and require immediate lifesaving interventions to survive.
b. Nonurgent category: Casualties that do not need immediate lifesaving interventions but will require medical care.
2. Conduct second pass triage and sort casualties based upon priority of medical and evacuation needs into three categories: urgent, priority, and routine.
a. Urgent: High priority casualty with severe or critical life-threatening injury or illness who will only survive with immediate surgery, rapid damage control resuscitation, or advanced medical treatment.
b. Priority: Medium priority casualty with serious injury or illness who will require surgery or advanced medical treatment at a delayed time (may include limb and eyesight threatening injuries).
c. Routine: Low priority casualty with minimal injury or illness who will require additional medical treatment, or expectant casualty for whom lifesaving interventions will be minimized.
2. Establish casualty count by precedence and patient type to determine resource allocation and accountability.
3. Communicate casualty status and situation reports with leaders and responders to inform tactical, logistical, and medical decision-making processes during TCCC.
4. Continually reassess and communicate casualty evacuation categories during all TCCC phases of care.
5. Casualties with an altered mental status, secondary to injury, illness, or mind-altering analgesia, should have weapons and communication equipment disabled or removed.
Expanded Guidance & Considerations
The Triage supplement to the TCCC Guidelines presents a comprehensive guide to improve Mass Casualty Management (MCM) across the military continuum, emphasizing an integrated, command-directed approach to synchronize medical and nonmedical efforts. The MCM is not merely about casualty care but about managing an incident with limited resources, chaotic conditions, and diverse responder capabilities.
MCM is a leadership responsibility that includes coordinated planning, security, triage, treatment, communication, casualty movement, and evacuation. Nonmedical personnel—who are often the first responders—are critical in casualty care and system effectiveness, especially in far-forward or resource-limited settings.
MASCAL incidents are inherently unpredictable, dynamic, and overwhelming. These events can range from a dozen casualties to thousands, often disrupting preplanned capabilities. Factors like mechanism of injury, time to surgery, responder expertise, and environmental threats heavily influence triage priorities and casualty outcomes.
A classification model proposes three MASCAL classes:
- Class 1: Manageable on scene.
- Class 2: Requires prioritization of evacuation over treatment.
- Class 3: Resources are insufficient for treatment or evacuation; survival and palliative care dominate.
MCM is expected to include preplanned casualty collection points (CCPs), adaptable evacuation plans (PACE), and procedures for expectant and end-of-life care.
The supplemental guideline recommends a two-pass triage approach based on TCCC principles:
- First pass: Focus on life-saving interventions (e.g., hemorrhage and airway control).
- Second pass: Sort casualties into urgent, priority, routine, or expectant categories.
Importantly, time is a triage tool—interventions like tourniquet application within minutes can be lifesaving, while delays in damage control surgery or blood transfusions (>1 hour) reduce survival odds significantly.
Expectant Casualty Care (ECC) is treated as a legitimate category, emphasizing comfort and re-triage over time. Ethical and psychological considerations are discussed, particularly for leadership and care teams making difficult prioritization decisions.
Effective MCM requires extensive planning that includes:
- Integration into all training and battle drills
- Defined roles for nonmedical and medical personnel
- Pre-identified CCP locations and SOPs
- Clear communication strategies with redundancy
Training recommendations call for holistic, team-based scenarios involving command-level personnel, not just medical staff. Stress is placed on simulation fidelity, standard objectives, and performance outcomes (e.g., “all hemorrhagic shock patients received transfusion within 30 minutes”).
The supplemental guideline outlines detailed CCP setup principles, security protocols, and communication frameworks (internal and external). Movement of casualties must be addressed in both tactical and operational contexts, with thoughts on optimizing evacuation load plans, protecting human remains, and resource consolidation.
Additionally, support roles like the Unit Ministry Team (UMT) are incorporated into the model for spiritual and emotional care.
TCCC Triage advocates for a standardized, leader-driven, team-centric, and scenario-adaptable MCM system and stresses that preparedness—not perfection—is the cornerstone of success. Realistic training, frequent rehearsal, and integration of medical and nonmedical domains are required to transform chaos into coordinated response and improve outcomes in mass casualty events.
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- Martin MJ. Crisis Standards of Care in Mass Casualty and Disaster Scenarios. 2019.
- Remley M, Rush S, Brown J, et al. Operational Planning Guideline: Standardizing Mass Casualty Management. Joint Trauma System. 2024.