Triage in Action: A Principles-Based Approach to Mass Casualty Management in Tactical Combat Casualty Care.

Current triage practices in military mass casualty (MASCAL) events are frequently misaligned with real-world operational needs, leading to delays, confusion, and suboptimal outcomes. Despite the existence of formal triage systems, field responders often default to simplified methods that emphasize speed, clarity, and survivability. This review supports the Committee on Tactical Combat Casualty Care (CoTCCC) recommended transition to a principles-based, two-pass triage system optimized for Role 1 prehospital environments. A multi-modal analysis incorporating retrospective case reviews, field surveys, and doctrinal review was conducted to evaluate real-world triage practices across recent military MASCAL incidents. Findings were synthesized to develop an updated triage methodology anchored in clinical judgment, tactical relevance, and operational simplicity. In 93% of reviewed MASCAL cases, formal triage tools involving color-coded tags and five-category algorithms were not used. Responders preferred a binary or simplified categorization (e.g., urgent vs. nonurgent) for rapid decision-making. The proposed two-pass system includes an initial "first pass" to identify casualties requiring immediate life-saving intervention and a more deliberate "second pass" to sort casualties into urgent, priority, or routine categories aligned with established evacuation precedence. This model emphasizes rapid assessment via the Massive Hemorrhage, Airway, Respirations, Circulation, Hypothermia/Head Injury (MARCH) framework, clear communication between medical and nonmedical personnel, and dynamic re-evaluation as conditions evolve. The principles-based two-pass triage model offers a practical and operationally aligned framework for Role 1 casualty care. It improves decision-making, communication, and casualty flow during complex MASCAL events while enhancing training, interoperability, and mission success. This approach is endorsed by CoTCCC and integrated into the 2025 TCCC guidelines to optimize outcomes across the full spectrum of military operations.