M.A.R.C.H. - Massive Hemorrhage

M.A.R.C.H. - What is Massive Hemorrhage?

Massive hemorrhage is the number one potentially survivable cause of death at the point of injury (POI). This includes life threatening bleeding from a compressible wound and/or extremity injuries. More than 90 percent of 4,596 combat deaths after September 11, 2001 were a result of hemorrhage-associated injuries. There are many opinions and definitions of what should be considered massive hemorrhage. They include color of the blood and rate of loss but most of these are hard to qualify and quantify under the stress of the scenario combined in some cases with the operational environment and tactical context. There is always a focus of bright red bleeding vs dark red and while one is more important that the other, they both should be addressed immediately. Additionally, penetrating trauma is not selective and commonly injures both arteries and veins which present externally as a mix of bright red and dark red blood.  The nature of serious bleeding leaves little time to consult the paint chart obtained from the local hardware store to compare colors and develop an appropriate treatment plan. Apply pressure! Pressure stops all bleeding.

Massive Hemorrhage in the Extremities

The hasty application of a tourniquet is the recommended management for all life-threatening extremity hemorrhage during the care under fire (CUF) phase. It should be placed immediately over clothing, if necessary, proximal to the wound and high and tight. During the tactical field care (TFC) phase, the deliberate application of a tourniquet is addressed when the threat has been suppressed and/or aid is being rendered behind cover to ensure proper hemorrhage control. In this phase, the tourniquet is placed against the skin, 2 to 3 inches above the wound. In either scenario the application time is written on the tourniquet at some point before the patient is evacuated or handoff is performed. Additionally, if one tourniquet is not able to control the bleeding, a second tourniquet can be placed adjacent to the first to obtain occlusion. Splinting and immobilizing the extremity after a tourniquet and pressure dressing have been applied will assist with hemostasis but should only be done after all life threats have been addressed using the MARCH algorithm and other associated treatment protocols.

External Compressible Hemorrhage

Bleeding that is not amenable to limb tourniquet use should be treated first using direct pressure in the TFC Phase until a hemostatic dressing can be applied to pack the wound. Once the bleeding is controlled, pressure should be maintained according to the manufacturer’s recommendation using manual compression, pressure dressings, or other commercially available devices.