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Introduction Combined injuries involving both physical trauma and exposure to chemical warfare agents present significant challenges in medical management. Currently, research and operational guidelines tend to address trauma and intoxications separately. 1–3 Hence, existing protocols for triage, diagnosis, life-saving interventions, skin decontamination, and specific medical treatments can significantly impact the severity and outcomes of combined injuries.Objective Identification of key complications in managing combined injuries and proposing improvements in clinical protocols, particularly in prehospital and acute care settings.Method A comprehensive literature review was conducted between April 2024 to February 2025, using PubMed and SciFinder, focusing on articles published within the last 30 years. A total of 86 references were included, supplemented by relevant NATO guidelines for military medical protocols.Results The coexistence of trauma and toxic chemical exposure complicates diagnosis, triage, and treatment prioritization. Overlapping symptoms can obscure critical diagnoses, while current triage systems often fail to account for both injury types, leading to mismanagement, particularly in mass casualty incidents. 4 5 Development of simple and reliable differential diagnostic support should therefore be developed to enable identification and exclusion of combined injuries. Subsequently, all personnel in both civilian and military trauma healthcare should receive training on the system.6 Using the similar decision support system will aid the patient transmission from military to civilian hospital care. Similarly, the triage algorithm utilized at the incident scene and at emergency departments should emphasize both physical trauma and chemical exposures, in addition to, references to live-saving interventions.7 Abstract A26 Figure 1Model of a prehospital triage algorithm, originally designed for trauma injuries, supplemented with symptoms of intoxication to facilitate use in mass casualty events that include combined injuries8Following exposure to chemical warfare agents, specific decontamination products are generally required for efficient agent removal from skin.9–11 The choice of decontamination should, in addition to efficacy, be based on the possibility of using the product on both intact and damaged skin to avoid the risk of ongoing chemical absorption and secondary contamination of healthcare personnel. The result will be shortened agent exposure time, a reduced need for immediate advanced hospital care and no additional measures is required, e.g. packeting of wounds, to manage the patient.Pharmacological interventions commonly used in trauma care, including anaesthesia and analgesia, can result in exacerbated symptoms of intoxication.12 13 In addition, increased awareness should be sought regarding that medical treatment can interfere with symptom interpretation.14 Conclusions Effective management of combined injuries requires the integration of differential diagnostic tools, triage systems that account for both trauma and toxic chemical exposure, decontamination products suitable for damaged skin, and pharmacological protocols that minimize interference or exacerbate symptoms of intoxication. Standardized guidelines addressing these factors will improve patient outcomes and optimize resource allocation in both civilian and military medical settings.Conflict of Interest Statement The authors did not report any conflict of interest.Funding The Swedish Ministry of Defence funded the contribution from L.T. and A.B. The Swedish Armed Forces funded the contribution from U.A. and M.G.References NATO. AMedP-1.10 - Medical Aspects in the Management of a Major Incident/Mass Casualty Situation. NATO Standardization Office (NSO); 2015.NATO. AMedP-7.2: CBRN First Aid Handbook. NATO Standardization Office (NSO); 2018.NATO. AJP-4.10 Allied Joint Doctrine for Medical Support. NATO Standardization Office (NSO)2019.Dorandeu F, Singer C, Chatfield S, Chilcott RP, Hall J. Exposure to organophosphorus compounds: best practice in managing timely, effective emergency responses. Eur J Emerg Med. 2023;30(6):402–7.Ben Abraham R, Rudick V, Weinbroum AA. Practical guidelines for acute care of victims of bioterrorism: conventional injuries and concomitant nerve agent intoxication. Anesthesiology. 2002;97(4):989–1004.NATO. Non-binding Guidelines for Civil-Military Medical Cooperation in Response to Chemical, Biological, Radiological and Nuclear (CBRN) Mass Casualty Incidents. NATO Defence Policy and Planning Division2022.SALT mass casualty triage: concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors Association. Disaster Med Public Health Prep. 2008;2(4):245–6.Thors L, Wigenstam E, Bucht A. Triagemetodik vid exponering för kemiska ämnen. 2019 FOI-R--4726--SE.Thors L, Wigenstam E, Qvarnstrom J, Bucht A. Efficient agent degradation within skin is important for decontamination of percutaneously exposed VX. 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