MARCH: treat what kills first

A significant share of trauma deaths could be prevented with immediate, correct care. Almost all of them come down to three causes, and all three can be treated with simple techniques. The problem is time.

The three preventable deaths

Cause	Time to death	What treats it
Arterial hemorrhage of a limb or junctional area	2 to 4 minutes	Tourniquet, wound packing, direct pressure
Compromised airway	4 to 6 minutes	Positioning, maneuvers, nasopharyngeal airway
Tension pneumothorax	More than 10 minutes	Chest seal; decompression (medical level)

The figure. Hemorrhage accounts for about nine out of ten potentially preventable deaths. A casualty with an arterial bleed in the thigh can die before anyone gets to assess their breathing.

The five letters

Once the direct threat is over, assessment and treatment follow a fixed order:

Letter	What is done
M · Massive hemorrhage	Control life-threatening bleeding.
A · Airway	Open it and keep it open.
R · Respiration	Treat chest injuries that prevent breathing.
C · Circulation	Recognize shock and look for undetected bleeding.
H · Hypothermia and head injury	Prevent heat loss and protect the brain.

And then, PAWS

Once life threats are controlled: pain, antibiotics (medical level), wounds and splinting of fractures. Some texts add an E, for “everything else”: eyes, burns and all other injuries.

An order of lethality, not a checklist

What looks worst is not what kills

An open fracture looks more dramatic than a small wound in the armpit, but it is the armpit that can kill in minutes. Under stress we tend to treat what is most striking; the MARCH order exists to correct that bias.

Several hands, same order

With several responders, several letters can be addressed at once. The order still sets what cannot be left undone.

Start again

MARCH is not run through just once. Every time the casualty is moved, gets worse or receives a treatment, you go back to M: a tourniquet can loosen during a drag and an open airway can close again.

The principles of tactical care

• Safety first: no intervention justifies creating another casualty.

• What kills first, first: massive hemorrhage comes before everything else.

• Only what is needed in each phase: other interventions wait.

• Always reassess: every change means going back to M.

• Record and communicate: the information travels with the casualty.

• Reach definitive care: get the casualty to the right hospital alive.

Some deaths cannot be prevented with the resources available in the field, such as severe brain or heart injuries or massive internal bleeding in the chest and abdomen. In those cases, the responder can still recognize the problem early and speed up evacuation.

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Note

This content is for general information. It does not qualify anyone to perform the interventions described, nor does it replace in-person training with supervised practice. Medical-level techniques are reserved for trained and authorized healthcare personnel, in accordance with each service’s protocols.

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