Mark Tozer, PhD

Sunday, October 19, 2025

Understanding MARCH - The Relevance of Respiratory Assessment

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From the MARCH Mnemonic Series – Tactical Trauma Care for EMS Providers

After controlling massive hemorrhage and ensuring a patent airway, the next priority in the MARCH sequence is Respiration.

Effective breathing is critical for oxygen delivery and carbon dioxide removal. When trauma impairs the chest wall or lungs, hypoxia and shock can develop rapidly - even when the airway is clear.

In tactical or prehospital settings, respiratory compromise is often caused by thoracic injury, such as a gunshot, stab wound, or blast trauma.

These injuries can lead to life-threatening conditions like tension pneumothorax or open chest wounds, both of which are preventable causes of death when identified and treated early.

This article - the third in a five-part series - will focus on that next critical step:

R – Respiration

Respiration refers to the body’s ability to move air into and out of the lungs and to exchange gases at the alveolar level.

Any disruption - mechanical, anatomical, or physiological - can cause hypoxia and threaten survival.

The responder’s task is to rapidly assess, seal, decompress, and support breathing as needed.

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Principles of Respiratory Management

1. Assess the Casualty’s Breathing

Begin by evaluating rate, depth, and effort of respirations. Look, listen, and feel for:

Asymmetrical chest rise or movement

Difficulty speaking, gasping, or labored breathing

Cyanosis around lips or fingertips

Tracheal deviation, jugular venous distention, or subcutaneous emphysema

Penetrating trauma to the chest or upper abdomen

If you’re operating in a tactical environment, conduct this assessment as efficiently as safety allows—rapid but systematic.

2. Expose and Inspect for Chest Injuries

Visually inspect the anterior, lateral, and posterior thorax for entry and exit wounds, contusions, or deformities. In low-light or confined spaces, gloved hands may detect what the eyes can’t.

Sucking chest wounds (open pneumothorax) occur when air enters the pleural space through a chest wall defect.

These must be sealed immediately with a vented or occlusive chest seal to prevent the progression to tension pneumothorax.

Modern products like the HyFin® Vent Chest Seal or FoxSeal™ are designed for field reliability and are standard in most tactical trauma kits.

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3. Manage a Tension Pneumothorax

A tension pneumothorax occurs when air becomes trapped in the pleural space and cannot escape, collapsing the lung and compressing the heart and great vessels.
Signs may include:

Severe respiratory distress

Decreased or absent breath sounds on one side

Hypotension and tachycardia

Tracheal deviation (a late sign)

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Intervention:

If tension pneumothorax is suspected and equipment/training allow, perform needle decompression:

Use a 14-gauge, 3.25-inch (8.25 cm) needle or catheter.

Insert into the 5th intercostal space, anterior axillary line (or 2nd intercostal space, midclavicular line if indicated).

Listen for escaping air and observe for improvement in breathing and perfusion.

Always reassess, if symptoms recur, repeat decompression or prepare for chest tube insertion at higher care levels.

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4. Support Oxygenation and Ventilation

If available and appropriate, administer supplemental oxygen to maintain SpO₂ above 94%.

For inadequate respirations, assist with bag-valve-mask (BVM) ventilation while maintaining airway alignment. In prolonged field care, consider monitoring SpO₂ and ETCO₂, if resources allow, to guide ongoing management.

5. Continue Monitoring and Reassessment

The chest is dynamic, bleeding, air leakage, or mechanical disruption can recur with movement or time. Reassess chest rise, breath sounds, and patient condition frequently during evacuation.

Key Takeaway for EMS and Tactical Providers

Thoracic trauma demands vigilance. While hemorrhage and airway compromise often draw attention first, unrecognized respiratory failure can kill just as quickly. The tactical provider must be proficient in identifying chest injuries, applying chest seals, and performing needle decompression when indicated.

In short: find the holes, seal the leaks, relieve the pressure, and keep the oxygen moving.

Coming Up Next: Part Four – Circulation

Once bleeding is controlled, the airway is secure, and breathing is restored, it’s time to assess circulation—the body’s ability to perfuse vital organs.

In Part Four of our MARCH series, we’ll explore recognition and management of shock, fluid resuscitation strategies, and maintaining perfusion in both field and tactical environments.

Because after oxygen, the mission is to keep it flowing where it matters most.

Friday, October 17, 2025

Understanding MARCH - The Importance of Airway Management

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From the MARCH Mnemonic Series – Tactical Trauma Care for EMS Providers

Following the control of massive hemorrhage, the next lifesaving priority in the MARCH algorithm is Airway.

Without a patent airway, oxygen cannot reach the lungs, and death from hypoxia can occur within minutes.

While exsanguination kills fastest, airway obstruction follows closely - especially in cases of head or neck trauma, decreased consciousness, or maxillofacial injury.

In tactical environments, airway management must be both rapid and situationally appropriate. Providers balance lifesaving intervention with operational safety - sometimes working under fire or in low-light, resource-limited conditions.

This article - the second in a five-part series - will focus on that next critical step:

A – Airway Management

A patent airway is one that is open and unobstructed, allowing air to move freely in and out of the lungs. Even a partial obstruction can reduce oxygen delivery and lead to hypoxia, brain injury, or cardiac arrest.

According to the National Safety Council (2023), foreign-body airway obstruction remains the fourth leading cause of unintentional death in the United States - emphasizing the universal need for early recognition and decisive management.

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Principles of Airway Management

1. Assess the Airway Early

Assessment begins with observing the casualty’s level of consciousness, respiratory effort, and ability to speak or make sounds.

The simple question, “Can the patient talk?” remains one of the fastest airway assessments available.

Look and listen for:

Gurgling, snoring, or stridor
Facial or neck trauma
Blood, vomitus, or foreign bodies in the mouth
Absent or inadequate respiratory effort

In tactical settings, assessment must be efficient and, if under threat, may need to wait until the situation is secure enough to act safely.

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2. Basic Airway Maneuvers

If the airway is obstructed or compromised, begin with manual positioning techniques:

- Head-Tilt/Chin-Lift: For non-trauma patients who are unconscious and without suspected spinal injury.

- Jaw-Thrust: For trauma patients or when spinal injury cannot be ruled out.

- Recovery Position: For semi-conscious patients who can maintain their own airway but may vomit.

These simple maneuvers are often enough to restore airway patency temporarily and can be performed quickly even under fire or during evacuation.

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3. Airway Adjuncts

When manual techniques are insufficient, adjunctive devices can maintain airway patency:

- Nasopharyngeal Airway (NPA): Preferred in tactical and field care. Well tolerated in conscious or semiconscious patients and effective even with facial injuries (unless contraindicated by basilar skull fracture).

- Oropharyngeal Airway (OPA): Used only in unconscious patients without a gag reflex. Easy to insert and effective when bag-valve-mask (BVM) ventilation is required.

Advanced airways (e.g., supraglottic devices, endotracheal intubation, or surgical cricothyrotomy) may be indicated in prolonged field care or when BVM ventilation fails, but such interventions should align with provider scope and environment.

4. Clear and Control the Airway

If obstruction is caused by a foreign body, blood, or vomitus, clear it quickly:

- Perform the abdominal thrusts in conscious choking patients.

- Use suction, if available, to remove debris or fluids.

- If foreign-body airway obstruction persists in an unresponsive patient, begin CPR following standard resuscitation protocols.

In tactical contexts, effective airway control often means doing the basics well—not overcomplicating care but ensuring the airway remains open during extraction and evacuation.

5. Ongoing Monitoring and Reassessment

Airway status can change rapidly. A casualty who was breathing adequately moments ago may deteriorate due to swelling, bleeding, or decreased consciousness.

Reassess frequently- especially after movement or as the tactical situation changes.

