M.A.R.C.H. is an acronym representing a standardized, sequential approach to prioritizing care in severe trauma situations. This system dictates the specific order in which injuries must be addressed to maximize a patient’s chance of survival. It provides a methodical framework for first responders and medical personnel to manage multiple life-threatening injuries effectively.
The Shift in Trauma Prioritization
For many years, the standard protocol for trauma care was the A-B-C sequence: Airway, Breathing, and Circulation. This framework was widely taught in civilian first aid and emergency medicine. However, military medical experience revealed a significant flaw in this prioritization, particularly in cases of severe penetrating trauma.
The traditional A-B-C approach meant responders focused on securing the airway before addressing severe blood loss. This delay proved deadly because massive external bleeding can cause death in minutes. The need to address this preventable death first led to the development of M.A.R.C.H., which emerged from the Tactical Combat Casualty Care (TCCC) guidelines. M.A.R.C.H. places immediate hemorrhage control above all other interventions.
M.A.R.C.H.: The Life-Saving Acronym
M.A.R.C.H. stands for Massive Hemorrhage, Airway, Respiration, Circulation, and Head Injury/Hypothermia. This sequence is structured to address the most immediate threats to life first, based on how quickly each injury can cause death. Following this order ensures the patient’s physiology is stabilized before moving to the next intervention.
M – Massive Hemorrhage
The “M” stands for massive hemorrhage, which is catastrophic blood loss that can lead to death within minutes. This is the first step because uncontrolled bleeding is the most frequent cause of preventable death in trauma. Actions involve quickly identifying and stopping all life-threatening external bleeding from compressible wounds, such as those on the limbs.
Responders apply a tourniquet high and tight on an injured extremity to stop arterial flow. For bleeding in areas where a tourniquet cannot be placed, such as the groin or armpit, specialized hemostatic dressings and direct pressure or wound packing are used. Stopping the massive leak of blood buys time for the patient to receive advanced medical care.
A – Airway
Once massive hemorrhage is controlled, the next priority is the airway, ensuring the patient can move air into their lungs. If the patient is conscious and speaking clearly, the airway is likely open. If they are unresponsive or showing signs of obstruction, immediate intervention is necessary.
Actions involve simple maneuvers like the head-tilt/chin-lift or jaw-thrust to reposition the tongue, a common obstruction in unconscious patients. If these methods fail, a responder may insert a nasopharyngeal airway to create a clear passage. Managing the airway may require a surgical airway in severe cases where the upper airway is damaged or blocked.
R – Respiration
Respiration focuses on the mechanics of breathing and ensuring the lungs are functioning properly. This involves assessing the chest for injuries that prevent effective oxygen exchange, such as open chest wounds or a collapsed lung. A tension pneumothorax occurs when air leaks into the chest cavity, compressing the lung and heart.
Open chest wounds are sealed immediately with specialized chest seals to prevent air from entering the chest cavity. If a tension pneumothorax is suspected, a needle decompression procedure is performed to release the trapped air and allow the lung to re-expand. This restores the patient’s ability to breathe and circulate oxygenated blood.
C – Circulation
The circulation step addresses less severe bleeding, assesses for shock, and initiates fluid replacement. This involves checking for a radial pulse to estimate blood pressure and assess circulatory status. Establishing intravenous (IV) or intraosseous (IO) access is a priority to administer fluids and medications.
Fluid resuscitation is initiated, often using blood products to replace lost volume and improve clotting ability. This step also includes checking for other sources of internal bleeding. The goal is to correct the state of shock caused by blood loss, where the body’s tissues are not receiving enough oxygen.
H – Head Injury/Hypothermia
The final letter, “H,” addresses both head injury and hypothermia, managed after immediate threats to life are stabilized. A severe head injury, or traumatic brain injury, is assessed by checking the patient’s level of consciousness and pupil response. Preventing a drop in blood pressure and oxygen to the brain is a goal to avoid secondary brain damage.
Hypothermia, a dangerously low core body temperature, is a frequent complication in trauma patients, especially those who have lost blood. Prevention involves removing wet clothing and insulating the patient with thermal blankets to maintain body heat. Maintaining a normal body temperature is directly related to a patient’s ability to clot blood, making this a later step in survival.
Understanding the Sequential Importance
The strict M \(\rightarrow\) H order is based on preventing the most rapid causes of death first. Massive hemorrhage is placed first because a person can bleed out and die in minutes, overriding the need for a clear airway or effective breathing. Controlling catastrophic bleeding effectively stops the clock on the patient’s survival.
Once blood loss is stopped, the focus shifts to ensuring the patient can receive and use oxygen through the Airway and Respiration steps. An open airway and functioning lungs are useless without circulating blood volume to carry oxygen to the tissues. The Circulation step then aims to restore the volume and pressure lost from the initial hemorrhage.
The Head Injury/Hypothermia step addresses conditions that, while not immediately fatal, impact long-term recovery and survival if left untreated. This sequential prioritization ensures treatment is logical and maximizes the benefit of each intervention. M.A.R.C.H. functions as a standardized algorithm for efficiently managing severe trauma.