MARCH Protocol
Tactical Combat Casualty Care — Primary Assessment
M
Massive Hemorrhage
- Expose and identify all bleeding sources
- Tourniquet — apply high and tight on limb bleeds, note time
- Wound pack with hemostatic gauze for junctional/neck wounds
- Maintain firm pressure 3–5 minutes
A
Airway
- Check for gurgling, snoring, stridor, no movement
- Responsive: position on side, chin forward
- Unconscious: insert NPA (nose to ear measurement), lubricate first
- Last resort: surgical cricothyrotomy
R
Respiration
- Check rate, depth, symmetry of chest rise
- Sucking chest wound: apply vented chest seal on exhale
- Tension pneumothorax (absent breath sounds + shock): needle decompression 2nd ICS MCL
- Target: 12–20 breaths/min
C
Circulation
- Check radial pulse — absent = systolic <80 mmHg
- Recheck all hemorrhage control before fluids
- IV/IO access — 18G antecubital or proximal tibia
- Target palpable radial pulse only (permissive hypotension)
- TXA 1g IV if within 3 hours of injury
H
Hypothermia Prevention
- Insulate from ground — largest single source of heat loss
- Remove wet/blood-soaked clothing
- Wrap in HPMK, space blanket, or any available dry insulation
- Warm IV fluids to body temperature before infusion
S-CABCDE
Civilian Systematic Trauma Assessment
S
Scene Safety
- 360° scan before approaching — traffic, fire, structural, hazmat
- Establish safety perimeter, keep bystanders back
- Call emergency services before patient contact
- PPE — gloves minimum, eye protection if blood splash risk
C
Catastrophic Hemorrhage
- Identify all life-threatening external bleeds
- Tourniquet for limb bleeding, proximal to wound
- Direct pressure with dressings for all other bleeds
- Hemostatic gauze for deep or junctional wounds
A
Airway
- Is patient speaking? → airway patent
- No spinal concern: head-tilt chin-lift
- Spinal concern: jaw thrust only
- Suction blood/vomit. OPA if no gag, NPA if gag present
B
Breathing
- Rate, depth, symmetry — normal 12–20/min
- Auscultate if stethoscope available
- SpO₂ target: >94% (COPD: >88%)
- Chest seal for open wounds, needle decompression for tension PTX
C
Circulation
- Pulse rate, strength, cap refill (<2 sec normal)
- Class III shock: HR >120, hypotension, confusion, cold skin
- IV access, controlled fluid resuscitation
- Permissive hypotension in hemorrhagic shock
D
Disability (Neuro)
- AVPU: Alert / Voice / Pain / Unresponsive
- GCS 8 or below → consider intubation
- Pupils: unequal fixed = raised ICP, emergency
- Blood glucose — always check, treat <4 mmol/L
E
Exposure / Environment
- Remove clothing, inspect all surfaces front and back
- Log roll — assess spine, back, buttocks, axillae, groin
- Cover and insulate immediately after inspection
- Core temp, pain score, scene documentation