A – Airway

After controlling massive hemorrhage, evaluate the trauma patient’s airway patency. Conscious patients should assume a comfortable position that allows air passage, particularly those with maxillofacial injuries. Unconscious patients may need airway intervention.

Two interventions for non-medical personnel with minimal training include inserting a nasopharyngeal airway (NPA) or placing the patient in the recovery position, which maintains an open airway and prevents aspiration.

Maintaining an open airway is crucial, especially in mass casualty scenarios where attention may be divided among multiple patients. Patients with airway obstructions or those unresponsive to basic measures require advanced intervention by a trained medic ASAP.

R – Respiration

For penetrating thoracic trauma, meticulously check the entire torso, from the umbilicus to the clavicle, including the axillae and any skin folds. An open chest wound (or “sucking chest wound”) can trap air in the chest, creating a pneumothorax. If too much air accumulates, it can become a tension pneumothorax, which can be fatal.

Cover open chest wounds with a vented chest seal whenever possible, allowing air to escape but not enter the chest cavity. If an occlusive chest seal must be used (not recommended), continuous patient assessment is critical as air may still accumulate inside the chest.

For laypersons, this means “burping” the dressing to release air. For providers, it involves needle decompression, finger thoracotomy, or tube thoracostomy.

C – Circulation

Double-check your Care Under Fire (CUF) interventions to ensure any life-threatening external hemorrhage control is still effective. If a broken pelvis is suspected, stabilize it with a splint. Perform a head-to-toe blood sweep with clean hands/gloves. Identifying new bleeding with already bloody hands can mislead you.

If a clean-handed sweep reveals blood, locate the wound, expose and evaluate it, then take appropriate action. Prepare all necessary equipment, including additional occlusive dressings, bandages, litters, and hypothermia blankets.

H – Hypothermia

Despite significant advancements in trauma care, trauma remains a leading cause of death across all age groups. Treating visible injuries is relatively straightforward: applying a tourniquet to a bleeding limb or a vented chest seal to a thoracic GSW is manageable.

What some find challenging is treating what cannot be seen. In penetrating trauma, the lethal triad of hypothermia, acidosis, and coagulopathy is deadly. The trauma triad of death is a significant cause of mortality in traumatic injuries. Failing to address any part of the triad leads to worsening hemorrhage and eventual death.

Hypothermia is often ignored for various reasons:

• “It’s unnecessary unless you are in a cold environment.”

• “We don’t need to treat it at the point of injury because they’ll ride in a warm ambulance.”

• “Carrying bulky hypothermia kits isn’t practical.”

These are excuses. If a patient has lost blood, they have lost body heat and are already in a deficit. Interrupt the lethal triad by all means available.

To treat hypothermia:

• Minimize the patient’s exposure to the elements.

• Change wet clothes for dry ones.

• Place the patient on a litter and wrap them in a hypothermia blanket. Improvise if necessary.

“The M.A.R.C.H. Algorithm is superior for trauma patient evaluation compared to the traditional ABC model. The ABC model fails in root cause analysis: the ultimate goal of maintaining an open airway is to oxygenate the blood, which is best done while still in the body. Stopping massive bleeding must be the first priority because failure to do so renders the remaining priorities pointless if the casualty dies from massive hemorrhage.” – Mike Shertz, MARCH Versions (2018)

Train the M.A.R.C.H. Algorithm until it becomes second nature. Carry everything needed in an ITK packed to TCCC/TECC standards to save a life.

Disclaimer: This article is for educational purposes only and is not a substitute for professional medical advice. For any concerns, consult a medical professional.