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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.
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 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.
Further Reading:
