The MARCH algorithm is laid out differently from Advanced Trauma Life Support (ATLS) which uses Airway, Breathing, and Circulation (ABC’s) as the order of treatment to instead use Massive Hemorrhage, Airway, Respiration, Circulation, Hypothermia/Head Injury for prioritizing lifesaving treatments.

The “C” portion of the MARCH acronym refers to the broad topic of Circulation. In the context of MARCH, circulation covers a wide gamut of responsibilities, from assessing for hemorrhagic shock to administering blood transfusions to non-blood-based fluid replacements like Tranexamic Acid (TXA). However, the “C” phase is also an opportunity to “SEE”, i.e. Not just LOOK at our patient, but to really SEE our patient.

In TCCC, we use the “C” phase to expose and reassess the need and effectiveness of our previous efforts and “SEE” the overall view of our patient’s status. In the “C” (or “See”) portion, we use a discriminate eye to determine and answer the following:

1. Does the method of injury indicate that we should stabilize the pelvis?

2. If we used a tourniquet, did the injury need it?

3. How is our tourniquet placement? If you performed a hasty tourniquet application in a care under fire circumstance, can we apply a new device now two to three inches above the wound directly on the skin?

4. Can we safely perform a tourniquet conversion to a pressure dressing if the situation warrants it?

5. Have we marked times of application on the tourniquet(s) we applied or converted?

6. Do we see signs of hemorrhagic shock such as altered mental status in the absence of brain injury?

7. Do we need to gain IV access?

8. Is fluid replacement or TXA applicable?

9. Field blood transfusion?

10. Blood product administration?

11. Is blood loss even the culprit behind the symptoms we are observing with our patient?

The circulation phase is where these deeper dive questions get answered, and we must use the “C” phase to “See” the answers.

Tools to Aid in Circulation

TacMed Solutions™ offers a variety of products built to help with this circulatory emergencies including the TacMed™ Vascular Access Kit (VAK), the Compact Syringe Kit, the Field Blood Transfusion Kit, the Saline Lock Kit (SLK), the IV Evaporative Cooling System (IVECS™), and more. To stock your kit with these essential tools, check out TacMed Solutions™ at tacmedsolutions.com/collections/m-a-r-c-h-tccc/circulation.

The MARCH algorithm is laid out differently from Advanced Trauma Life Support (ATLS) which used Airway, Breathing, and Circulation (ABC’s) as the order of treatment. MARCH stands for Massive Hemorrhage, Airway, Respiration, Circulation, Hypothermia/Head injury. Respiration consists of penetrating thoracic trauma.

When it comes to penetrating thoracic trauma, it is important to systematically check the entire torso for wounds, from the umbilicus to the clavicle, including the axillae and any folds of skin. Medics often use a raking motion in opposite or off angle directions to assist in identifying difficult to see or smaller wounds.

An open chest wound, sometimes referred to as a “sucking chest wound”, will trap air in the chest, creating a pneumothorax. If too much air builds up, it will create enough pressure to become a tension pneumothorax, which can lead to decreased function in the non-injured lung and heart and could lead to death.

According to the Committee on Tactical Combat Casualty Care, assessing and treating tension pneumothorax should progress as follows:

Suspect a tension pneumothorax and treat when a casualty has significant torso trauma or primary blast injury and one or more of the following:

• Severe or progressive respiratory distress

• Severe or progressive tachypnea

• Absent or markedly decreased breath sounds on one side of the chest

• Hemoglobin oxygen saturation < 90% on pulse oximetry

• Shock

• Traumatic cardiac arrest without obviously fatal wounds

If not treated promptly, tension pneumothorax may progress from respiratory distress to shock and traumatic cardiac arrest.

All open and/or sucking chest wounds should be treated by immediately applying a vented chest seal to cover the defect. If a vented chest seal is not available, use a non-vented chest seal. If you must use a non-vented chest seal, then you must be vigilant in continued patient assessment, as air from the damaged lung may continue to build up inside the chest. For the layperson, this means “burping” the dressing to release air. For providers, this means needle decompression, finger thoracotomy, or tube thoracostomy.

Initial treatment of suspected tension pneumothorax:

• If the casualty has a chest seal in place, burp or remove the chest seal.

• Establish pulse oximetry monitoring.

o All individuals with moderate/severe TBI should be monitored with pulse oximetry. Readings may be misleading in the settings of shock or marked hypothermia.

