SECONDARY INJURY ASSESSMENT (PAWS-MIST)
Source: ATP 4-02.11, Chapter 9 — Secondary Assessment, 23 March 2026
Key Points
- P-A-W-S covers: Pain, Antibiotics, Wounds (secondary), Splinting
- CWMP = Combat Wound Medication Pack (pain/antibiotics)
- CWMP contains: acetaminophen 1,000mg + moxifloxacin 400mg + meloxicam 15mg
- Do NOT give CWMP to unconscious casualties or those who cannot swallow
- Ibuprofen, naproxen, and aspirin interfere with platelet function — do NOT use
- All wounds must be reassessed for re-bleeding under gauze
- MIST report: Mechanism, Injury, Signs, Treatment
Common Mistakes
- Giving ibuprofen or aspirin for pain (affects clotting — contra-indicated)
- Giving CWMP when casualty cannot swallow
- Not reassessing all wounds for re-bleeding after movement
- Leaving eye injuries unshielded
- Incomplete or missing DD Form 1380
MIST Handoff Report
- M — Mechanism of injury
- I — Injuries found
- S — Signs and symptoms (vitals)
- T — Treatment rendered (TQs, dressings, meds given)
Beyond MARCH, the P-A-W-S components address additional or secondary injuries identified and treated in TFC. These are addressed only after the primary MARCH priorities are controlled. The full sequence is MARCH-PAWS. (ATP 4-02.11, para 9-15)
P — Pain Management (CWMP)
Pain management in combat uses the Combat Wound Medication Pack (CWMP). This pack was designed to manage mild-to-moderate pain without affecting blood clotting. (ATP 4-02.11, paras 9-8 through 9-14)
CWMP Contents
- Acetaminophen — Two 500mg caplets (total 1,000mg), extended-release form
- Moxifloxacin — One 400mg tablet (antibiotic)
- Meloxicam — One 15mg tablet (NSAID, preferred — does not alter platelet function)
Ibuprofen, naproxen, and aspirin interfere with platelet function and blood clotting, significantly increasing the risk of bleeding in combat casualties. Meloxicam is the preferred NSAID for personnel who may see combat in the next 7–10 days. (ATP 4-02.11, para 9-10)
When to Give CWMP
GIVE CWMP when the casualty:
- Is conscious and able to swallow
- Has mild to moderate pain
- Is still able to fight if needed
- Has any penetrating wounds or break in skin
Do NOT give CWMP when:
- Unable to swallow (unconscious, severe facial trauma, burns)
- Known allergies to CWMP medications
- If no break in skin — consult medical personnel before giving
A — Antibiotics
Battlefield wounds are often dirty and susceptible to infection. Early administration of the moxifloxacin in the CWMP may reduce later infections. The CWMP should be given as soon as possible for wounds after life-threatening issues have been addressed. Wound infections can kill the casualty or delay recovery. (ATP 4-02.11, para 9-14)
W — Wound Reassessment (Secondary Survey)
Once the casualty's hemorrhage has been controlled, all wounds must be frequently reassessed. (ATP 4-02.11, paras 9-16 to 9-17)
- Check for blood flowing around or under TQs, bandages, and dressings
- If bleeding not controlled: tighten TQ or pressure bandage, redress wounds as necessary
- Confirm all wounds have been addressed:
- Eye injuries are shielded
- Open chest wounds are sealed
- All wounds are wrapped
- Fractures are splinted
S — Splinting
The "S" in MARCH-PAWS denotes splinting. Splint all fractures in TFC if circumstances permit to immobilize the affected area, prevent further damage, and minimize pain. See the Fractures & Splinting page for detailed procedures.
MIST Handoff Report
Before transferring the casualty to medical personnel, prepare a MIST report to ensure continuity of care:
| Letter | Element | Example |
|---|---|---|
| M | Mechanism of injury | GSW to left thigh, IED blast, fall from vehicle |
| I | Injuries found | Penetrating wound left thigh, suspected femur fracture |
| S | Signs/symptoms (vitals) | Conscious, radial pulse 120, rapid breathing, pale skin |
| T | Treatment rendered | CAT TQ applied 0915, CWMP given, chest seal applied |
ATP 4-02.11 Source
Chapter 9: Secondary Assessment — Army Techniques Publication 4-02.11, Casualty Response, Tactical Combat Casualty Care, and First Aid. Headquarters, Department of the Army, 23 March 2026.
See It in Practice — ESB Tasks
These ESB Medical Lane tasks apply this doctrine directly: