Set in the fictional country of Kookistan during 1999, players assume the role of Captain Carnage and Major Mayhem from the Doomsday Squad in a last-ditch effort to overthrow dictator General Akhboob and his army of mutants from conquering the world, while also rescuing POWs held by his military force.

Total Carnage is a multidirectional shooter similar to Smash TV where players assume the role of Captain Carnage (P1) and Major Mayhem (P2) from the Doomsday Squad across three stages, each with a boss at the end that must be fought before progressing any further, in a last-ditch effort to overthrow dictator General Akhboob (loosely based on Saddam Hussein) and his army of mutants from conquering the world by invading Akhboob's "Baby Milk Factory" base, while also rescuing POWs held by his military force as the main objective.

[2][3][4][5] The players' characters are patterned after John Rambo while the setting is influenced by the 1991 Persian Gulf War (including the Abu Ghraib Infant Formula Plant).

[5] Getting hit by enemy fire or colliding against dangerous stage obstacles will result in losing a life and once all lives are lost, the game is over unless the players insert more credits into the arcade machine to continue playing.

[8][9] Artists Jim Gentile, John Tobias and Tony Goskie were responsible for the pixel art, while Jonathan Hey was in charge of its sound design.

[10] The Amiga and CD32 versions were created by UK-based developer International Computer Entertainment, with Keith Weatherly and Simon Fox acting as programmers of the conversion, while Ellen Hopkins and Mike Jary were responsible for adapting the artwork as well.

[11][12] Midway provided both artwork and source code of the arcade original to the team at ICE, although adapting the former into the Amiga proved to be difficult, as both Weatherly and Fox stated that the number of colors and animations were reduced to fit the hardware.

[5] This version mimics the dual control aspect of the arcade original by mapping the console's four main buttons (A, B, X and Y) like a D-pad, enabling the player to shoot in one direction while running in another.

[5] In 2005, an Atari Jaguar version by Hand Made Software that previously went unpublished was released worldwide by Songbird Productions, nearly ten years after work on the game originally began.