I love to make things easy to remember and repeat, because our job requires us to remember more than we have the ability to. We all learned that the ABC acronym (airway, breathing, circulation) is the most globally accepted approach to medical assessments, and some might argue that CAB (circulation, airway, breathing) is the most renowned for trauma. I would like to take this a bit further and clear the air in trauma assessment.
When the U.S. military started operations in Afghanistan, something simplistic was created to aid combat medics in fast trauma assessment and life-saving interventions: MARCH stands for massive hemorrhage, airway, respiratory, circulation, head injury/hypothermia.
MARCH broken down
On arrival, you evaluate a patient for trauma. The most notable, life-threatening condition is massive hemorrhage. Massive hemorrhage can kill people faster than an airway complication, because we don’t have much blood in the first place.
Depending on the location of the wound, direct pressure, pressure dressing, wound packing with or without a hemostatic agent or tourniquets will fix the problem.
Moving on to airway, you can evaluate the need for any type of adjunct. You still are in lifesaving mode, so you only have a few options. The most noninvasive is the head tilt/chin lift or jaw thrust maneuver. You also have the ability for quick airways, such as nasopharyngeal airways, or iGel, intubation or surgical cricothyrotomy. All of this is situational based off of the number of patients and allocated resources that are on scene to manage the patient post-intervention.
With respirations, you assess the adequacy of the patient’s ventilatory effort and manage life-threating conditions. If your patient shows signs of a tension pneumothorax, you must employ either chest needle decompression to the second intercostal space, midclavicular, or in the fifth intercostal space, either mid- or anteroaxillary. Also consider conducting a simple finger thoracostomy in the fifth intercostal midaxillary line, which is quite the process for starting a chest tube but without inserting said tube.
If the patient has a sucking chest wound, a vented chest seal is most appropriate, to relieve the pressure as needed.
Circulation is administration of either an IV or an IO to replenish fluids from exsanguination (massive bleeding). Patients benefit mostly from blood products, such as whole blood, or a combination of red blood cells, plasma and platelets. Obviously, this depends on timely access to those.
If patients only receive normal saline solution (in the world of trauma, we call it pasta water), the patient can become more acidotic and hypothermic, which cause difficulties in clotting and long-term outcome.
When administering fluids, you want to maintain a mean arterial pressure, or MAP, of 65, which means that the entire body is being perfused. If you increase the pressure, the patient will be fluid-overloaded, and clots will be dislodged from the structure they are secured to.
Hypothermia isn’t treated in trauma nearly as well as it should be. A good rule of thumb is that if you are transporting your patient in ambulance and you aren’t sweating, your patient is too cold. Keep the patient warm with blankets above and below. Becoming hypothermic is extremely detrimental for the capability to clot.
If a patient has a head injury, you might need to increase MAP pressure to approximately 110 to overcome the increased intercranial pressure in the head.
Saving more lives
Once you practice the MARCH process and procedures, you will become a much more comfortable/competent provider for trauma cases. I encourage you to sign up for a Tactical Combat/Emergency Casualty Care (TCCC/TECC) course and really refine your abilities to treat trauma patients with current trauma treatment standards. With appropriate knowledge on trauma, many more lives will be saved.