Key Takeaway for EMS and Tactical Providers

Airway management is the second priority in the MARCH sequence, but it’s equally vital to survival. The tactical provider’s goal is to establish and maintain a patent airway using the simplest effective method appropriate to the situation.

In many cases, that means manual maneuvers and an NPA—reserving advanced interventions for when time, equipment, and safety allow.

In every case, the principle remains: “Keep it open, keep it simple, keep reassessing.”

Coming Up Next: Part Three – Respiration

With bleeding controlled and the airway secured, attention turns to respiration—assessing and managing chest injuries that can silently compromise ventilation and oxygenation.

Part Three of our MARCH series will explore the recognition and treatment of life-threatening thoracic trauma, including tension pneumothorax and open chest wounds.

When the airway is open but the chest can’t move air, the mission shifts to restoring the breath.

Wednesday, October 15, 2025

Understanding MARCH - A Tactical Approach to Massive Hemorrhage

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From the MARCH Mnemonic Series – Tactical Trauma Care for EMS Providers

In prehospital medicine, chaos is a constant. Whether in combat zones, tactical operations, or austere environments, responders need an effective method to prioritize lifesaving interventions.

The MARCH mnemonic provides that structure.

Used in Tactical Combat Casualty Care (TCCC) and increasingly adapted into Tactical Emergency Casualty Care (TECC), MARCH guides providers through the sequence of treating trauma in order of urgency:

M – Massive Hemorrhage

A – Airway

R – Respiration

C – Circulation

H – Hypothermia/Head Injury

Each step addresses a preventable cause of death, beginning with what kills fastest.

This article - the first in a five-part series - focuses on the first and most critical step:

M - Massive Hemorrhage.

Massive hemorrhage is the leading cause of preventable death in trauma. Life can be lost in minutes from uncontrolled bleeding, making rapid identification and intervention paramount.

Clinically, a massive hemorrhage may be defined as the loss of more than 50% of circulating blood volume within three hours, but in the field, it’s simpler: if it looks bad, treat it fast.

Principles of Care

1. Control the Bleed Immediately

Identify and manage life-threatening external bleeding before addressing airway or breathing. In tactical settings, hemorrhage control often occurs under fire or while the threat is active, emphasizing the importance of speed and training.

2. Direct Pressure

Apply firm, targeted pressure directly over the bleeding source using a gloved hand and dressing. Direct pressure remains the most reliable method of hemorrhage control and should be maintained until bleeding stops or another intervention takes effect.

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3. Tourniquet Application

If the bleeding is from an extremity and direct pressure fails, apply a commercially approved tourniquet as high and tight as possible, proximal to the wound. Tighten until the bleeding stops and document the time of application. Avoid improvised or untested devices, equipment failure can cost lives.

4. Hemostatic and Pressure Dressings

For junctional or compressible areas (e.g., the groin, axilla, or neck), use a hemostatic dressing and apply continuous firm pressure for at least three minutes or as directed by the manufacturer. Secure with a pressure dressing and reassess frequently.

5. Reassess Constantly

Bleeding control is not a one-and-done task. Reassess interventions after movement, transport, or environmental changes. Tourniquets can loosen, and pressure dressings can shift during casualty movement or extraction.

Key Takeaway for EMS and Tactical Providers

Massive hemorrhage is fast, silent, and deadly - but also the most preventable cause of battlefield and tactical death.

Responders must adopt a mindset of “Stop the bleed, then everything else.” Consistent training, reliable equipment, and disciplined reassessment make the difference between life and loss in tactical trauma care.

Coming Up Next: Part Two – Airway

Once life-threatening bleeding is controlled, the next critical step is ensuring the casualty can breathe.

In Part Two of our MARCH series, we’ll examine airway management in tactical and prehospital settings—covering essential assessment, manual maneuvers, airway adjuncts, and when to escalate to advanced interventions.

Because once the bleeding stops, oxygen is your next priority!

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