Injury and Strain

Injury Rolls

• When a target is reduced to 0 HP after all current Turn effects are resolved or when successfully attacked while Off-Guard (see Conditions):
  • PCs make a straight d20 Roll on the Injury Table.
  • NPCs or monsters die outright. Non-lethal attacks are covered in the Combat section here (coming soon™).
• Any additional successful attack against a PC while they are at 0 HP or Off-Guard requires another roll on the Injury Table.
• If a successful attack or effect deals damage greater than a PC’s maximum HP, they roll on the Injury Table with Disadvantage.

Injury Table

*Adrenaline Rush: A PC recovers 10 HP unconditionally. In addition, they gain Advantage on STR Ability Rolls and their speed is doubled.

Strain

• Strain represents lasting injury and fatigue for PCs. Strain points are cumulative.

• Extreme cold, heat, lack of sleep, food, or water can all cause Strain. Overexertion (e.g. forced marching) and combat injuries also cause Strain.

• When a player character reaches 11 points of Strain or higher, they die from their wounds and fatigue.

• While having Strain points, a PC gets:

  • a Penalty to all d20 Rolls equal to the Strain points divided by 2 (rounded down).
  • a Penalty to Spellcasting DC equal to the Strain points divided by 3 (rounded down).

  The following table illustrates these penalties:

  Strain points	1	2	3	4	5	6	7	8	9	10	11
  Penalty to d20 Rolls		-1		-2		-3		-4		-5	DEAD
  Penalty to Spellcasting DC			-1			-2			-3		DEAD

• Strain points can be reduced by taking Rests or with the help of certain magical effects from potions, spells, etc.

Recovery

• Short Rests require a full night’s sleep (6-8 hours) in a safe location, uninterrupted by combat.
• On taking a Short Rest, a PC fully recovers all HP, Short Rest abilities, and reduces their Strain by 1 point (if higher than 0).
• Pushed Short Rests take roughly an hour, uninterrupted by fights or strenuous activity, while at dangerous locations such as dungeons. PCs incur 1 point of Strain for each Pushed Short Rest they took, but only after leaving the dangerous environment.
• Long Rests require two full days with proper sleep in a safe location, uninterrupted by combat.
• On taking a Long Rest, a PC fully recovers their HP, all Short and Long Rest abilities, spells and magic item charges. In addition, they reduce their Strain by 5 points (if higher than 0).

Clarifications

• Strain completely replaces the existing 5e “Exhaustion” mechanic, while Injury Rolls replace the existing 5e “Death Saves”.
• The Injury and Strain rules work best with the revised Conditions, which soften effects like Stunned and introduce new ones like Battered, Staggered and Off-Guard.

Optional Rules

• If sudden death Conditions like Off-Guard are deemed too strong, ignore all Off-Guard references in the Injury Rolls rules and use the optional variant for Off-Guard in Conditions.
• Classic 5e Recovery: (Short Rests: one hour, Long Rests: 8-hour downtime) Short Rests do not reduce Strain at all, Long Rests reduce Strain by 1 point (heroic option: 2 points).
• Supply: 1 Supply represents all things necessary to recover properly for one night: food, water, herbs, bandages, ointments, etc.
  • Short Rests and Pushed Short Rests require 1 Supply per PC.
  • Long Rests require 2 Supplies per PC.
  • If a PC lacks Supply, they cannot recover Strain points. They also gain 1 additional point of Strain for each consecutive night after the 3rd without Supply.
• Heroic Long Rests: reduce Strain to 0 points and PCs gain temporary HP equal to their level. These temporary HP do not stack.

Design Notes

The main goal of these rules is to model lasting injury that provides players with options to either push their characters to their limits (and risk death) or retreat from battle, while not completely hobbling their PCs.

• The 5e “Death Saves” while impactful are not very active. Players mostly leave the dying character alone until absolutely necessary (it’s a good idea to make Death Saves in secret to disincentivise meta gaming). Meanwhile, the character rolling the Saves does nothing for potentially two to four combat Turns.
• Because Strain points are added only after combat ends, theoretically, a PC can finish any fight but then instantly die from their injuries unless somehow their Strain was reduced to below 11 points during combat.
• The new Rest system also has a big impact on class dynamics: Warlocks become much stronger with their two spells per Short Rest, for example. At my table, there are seldom more than two or three combats per adventuring day, so players often would go “nova” and use their most powerful abilities first. The new Recovery rules are designed to address that.
• HP in the latest 2024 D&D rules represent “durability and will to live”, but there is virtually no difference between a character being on one or full Hit Points. If I were designing an RPG from scratch, I would replace the term “Hit Points” with Stamina to better match the mechanical effect in-game.

GM Tips

• Consider giving the players time for final words from their characters when they reach 11 Strain points.
• Recovery is designed to stretch an “adventuring day” into an “adventuring week” with 3-5 active days featuring Short Rests and one two-day Long Rest. This has the added benefit of stretching the passage of time so you no longer get level 10 characters who, in-game, only started their journey two weeks ago at level 1.
• Narrating every minute of every Rest is not necessary. You can try a bird’s-eye view approach and summarise activities in a roll or two if required.
• You can use the optional “Classic 5e Recovery” rules above if your table is closer to a traditional dungeon crawl with more combats per adventuring day or if you simply do not like extended Rests but are keen on trying the Strain mechanic.

Attribution

I started working on this concept a few years back after being inspired by Dael Kingsmill from Monarch’s Factory and her original homebrew Another D&D Thing to Use: Major Injury Table. I had some issues with it: a CON Save would make rolling a 1 virtually impossible (most PCs have at least one point invested in their CON score). I also found the consequences too punishing. There is a newer, more advanced version of this table that fixes these points: Major Injuries Updated, but the implementation is a bit too complex. Still, it’s an amazing idea and I kept tinkering with it for some time and this page is the result.
Other games with somewhat similar design ideas worth mentioning are:

• MCDM’s Draw Steel is a novel tabletop game (partly inspired by 4e) with its own approach to dealing with combat injuries that encourages an active, engaged playstyle.
• Ghostfire Gaming’s Grim Hollow is a 5e conversion that features extended rest mechanics tied to safe havens, reinforcing its dark-fantasy tone.
• Chaosium’s Call of Cthulhu has a secondary axis in Sanity in addition to HP, requiring players to balance both to keep their character functional.

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