ZMIST Patient Handoff
When you transfer a casualty — from scene to evacuation, or to a higher level of care — the ZMIST report ensures critical information is communicated clearly, fast, and nothing is forgotten.
What is ZMIST?
ZMIST is the standard casualty handoff format used across TCCC and most military and paramilitary medical systems. It provides a structured, five-element framework that ensures every receiving provider gets the same critical information, regardless of how chaotic the environment.
MARCH is what you DO. ZMIST is what you REPORT. The two systems work alongside each other — you run MARCH to treat the casualty, then deliver a ZMIST report whenever you transfer care. This keeps treatment and communication clearly separated.
A complete ZMIST takes 30–60 seconds. It can be delivered verbally during a handoff or written on a field casualty card and sent with the patient. Either way, every element must be covered — omitting even one field can have serious consequences for the receiving provider's decisions.
The 5 ZMIST Fields
Report what caused the injury — gunshot wound (GSW), blast/IED, motor vehicle collision (MVC), fall, burn, or medical event. Mechanism predicts injury patterns, which allows the receiving provider to anticipate injuries that may not yet be visible or symptomatic.
Always include the estimated time of injury, not just the mechanism. Time-sensitive conditions like hemorrhagic shock, TBI, and tourniquet conversion windows all depend on knowing when the injury occurred.
- GSW right upper thigh → suspect femoral artery involvement, prepare for massive hemorrhage and vascular repair
- Blast/IED → anticipate TBI, blast lung, multiple fragment wounds, tympanic membrane rupture
- MVC at speed → consider spinal injury, internal hemorrhage, pneumothorax from seat belt loading
- Fall from height → calcaneal fractures, vertebral compression, internal abdominal injury
Provide a systematic head-to-toe description of all injuries found. Be specific about location, injury type, and severity. Distinguish penetrating from blunt trauma. For gunshot wounds, note entry and exit wounds. For burns, estimate the percentage of body surface area (BSA) affected.
Use anatomical landmarks, not colloquial descriptions. "5cm laceration left lateral neck at the level of C4" is useful. "Cut on the neck" is not. The receiving provider needs to triage and prepare without re-examining from scratch.
Describe findings in a logical order — head, neck, chest, abdomen, pelvis, extremities. Include:
- Penetrating injuries: entry/exit, trajectory if estimable
- Burns: location and approximate % BSA, depth if assessed
- Fractures: open vs. closed, suspected based on mechanism/deformity
- Airway or breathing compromise signs observed
Report all treatments given, in chronological order, with time stamps. This is the most information-dense element of the ZMIST. Include vital signs if measured, GCS, and any medication administration.
Document the following if applicable:
- Tourniquet: location, type (CAT, SOFTT-W), and exact time applied
- Hemostatic agents: QuikClot, Combat Gauze — wound packed and packed time
- IV/IO access: site, gauge, fluids running (type and volume)
- Medications: TXA, morphine, ketamine, antibiotics — dose, route, time
- Airway: NPA size inserted, surgical airway performed, BVM used
- Chest: needle decompression (side, time), chest seal placed (occlusive/vented)
- Vitals: BP, HR, RR, SpO₂, GCS — with measurement time
Report the casualty's current status at the moment of handoff — not their status when you first found them. This tells the receiving provider what they are taking on right now and whether the patient is trending better or worse.
Cover the following:
- Consciousness: AVPU (Alert / Voice / Pain / Unresponsive) or GCS
- Breathing: rate, depth, symmetry, quality (labored, agonal, absent)
- Circulation: heart rate, radial pulse quality (present/absent/weak/strong)
- Skin: color (pale, mottled, cyanotic), temperature (cool, warm), moisture (diaphoretic)
- Trend: improving, stable, or deteriorating — include any changes since initial assessment
Trending information is critical. A patient with GCS 12 is managed very differently if they were GCS 15 twenty minutes ago versus GCS 8. Tell the full story, not just a snapshot.
Communicate what additional care is needed that you were unable to provide in the field — and anything the receiving provider must act on immediately. This is the forward-looking element of ZMIST: the handoff of responsibility.
Include:
- Surgical needs: hemorrhage control, exploratory laparotomy, vascular repair, fasciotomy
- Imaging: FAST ultrasound, CT, X-ray for suspected internal injury or fractures
- Fluids/blood: ongoing resuscitation needs, massive transfusion protocol activation
- Medications: second dose TXA if indicated, continued pain management, antibiotics not yet given
- Allergies: known drug allergies (state "no known allergies" if confirmed, not just unknown)
- Tourniquet conversion: flag if tourniquet has been on approaching the 2-hour window
- Patient directives: DNR status or expressed wishes if relevant to the care context
Full 30-Second ZMIST Script
This is how a complete ZMIST sounds when delivered verbally at the point of handoff. Practice saying this aloud until the sequence is automatic — under stress, you should be able to deliver it in under a minute without notes.
M — Through-and-through GSW, entry medial mid-thigh, exit lateral, active arterial bleed identified on scene.
I — CAT tourniquet applied 14:30, QuikClot packed wound, 500mL LR running left AC, TXA 1g IV at 14:33. GCS 13, HR 125, BP by radial pulse present but weak, RR 18.
S — Alert, GCS 13 — down from 15 at scene. Breathing adequate, skin pale, trending down.
T — Needs OR for vascular repair. Second TXA dose due 15:33. Tourniquet at 14:30, conversion at surgeon's discretion. No known allergies.
Common Handoff Mistakes
Skipping Interventions Entirely
Some providers deliver Z, M, S, and T but leave out I — especially under pressure. The receiving team then has no idea what medications have been given, what access is in place, or what fluids are running. Re-dosing morphine in a patient who already received it is a serious risk. Always report every intervention, even if it feels like an obvious step.
Vague Mechanism Reporting
"He got shot" conveys almost no useful information. "GSW right upper thigh at approximately 14:28, through-and-through, suspected femoral involvement" tells the surgeon exactly where to focus. Mechanism specificity directly influences triage priority and OR preparation. Approximate time alone can determine whether blood products need to be on standby.
Reporting Status Without Trend
Saying "GCS 13" is less useful than "GCS 13, down from 15 at scene over 25 minutes." A declining trend with any vital sign is an immediate escalation signal. A stable patient at GCS 12 and a deteriorating patient at GCS 13 are managed completely differently. Always report the direction of travel, not just the current reading.
When to Deliver a ZMIST
ZMIST applies any time care is transferred from one provider to another. Three common scenarios: