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MARCH Protocol · Lesson 2 of 6

MARCH Protocol

A systematic approach to life-threatening trauma — applied in order, every time, without exception. MARCH is the operational heart of TCCC's Tactical Field Care phase.

MARCH is both a mnemonic and a strict priority framework for managing traumatic casualties in tactical environments. The letters stand for Massive Hemorrhage, Airway, Respiration, Circulation, and Hypothermia/Head Injury — each representing a category of life-threatening problem addressed in sequence. The order is deliberate and evidence-based: it reflects how quickly each threat kills. Massive hemorrhage is placed first because uncontrolled bleeding is the leading cause of preventable death on the battlefield, responsible for up to 90% of potentially survivable combat fatalities. This runs counter to standard Basic Life Support training, which places Airway first — but that logic breaks down in trauma. As the TCCC doctrine states plainly: "An open airway is useless if the patient bleeds out in 3 minutes." Understanding not just the steps but why they are ordered this way is what separates competent field care from rote checklist execution.

Why It Comes First

Hemorrhage is the number one cause of preventable death in trauma — military and civilian alike. Uncontrolled extremity bleeds can kill in under three minutes. Every second spent on other assessments before bleeding is controlled is a second of unnecessary blood loss. The moment you reach a casualty, your hands go to the bleed.

Interventions — In Order

  1. Tourniquet — for extremity bleeds. Apply 2–3 inches (5–7 cm) above the wound, not over a joint. Tighten until bleeding stops and distal pulse is absent. Mark the time of application directly on the tourniquet or the patient's forehead with a marker. Do not remove in the field.
  2. Wound packing + direct pressure — for junctional and truncal bleeds. Pack the wound cavity tightly with hemostatic gauze (QuikClot Combat Gauze or Celox), working from the deepest point outward. Apply firm, continuous direct pressure for a minimum of 3 minutes. Then apply a pressure dressing to maintain compression.
  3. Pressure dressing — for less severe surface bleeds. Where tourniquet placement is not anatomically possible and packing is excessive, a well-secured pressure dressing (Israeli bandage) can control moderate bleeding. Reassess frequently.
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Tourniquet First, Questions Later
If in doubt, tourniquet. A tourniquet applied when not needed causes far less harm than one not applied when needed. Reversible limb ischemia from a correctly applied tourniquet is manageable. Exsanguination is not.

Key Supplies

  • CAT (Combat Application Tourniquet) — windlass-style, one-handed application
  • SOFTT-W (Special Operations Forces Tactical Tourniquet Wide) — wider band, reduced pressure injury
  • Hemostatic gauze: QuikClot Combat Gauze or Celox Gauze — kaolin or chitosan-based
  • Pressure bandages (Israeli Emergency Bandage)
  • Permanent marker — for tourniquet time notation

Common Error

Tourniquet applied too loosely (painful but not effective), too low (over the wound, not above it), or without documenting application time. A loose tourniquet that doesn't stop arterial flow increases venous congestion and can worsen bleeding.

Initial Assessment

A conscious casualty who is speaking clearly has an adequate airway — move on. An unconscious casualty, or one with gurgling, stridor, or absent breathing sounds, must be assumed to have a compromised airway until proven otherwise. Look, listen, and feel before intervening.

Interventions — In Order

  1. Jaw thrust (not head-tilt chin-lift in trauma). Head-tilt chin-lift is contraindicated in trauma due to potential cervical spine injury. Use the jaw thrust maneuver to open the airway without moving the neck.
  2. Nasopharyngeal airway (NPA) — preferred field adjunct. The NPA maintains airway patency in semiconscious or unconscious patients and is tolerated far better than an oropharyngeal airway (OPA) in patients who are not fully unconscious. Lubricate well; insert into the right nostril with a beveled edge toward the septum. Contraindicated in suspected basilar skull fracture.
  3. Surgical cricothyrotomy — airway of last resort. When all other means fail to establish a patent airway (facial trauma, foreign body obstruction, severe angioedema), a surgical cric provides a definitive airway. Identify the cricothyroid membrane (below thyroid cartilage, above cricoid cartilage), make a horizontal stab incision, and insert a cuffed tube.

Patient Positioning

An unconscious casualty without suspected spinal injury should be placed in the recovery position (lateral recumbent) to prevent aspiration of blood, vomit, or secretions. Keep airway open and monitor breathing continuously.

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Cervical Spine Immobilization in Penetrating Trauma
In penetrating trauma, routine cervical spine immobilization is not recommended by TCCC guidelines. It delays treatment, restricts airway management, and the incidence of unstable cervical spine injury from penetrating mechanisms is extremely low. Do not let a collar compromise the airway.

Key Supplies

  • Nasopharyngeal airway (NPA), size 28–34 Fr, with water-based lubricant
  • Surgical cricothyrotomy kit (scalpel, bougie, cuffed ETT or dedicated cric tube)

Three Immediate Threats

Once the airway is secured, assess breathing for three life-threatening chest injuries. Expose the chest, look for asymmetric rise, listen for absent breath sounds, and assess respiratory rate and effort.

1 — Tension Pneumothorax

Signs: Absent or decreased breath sounds on one side, progressive respiratory distress, hypotension, distended neck veins (late sign), tracheal deviation (very late). In a haemodynamically compromised trauma patient, assume tension pneumothorax until decompressed.

Treatment — Needle Decompression: Insert a 14g needle/catheter at the 2nd intercostal space, midclavicular line (2nd ICS MCL), or the 4th/5th intercostal space, anterior axillary line (4th/5th ICS AAL — preferred in large or muscular patients due to chest wall thickness). Listen for a rush of air. Secure the catheter and monitor for re-accumulation.

2 — Open Chest Wound (Sucking Chest Wound)

Any penetrating chest wound larger than approximately two-thirds the diameter of the trachea will preferentially draw air through the wound rather than the trachea during inspiration. This prevents effective ventilation. Treatment: Apply a vented (one-way valve) chest seal immediately — Hyfin Vent or Bolin Chest Seal. The vent prevents conversion to tension pneumothorax while sealing the wound. Monitor continuously; if the patient deteriorates, burp or remove the seal.

3 — Hemothorax

Blood in the pleural space compresses lung tissue. Signs are similar to pneumothorax but without immediate tension physiology. Dullness to percussion differentiates it from pneumothorax. Field treatment is supportive — chest seal if there is an open wound, position of comfort, rapid evacuation. Tube thoracostomy is a provider-level intervention.

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Decompress if Unsure
Tension pneumothorax is rapidly fatal — minutes, not hours. If a trauma patient is deteriorating and you suspect tension pneumo, decompress without waiting for textbook signs. The risk of performing an unnecessary needle decompression is far lower than the risk of not decompressing a real tension pneumo.

Key Supplies

  • Vented chest seals ×2 (Hyfin Vent Chest Seal Twin Pack or Bolin) — carry two for entrance and exit wounds
  • 14g × 3.25" needle/catheter for needle decompression

Shock Assessment

Use the AVPU scale for rapid mental status: Alert, responds to Voice, responds to Pain, Unresponsive. Check skin color and temperature (pale, cool, clammy = shock), capillary refill (>2 seconds is abnormal), and radial pulse quality — weak or absent radial pulse indicates systolic BP ≀80 mmHg and constitutes hemorrhagic shock until proven otherwise.

IV / IO Access

Establish vascular access if fluid resuscitation or medication administration is needed. An 18g peripheral IV in the antecubital fossa is the first choice. If peripheral access fails in two attempts or the patient is in extremis, intraosseous (IO) access — tibial or humeral — provides immediate, reliable access and accepts all resuscitative medications and fluids.

Fluid Resuscitation

The goal of prehospital fluid resuscitation in penetrating hemorrhagic shock is permissive hypotension — administer just enough fluid to maintain a palpable radial pulse, targeting a mean arterial pressure of approximately 50 mmHg. Do not aggressively normalize blood pressure; over-resuscitation dilutes clotting factors, disrupts forming clots, and worsens coagulopathy.

Fluids of choice: Whole blood (far forward) is the gold standard. Packed red blood cells with fresh frozen plasma in 1:1 ratio when available. Lactated Ringer's (LR) as crystalloid fallback. Hextend (6% hetastarch) in limited quantities. Normal saline is last choice due to hyperchloremic acidosis risk.

TXA — Tranexamic Acid

TXA is a proven life-saving intervention in hemorrhagic shock. It inhibits fibrinolysis — the breakdown of blood clots — and significantly reduces mortality when given early. TCCC protocol: 1g IV over 10 minutes, followed by a second 1g dose over 8 hours. Must be given within 3 hours of injury — after 3 hours, TXA may increase mortality. Do not delay. If in doubt about timing, give it.

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Permissive Hypotension — TCCC Doctrine
Maintaining a systolic BP of approximately 80–90 mmHg (radial pulse present) in penetrating trauma reduces re-bleeding by not disrupting clot formation. This is accepted TCCC doctrine and differs from civilian trauma protocols. Do not chase a normal blood pressure in the field — that costs clots and lives.

Key Supplies

  • IV catheter kit: 18g × 1.25" catheter, extension set, tape
  • IO device: EZ-IO or FAST1 with appropriate needles
  • 500 mL Lactated Ringer's or Hextend
  • TXA: 1g/10 mL ampoule × 2, with 100 mL NS for infusion
  • Blood pressure cuff or pulse oximeter (capillary refill is field-sufficient)

Hypothermia — The Lethal Triad

Hypothermia, acidosis, and coagulopathy form the "lethal triad" of trauma death. Each amplifies the others: hypothermia impairs clotting enzymes, worsening coagulopathy; coagulopathy prolongs bleeding, worsening acidosis; acidosis further impairs cardiac function and clotting. Prevention is far more effective than treatment — once core temperature drops significantly, field reversal is nearly impossible.

Prevention steps: Remove wet clothing as soon as tactically feasible. Wrap the casualty in a heat-reflective emergency blanket or hypothermia prevention and management kit (HPMK). Cover the head — significant heat is lost through the scalp. Insulate from the ground using a sleeping pad, litter, or any available material. Warm IV fluids if available.

Head Injury (TBI)

Signs of TBI: Altered or declining level of consciousness (use GCS — Eye, Verbal, Motor), unequal or non-reactive pupils (suggests raised intracranial pressure), cerebrospinal fluid (CSF) leaking from ears or nose, persistent vomiting, combativeness without apparent cause.

Management: Protect and maintain the airway. Prevent hypoxia (SpO₂ ≄94%) and prevent hypotension — both dramatically worsen TBI outcomes. If no spinal injury is suspected, elevate the head of the litter to 30° to reduce intracranial pressure. Monitor GCS trend (improving, stable, or declining). Deteriorating GCS is a high-priority evacuation indicator.

Penetrating head injury: Cover the wound with a sterile dressing. Do not remove impaled objects — removal can precipitate catastrophic hemorrhage. Stabilize any impaled object in place and transport.

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BP and TBI — The Single Most Important Number
For TBI patients, every episode of hypotension doubles mortality. A single hypotensive event in the first hour after TBI is an independent predictor of death. Maintaining systolic BP ≄90 mmHg is the single most impactful field intervention for head-injured casualties — even above any medication or specific TBI treatment.

Key Supplies

  • Emergency thermal blanket (heat-reflective foil blanket) — minimum
  • Heat-reflective bivvy bag (HPMK) — preferred in cold environments
  • SAM splint or padded dressing for stabilizing impaled objects
  • Sterile dressings for open head wounds
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Reassess — MARCH Is a Loop, Not a Checklist
The MARCH sequence is a priority order, not a checklist you tick off once. Reassess the patient after completing H — loop back through M-A-R-C-H if condition changes. Tourniquets can be displaced, chest seals can fail, and hemodynamic status evolves. Continuous reassessment is the difference between a patient who survives to definitive care and one who doesn't.