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MARCH Protocol

Tactical Combat Casualty Care — Primary Trauma Assessment

M
Massive Hemorrhage Act first
  • Expose wound — cut clothing away, identify all bleed sites
  • Limb bleeding: tourniquet high and tight, windlass until bleeding stops, record time
  • Junctional / cavity: pack deep with hemostatic gauze (Combat Gauze/Celox), firm pressure 3–5 min
  • Pelvic fracture: circumferential binder or improvised wrap at greater trochanters
⚡ Fear of tourniquets kills. Safe up to 2 hours. Apply, note time, move on.
A
Airway
  • Conscious, talking: monitor, position on side
  • Snoring/gurgling (AVPU: V/P): NPA — measure nostril to earlobe, lubricate, insert bevel to septum
  • Unconscious, no gag: supraglottic airway (i-gel/King LT)
  • Can't intubate, can't oxygenate: surgical cricothyrotomy — cricothyroid membrane, vertical skin, horizontal membrane, insert tube
⚡ NPA contraindicated only with clear evidence of basilar skull fracture (Battle's sign, CSF leak).
R
Respiration
  • Rate, depth, symmetry — normal 12–20/min
  • Sucking chest wound: vented chest seal on exhale — monitor for tension development
  • Tension PTX (absent sounds + shock + tracheal deviation): needle decompression 2nd ICS MCL or 5th ICS AAL
  • If seal applied and breathing worsens → release one edge, needle decompress
⚡ Chest seal + patient worsens = tension PTX. Burp the seal or needle decompress immediately.
C
Circulation
  • Recheck all hemorrhage control before fluids
  • Radial pulse absent = systolic <80 mmHg — establish IV/IO
  • Target: palpable radial pulse only — NOT normal BP (permissive hypotension)
  • Warm Ringer's Lactate or whole blood — cold fluids worsen coagulopathy
  • TXA: 1g IV over 10 min — must give within 3 hours of injury
⚡ Radial = >80. Femoral only = 60–70. Carotid only = 50–60. No cuff needed.
H
Hypothermia Prevention
  • Insulate from ground first — pad, pack, cardboard, anything
  • Cut away wet/blood-soaked clothing — wet fabric = 25× more heat loss
  • HPMK or space blanket wrapping all exposed surfaces
  • Warm IV fluids to body temp — store bags inside clothing before use
⚡ At 34°C core temp, 30% of clotting is gone. Wrap early, wrap aggressively.
Train online at medready.io — MARCH/TCCC scenarios
Training reference only · CoTCCC Guidelines