The Rapid Trauma Assessment
MARCH for Success
Patrick O’Neil, PA
In other articles, I explained why the ABCs of trauma treatment had fallen out of favor and was replaced by another treatment sequence. Now, I think it is really important to explain that this is not just Pat O’Neil’s personal opinion of how things should be done. The Committee on Tactical Combat Casualty Care (CoTCCC) made the recommendation to change the treatment sequence many years ago. This body of medical experts relied on years of trauma data gathered in both the civilian and military sectors. They came to the conclusion that we had been doing it wrong all these years, and came up with a new treatment sequence.
The sequence I am going to describe, is the MARCH sequence. Other courses may use a different acronym, but I find this is the easiest one to remember. I have seen it described as CABCH, HABC, and a couple of others. I believe in keeping it simple; so MARCH is what you will learn here.
The Preventable Causes of Death are what we will concentrate on. Hemorrhage, Airway, Tension Pneumothorax, and Hypothermia. The data shows that if we maximize our training and treat for these four occurrences, we will stand the greatest chance of saving our patient.
The MARCH Trauma Treatment Sequence
M – MASSIVE BLEEDING
Without a doubt, the number one preventable cause of death was uncontrolled hemorrhage. Specifically, controlling massive blood loss from an arterial bleeder. It cannot be emphasized enough that it is absolutely crucial to “keep the red stuff inside the body.” Without blood, your tissues will not receive enough oxygen, your blood pressure will drop and no longer perfuse vital organs, the heart rate will increase dramatically, and much more. An arterial bleed is characterized by pulsatile bleeding. In other words, every time your heart beats blood squirts from the wound. Sometimes this pulsatile “squirting” can be quite dramatic and will shoot across the room. To give you an idea how quickly someone can bleed out from an arterial wound, think about this: The femoral artery runs down both thighs. If this artery is cut, you can lose up to 1.5 liters of fluid per minute. Your body only holds 5-6 liters of blood. A patient can easily bleed out within a few minutes. This is why Massive (or arterial) bleeding is the first thing that must be addressed. If it is pumping or squirting blood out, you had better make that a priority, and I mean right now!
A – AIRWAY
When the CoTCCC looked at the data, they found that the second and third most common causes of death were due to Airway and Tension Pneumothorax. The results were so close that it was decided to maintain the treatment sequence as most of us had previously learned, with Airway taking priority over Respirations. Airway is important and just because it was moved down in priority does not lessen the fact that you will die if you cannot get air into your lungs. And this is the definition of Airway control: Having an open passage from your lips down to your lungs, so that air can pass freely. The actual breathing part with the lungs comes in the Respiration phase. Without an airway, a patient can lose consciousness very quickly, especially if they have been participating in a physical activity. I am sure most of us have seen a Mixed Martial Arts fight where an opponent has their airway blocked and has to “tap out” or “pass out.” When physically active, your body requires more oxygen and thus you will pass out more quickly if that airway is occluded for even 30 seconds. At rest, when a person is calm, they may last several minutes before losing consciousness, and some may even go for longer periods if they have trained in breath holding techniques. But, for a general rule, let’s say 90 seconds to two minutes for most people. This is why I agree with placing this second in the treatment sequence.
R – RESPIRATIONS
This is the mechanical action of breathing and the exchange of oxygen and carbon dioxide within the tissues of the lungs. (Another reason why Airway was given higher priority. If you can’t get air into the lungs, you can’t have a successful respiration.) There are a host of things that can lead to death here. Tension pneumothorax will cause pressure to rise within the chest cavity, collapsing the lung. That pressure will continue to increase until it starts to collapse the other lung and then the heart. It is not a good prognosis for the patient if you have two collapsed lungs and a heart.
C – CIRCULATION
Ok, so this may sound a bit hokey, but we needed to come back and address bleeding once more. “But wait, Pat, we already did this in the first step, right?” No, we addressed “arterial bleeding” in the first step. Now we need to take the time in the sequence to address non-arterial bleeding. This would be the venous and capillary bleeding that we have going on. With venous and capillary bleeding, it doesn’t come squirting out with each heartbeat. Venous bleeding flows out of the body. Don’t get me wrong, it can still make a big puddle on the ground; but at a much slower rate than arterial bleeding. The bottom line here is: I have time to get to venous or capillary bleeding. It IS a priority, but I can wait to tackle this until I have addressed the more important items listed in the MARCH sequence
H – HYPOTHERMIA
Trauma patients lose their ability to control their body temperature. This cannot be emphasized enough. The CoTCCC recognized that a cool patient could cause problems with blood clotting appropriately, with the acid base balance of the body, and in overall survivability. It is important to keep a trauma patient warm. It is a huge morale killer when you have done a great job keeping the patient alive by performing a great trauma sequence with all the appropriate lifesaving interventions; only to have the patient succumb to the effects of hypothermia.
Now that we have discussed the MARCH treatment sequence, we have opened up Pandora’s Box for further information. As you attempt to navigate the way forward, I would start off with the following classes:
► Training for Medical Emergencies: This is going to set the stage for the proper mindset as you go forward in the training process
► Hemorrhage Control: Compressible Arterial Hemorrhage, Non-compressible Arterial Hemorrhage, Venous and Capillary Hemorrhage Control
► Airway techniques: Chin Lift – Jaw Thrust, improvised airways, recovery positions
► Hypothermia prevention
► Splinting techniques for possible fractures
► MARCH sequence video: What “Right” looks like. This video will show you the proper sequence and interventions to save a trauma patient.