M – Massive Hemorrhage

The first thing we must do is control any massive hemorrhage. We are looking for blood that is spurting out under pressure or gushing out. We are not concerned with small sources of bleeding.

The most effective way to check a patient for massive hemorrhage is by doing a blood sweep. You are looking for “wet, red, and a lot.” If you locate a source of significant bleeding, you must immediately take steps to stop it. You could stop this bleeding by using a tourniquet or packing a wound.

• Tourniquets are for use on extremities ONLY. If you CANNOT easily see the source of the bleeding, you should place the tourniquet “high and tight” on the limb. If you CAN see the source of the bleed, place the tourniquet a few inches above the source of the bleed. Notes:
• Tourniquets CAN be placed on the lower part of a limb. It is a myth that you cannot put it on the lower arm or leg due to an inability to “compress the bones.” That is not how it works. A tourniquet works by compressing a vessel against something rigid. This happens by pressuring all of the tissue together and compressing the vein or artery in a lower extremity.
• NEVER place a tourniquet over a joint.

Tourniquets are used to buy time to perform well-aimed direct pressure. It is possible to remove a tourniquet later if you can convert it to a less aggressive form of hemorrhage control.

Wound packing is done in junctional areas: the sides of the neck, the armpits, and the groin. Wound packing is not done to absorb blood or help to clot. It works by filling the wound cavity and creating pressure against the tissue inside a wound sufficient to stop bleeding. It is an aggressive procedure but relatively easy to perform.

You should keep one finger inside the wound cavity and avoid switching fingers (like a sewing machine). The reason is that you would repeatedly be relaxing pressure on the source of the bleed once you have it controlled. Also, you should maintain control of the packing material. Try to prevent it from laying on the ground where it can pick up organic materials like sticks and soil.

A – Airway

You need to ensure the airway is open, secure, and intact. Most of the time, this is simply repositioning the head or the patient to remove any kinks in the airway. Unless there is trauma to the airway or the patient’s mental status is significantly compromised, they should move air naturally. If you note the patient is “snoring” or making stressed breathing sounds, check the position of the airway and correct if necessary.

You should check for penetrating trauma into the chest wall, both left and right sides, and the patient’s front and back. If there are any openings, you need to seal them immediately with a vented chest seal. If you do not have a commercial chest seal, you can form one with a piece of flexible plastic (like an MRE bag or plastic wrap) that is anchored on three sides.

R – Respiration

Ensure the patient has adequate respirations. Normal breathing for an adult is 12-20 respirations per minute. They should be full, smooth, and regular. If the patient is breathing too slow or too fast, and they are cyanotic (turning blue) or have an Altered Mental Status, you may need to perform rescue breaths.

C – Circulation

Does the patient have a pulse? We will check for a radial pulse first. If we cannot find a radial pulse, we will check the carotid artery. At this point, we are NOT trying to count the rate. We just want to confirm that a pulse is present. If the pulse is not found, we should begin CPR. Current recommendation is compression only.

H – Head & Hypothermia

What we are assessing at this point is the patient’s level of consciousness (LOC) and mental status (MS), as well as the integrity and stability of the spinal cord and spinal column.

We can think of the LOC as a measurement of how conscious or unconscious someone is, as well as to “what degree.” AVPU is a commonly used medical acronym to define the level of consciousness and mental status.

A – awake.

• If the patient is awake, then we need to assess their mental status. If they are:
• Acting normal, AND can answer questions AND are aware of their surroundings; then they have a “Normal Mental Status.”
• A patient who is awake but NOT acting normal, OR not able to answer questions OR not aware of their surroundings, then they have an “Altered Mental Status.”
• A patient that is not awake/unconscious has an Altered Level of Consciousness. Further assessment is done to determine the severity:

V – verbally responsive.

If the patient is not awake but makes some attempt to respond to a verbal command like “Open your eyes,” “Squeeze my hand,” or “Move your fingers,” that patient is “verbally responsive.”

P – pain responsive.

If the patient is not awake, does not respond to verbal commands but DOES react to pain, they are said to be “pain responsive.” You can perform a sternal rub or triceps pinch. A patient that is pain responsive will try to move away from the pain or will indicate with a verbal response like a moan.

U – unresponsive.

An unresponsive patient is not awake, does not respond to verbal commands or painful stimulus.

Remember: the patient’s consciousness and mental status can change very quickly or very slowly and get better and then worsen. This means you need to pay attention to your patient and continuously engage with them.

The second concern is the spine. You should not move patients with an uncertain or positive mechanism for spine injuries until we can do a further assessment. The only time this would not apply is for an airway problem or a safety issue.

Our final concern in the last step of MARCH is treating the patient for hypothermia. Patients that are on the ground are losing heat. They may be compromised in many ways, and hypothermic patients have worse outcomes and longer recoveries. You should take steps to improve your patient’s exposure to the environment by protecting them from the ground and further heat loss.