MARCH Algorithm - Trauma Prioritization
The MARCH algorithm is extremely helpful to remember if you are a first responder or simply want to be prepared to help others in the event of a car accident, gunshot wound, penetrating trauma, or other bleeding emergency. MARCH is the standard for Tactical Combat Casualty Care as explained in the TCCC handbook (Chapter 4), and is used all over the world for tactical field care and advanced trauma life support.
What Is the MARCH Algorithm?
MARCH is a mnemonic device that stands for “massive hemorrhage, airway, respiration, circulation, hypothermia/head injury.” This easily memorized algorithm, developed by special operations forces in 1996, is used to help first responders prioritize the most critical injuries first when treating trauma patients.
After the September 11th, 2001 attacks, the US and its allies began implementing these Tactical Combat Casualty Care instructions in training for wound care. However, anyone can learn these proven steps and keep a bleeding control kit in their car, at home, and at work for better outcomes in cases of traumatic injuries.
A Note about the “MARCH PAWS” Mnemonic
The MARCH mnemonic device is followed by PAWS in the TCCC handbook. The “PAWS” part of the mnemonic is used once the patient is stable. It stands for “pain management, antibiotics, wound management, and splinting.”
1. Massive Hemorrhage
The first letter in M.A.R.C.H. stands for “massive hemorrhage.” Treating massive hemorrhage is the first priority when treating a trauma patient. There is not much time before the body loses too much blood and goes into hemorrhagic shock, so it is of utmost importance to be able to recognize and treat massive bleeding effectively to decrease casualty rates.
What Is a Massive Hemorrhage?
One of the ways to define a massive hemorrhage is 50% of the circulating blood volume lost in a three-hour time frame. This type of hemorrhage can quickly turn into a casualty if bleeding is not immediately curbed. Quick thinking and quick action are required to improve outcomes.
How to Treat a Massive Hemorrhage in an Extremity
When assessing a patient with a massive hemorrhage in an extremity, the primary goal is to curb the bleeding as quickly as possible. Here are three simple steps to help in this situation:
- Apply Direct Pressure: The first step is to apply firm pressure to the wound using a sterile cloth or dressing. This will aid in blood clotting. Call—or send someone to call—the emergency medical services while pressure is being applied.
- Elevate the Extremity: Elevating the area of the hemorrhage above the heart helps reduce the blood flow to the injury. This helps with hemorrhage control and aids in clot formation.
- Tourniquet Application: If the application of direct pressure and elevation fails to decrease bleeding in a minute or two, apply a tourniquet to decrease circulation to the extremity as quickly as possible. A limb tourniquet should be placed on the heart side of the wound, tightened until the bleeding stops, and secured and labeled with the time of application. There are many tourniquets that can be purchased either online or from retail stores. However, make sure to buy your tourniquet(s) from a reputable trauma kit retailer as cheap knockoffs could fail when the time comes.
How to Treat an External Compressible Hemorrhage
Compressible hemorrhages are hemorrhages that can be controlled with external pressure and are located on parts of the body besides the limbs. This could include a head injury, wounds on the torso, or wounds on the neck.
As you can’t apply a tourniquet to the head, neck, or torso, you’ll need to take a different approach. After applying firm pressure to the site, apply a hemostatic dressing to the wound to accelerate clotting. Once the bleeding is contained, continue to maintain pressure.
2. Airway
The second letter in M.A.R.C.H. stands for "airway." Patients need a patent airway to survive. A patent airway is an open airway through which air can flow freely. Casualty rates increase with an obstruction in the airway. According to the National Safety Council Statistics, foreign-body airway obstruction is the 4th leading cause of unintentional death. Because of this, it is extremely important to check for normal breathing patterns and respiration rates and assess for any airway obstruction that may be present.
If someone is able to breathe on their own, they should! If they are conscious but have an obstruction, they may need basic maneuvers such as the Heimlich maneuver or CPR. If the person is unconscious, they may need a simple head tilt and jaw thrust to open their airway.
3. Respiration
The third letter in the M.A.R.C.H. mnemonic device stands for “respiration.” Assisting patients with breathing can move more air as well as lessen the injured person’s respiratory effort.
- If you are medically trained, assess the person's rate, depth, and quality of breathing. Supplemental oxygen may be needed to reduce the chances of death.
- When a first responder assesses the respiratory system for needed treatment, it’s important to look for chest trauma or a sucking chest wound. These injuries can be treated with chest seals, such as the HyFin Compact Vent Chest Seals that are included in the intermediate and premium versions of our bleeding control kit.
- First responders will need to check for a tension pneumothorax and may use needle decompression if one is present.
4. Circulation
The fourth letter in M.A.R.C.H. stands for “circulation.” One should check for pulse, blood pressure, and other non-life-threatening bleeding. In typical combat tactical field care, blood pressure cuffs are not used. However, shock casualties are addressed in this assessment by checking for a weak or absent radial pulse as well as an altered mental status.
5a. Hypothermia
A large amount of blood loss can cause a drop in body temperature leading to hypothermia. Look for the following symptoms to identify low body temperature:
- Shivering
- Cold skin
- Pale or bluish skin color
- Slurred speech
- Slow breaths
If possible, take the person's temperature and note if it is below 95 degrees Fahrenheit. Consider environmental factors surrounding the patient that can cause hypothermia such as wind, wet clothing, or low temperatures. If needed, cover him or her with clothes or blankets to reduce heat loss and the chance of developing hypothermia.
5b. Head Trauma
Head trauma is the second term to remember with the “H” in M.A.R.C.H. Patients with head trauma should be observed for the following symptoms:
- Decreases in levels of consciousness
- Pupil dilation
- Regular blood pressure and oxygen stats
- Hypothermia
- Specific penetrating trauma to the head
Remember the MARCH Algorithm to Save a Life
Commit to memory the life-saving “MARCH” algorithm: massive hemorrhage, airway, respiration, circulation, hypothermia/head trauma. This simple word should be a top priority when thinking of first aid tips for evidence-based life-preserving tactics that minimize preventable death. Using this simple mnemonic device helps first responders recognize life threats and respond quickly—and can be useful for lay rescuers as well.
Whether you are a first responder such as a firefighter or EMS worker, a combat caregiver, or someone who is interested in self-aid, the MARCH mnemonic device is on point for delivering effective trauma care. As we learn from MARCH, assess the patient for the most critical issues first and continue supporting the patient with evidence-based interventions until more help arrives.
