EMS A to Z: The MARCH Algorithm

Show Notes:

From your hosts, Dr. Josh Gaither, Dr. Amber Rice, and Dr. Rachel Munn

The MARCH approach to patient assessment: 

M – massive hemorrhage: evaluate for and stop all significant bleeding with direct pressure, tourniquet, or pressure dressing

A – airway: assess for airway obstruction, then chin lift to open airway; consider NPA, ETI, cricothyrotomy depending on resources, practice environment, etc.

R – respirations: assess work of breathing and oxygenation, then provide supplemental oxygen, assist ventilations, needle decompression  

C – circulation: evaluate circulation and begin resuscitation 

H – head injury / hypothermia: evaluate for TBI / neurologic disability, prevent or treat hypothermia  

I like to add “naked” to the end, making it “march naked” to remind us that we need to fully undress / assess trauma patients, and then cover them back up immediately to prevent hypothermia as we’ve discussed. 

 

Let’s review bleeding control:

How do you properly place a tourniquet?

Where does it go: proximal to the injury, but it doesn’t have to be as high as the adage of “high and tight” would suggest.

You may have to undo the tourniquet to place it, depending on the injury.

Making it as tight as possible with the velcro is ideal, and then tightening further with the winless. 

The tourniquet should be tight enough that a distal pulse is no longer palpable, or if in an amputation, the bleeding has stopped. 

Remember to time it if you can.

A tourniquet can be on for at least 2 hours, possibly longer, without significant tissue damage.

They are PAINFUL; administer pain meds if you can. 

How do you properly pack a wound or place a pressure dressing? 

If you have a deep, bleeding wound, and cannot keep direct pressure using a finger, then you may need to pack the wound and / or place a pressure dressing.

If packing the wound, clean gauze should be directed to the depth of the wound bed and continue to be layered in the wound until the entire cavity is filled tightly. Make note of how many rolls of gauze you used.

If using a pressure dressing, use folded or packed gauze to create a focal point for the pressure, then wrap the ace around. 

What can we do for pelvic injuries?

A pelvic binder may help reduce bleeding and prevent further injury in a pelvic fracture.

A pitfall with placing pelvic binders is that we often place them too high; they should sit over the greater trochanter / essentially the top of the femur, not the top of the pelvic bones. 

Chest

While we can relieve a tension pneumo in the field, the other chest injuries / sources of bleeding typically require the bright lights and cold steel of an ED / OR.