• Place the casualty in the supine or recovery position unless he or she is conscious and needs to sit up to help keep the airway clear as a result of maxillofacial trauma.

• Decompress the chest on the side of the injury with a 14-gauge or a 10-gauge, 3.25-inch needle/catheter unit.

• If a casualty has significant torso trauma or primary blast injury and is in traumatic cardiac arrest (no pulse, no respirations, no response to painful stimuli, no other signs of life), decompress both sides of the chest before discontinuing treatment.

o Either the 5th intercostal space (ICS) in the anterior axillary line (AAL) or the 2nd ICS in the mid-clavicular line (MCL) may be used for needle decompression (NDC.)  If the anterior (MCL) site is used, do not insert the needle medial to the nipple line.

o The needle/catheter unit should be inserted at an angle perpendicular to the chest wall and just over the top of the lower rib at the insertion site. Insert the needle/catheter unit all the way to the hub and hold it in place for 5-10 seconds to allow decompression to occur.

o After the NDC has been performed, remove the needle and leave the catheter in place.

The NDC should be considered successful if:

• Respiratory distress improves, OR

• There is an obvious hissing sound as air escapes from the chest when NDC is performed (this may be difficult to appreciate in high-noise environments), OR

• Hemoglobin oxygen saturation increases to 90% or greater (note that this may take several minutes and may not happen at altitude), OR

• A casualty with no vital signs has return of consciousness and/or ` radial pulse.

If the initial NDC fails to improve the casualty’s signs/symptoms from the suspected tension pneumothorax:

• Perform a second NDC on the same side of the chest at whichever of the two recommended sites was not previously used. Use a new needle/catheter unit for the second attempt.

• Consider, based on the mechanism of injury and physical findings, whether decompression of the opposite side of the chest may be needed.

• Continue to re-assess!

If the initial NDC was successful, but symptoms later recur:

Perform another NDC at the same site that was used previously. Use a new needle/catheter unit for the repeat NDC.

• Continue to re-assess!

If the second NDC is also not successful:

• Continue on to the Circulation section of the TCCC Guidelines.

These recommendations are from the TCCC Guidelines which can be found at: www.deployedmedicine.com/content/40

Tools to Aid in Respiration

TacMed™ Solutions offers a variety of products built to help with this respiratory emergencies including HALO™ Chest Seals, TPAKS for Needle Decompression, a Standard and Complete Chest Tube Kit, a Basic Chest Wound Kit and more. To stock your kit with essential tools, check out TacMed™ Solutions at tacmedsolutions.com/collections/m-a-r-c-h-tccc/respiratory.

A dryer, a toilet, a flashlight, and a refrigerator door. Although you may not be an expert on these items, you could probably find out how to fix them all by watching a YouTube video. But can you expect the same success by watching a video or taking an online course on a trauma-related skill? Let’s try and figure it out.

Over the years, trauma and austere medicine is often described as a contact sport; let’s face it, when things get hectic, you have got to get in there and get your hands dirty. However, to do this well, you need competent instruction. You will probably not be able to achieve this through online education alone. While online training has its strengths, it’s a poor substitute for quality in-person training for trauma medicine. It all comes down to getting your hands dirty, and that is where online training loses out. Having a competent instructor watching you or watching them demonstrate a task (especially one that you might have to perform under stress) is still not replicable online.

That’s not to say online training is without benefits. For example, in today’s pandemic, factors like ease of access, cost-effectiveness, and social distancing sometimes make online training the only option available for staying current or improving your skills. Here are some ways to use online training to augment and enhance your knowledge, skills, and even improve your in-person sessions:

Pre-Training Materials:

Online materials like videos, PDFs, or PowerPoint presentations you provided to students or read before attending the class. Having a better understanding of the subject before training cuts down on time spent hammering in on more straightforward topics and allows you and the instructor to focus on the more complex subjects.

Post-Training Materials:

Online training works great to refresh our memory after hands-on training is over and later provides reference materials for study.

As you build your skills in trauma medicine, in-person training with a competent trainer teaching solid, evidence-based instruction should always be your first choice. However, using online training to augment this will only make you a more qualified provider in the long run.

At TacMed™, we offer TMS University™, our online training portal, for e-learning and information-sharing to find relevant information of pre-hospital trauma treatment and equipment. This online platform is a great opportunity to have better knowledge pre-training and serves as a great tool to refresh your memory post-training.

For access to TMS University™, check out tacmedsolutions.com/tms-university.