7.2 MARCH PAWS Assessment: Massive Hemorrhage and Airway Management

MARCH PAWS Assessment: Massive Hemorrhage and Airway Management

Core Doctrine: Modern tactical casualty care under TC 4-02.1 and ATP 4-02.83 organizes battlefield assessment through the MARCH PAWS mnemonic. Designed by the Committee on Tactical Combat Casualty Care (CoTCCC), MARCH PAWS establishes a rigorous clinical sequence that prioritizes combat trauma interventions based strictly on their potential to prevent battlefield mortality.

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1. The Tactical Paradigm: Why MARCH Replaces Civilian ABCs

For generations, basic life support taught the civilian "ABCs" (Airway, Breathing, Circulation). While appropriate for medical emergencies such as myocardial infarctions or strokes in suburban homes, the ABC paradigm fails on the battlefield. Arterial bleeding from a severed femoral or axillary artery causes irreversible hemorrhagic shock and exsanguination within 60 to 90 seconds.

By contrast, complete airway obstruction typically requires 4 to 6 minutes to cause irreversible brain death, and tension pneumothorax develops over tens of minutes. Placing airway assessment ahead of hemorrhage control causes responders to fiddle with airways while a casualty bleeds to death into their uniform. MARCH repositions life-saving priorities to match terminal trauma mechanics:

   CIVILIAN EMS PARADIGM                   TACTICAL COMBAT CASUALTY CARE (TCCC)
   ──────────────────────────────          ────────────────────────────────────
   A — Airway                              M — Massive Hemorrhage (Stop blood loss NOW)
   B — Breathing                           A — Airway (Secure patent airway)
   C — Circulation                         R — Respiration (Seal chest & decompress)
   D — Disability                          C — Circulation (Pelvic sling & pulses)
   E — Exposure                            H — Hypothermia Prevention (Warm the blood)
                                           ────────────────────────────────────
                                           PAWS SECONDARY SEQUENCE:
                                           P — Pain Management (CWMP / Analgesia)
                                           A — Antibiotics (Infection prophylaxis)
                                           W — Wounds (Dressings & eye shields)
                                           S — Splinting (Fracture immobilization)

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2. M — Massive Hemorrhage: Identification and Mechanics

The initial action upon transitioning to Tactical Field Care is identifying and arresting all life-threatening external bleeding. Responders perform a rapid, aggressive blood sweep using gloved hands to rake behind the casualty's neck, axillae, groin, and extremities.

Clinical Indicators of Massive Hemorrhage:

• Bright red pulsatile or spurting blood emerging from a wound.
• Continuous pooling of blood on the ground or litter beneath the casualty.
• Overlying clothing or battle dress uniform completely soaked with dark or arterial blood.
• Traumatic partial or complete amputation of an arm or leg.
• Previously applied dressings or improvised wraps saturated and actively leaking.

Deliberate Tourniquet Application Mechanics (TFC Phase)

Unlike the hasty "high and tight" tourniquet placed over clothing during Care Under Fire, a deliberate tourniquet placed during Tactical Field Care adheres to strict anatomical guidelines:

1. Expose the wound: Cut away clothing to clearly visualize the bleeding site.
2. Anatomical landmark: Place the tourniquet 2 to 3 inches above the proximal margin of the wound directly against the skin. Never place a tourniquet directly over an anatomical joint (knee or elbow); if the wound is 1 inch below a joint, place the tourniquet 2 inches above the joint.
3. Eliminate slack: Pull the self-adhering band as tightly as humanly possible before engaging the windlass rod. Eliminating circumferential slack is the single most critical factor in successful tourniquet application; loose straps require excessive windlass rotations and lead to mechanical failure.
4. Twist the windlass rod: Turn the windlass until all bright red bleeding stops and the distal pulse (radial or dorsalis pedis) is completely absent. A tourniquet that stops venous oozing but allows an arterial pulse to persist will engorge the limb and accelerate blood loss.
5. Lock the rod: Secure the windlass rod inside the windlass clip.
6. Route strap and secure: Pass the remaining band over the rod and through the clip, then fasten the white windlass safety strap.
7. Document time: Record the exact time of application on the white strap and casualty's forehead with an indelible marker using military 24-hour format: "T = HHMM" (e.g., "T = 1425").

   INSUFFICIENT HEMOSTASIS (SECOND TOURNIQUET DOCTRINE)
   ─────────────────────────────────────────────────────────────────
   If the initial deliberate tourniquet is tightened completely but
   arterial bleeding continues or the distal pulse remains palpable:
   • DO NOT remove the initial tourniquet.
   • Apply a SECOND CoTCCC tourniquet immediately adjacent and
     proximal (above) to the first tourniquet.
   • Tighten the second tourniquet until bleeding is fully arrested.
   ─────────────────────────────────────────────────────────────────

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3. Junctional Hemorrhage Management

Junctional hemorrhage refers to life-threatening bleeding occurring at the junctions of the extremities and the torso: the inguinal region (groin), the axilla (armpit/shoulder), and the base of the neck. Because these anatomical regions lack a cylindrical bony framework, standard extremity limb tourniquets cannot be effectively seated.

Specialized Junctional Equipment

When available, specialized CoTCCC-recommended junctional tourniquets must be applied:

• Junctional Emergency Treatment Tool (JETT): Features two adjustable compression pads targeting the common femoral and external iliac arteries in the groin.
• SAM Junctional Tourniquet (SJT): Utilizes targeted pneumatic Target Compression Devices (TCDs) to occlude junctional vessels in the inguinal or axillary spaces.
• Combat Ready Clamp (CRoC): A mechanical clamp system that provides stable, hands-free osseous compression against the pelvic or shoulder girdle.

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4. Wound Packing and Hemostatic Gauze Techniques

When junctional tourniquets are unavailable, or for deep cavitary wounds in the groin, buttocks, or axilla, wound packing with hemostatic gauze is the mandatory tactical treatment.

   HEMOSTATIC DRESSING STANDARDS (CoTCCC APPROVED)
   ─────────────────────────────────────────────────────────────────
   Agent                   Mechanism of Action          Heat Generation
   ─────────────────────────────────────────────────────────────────
   QuikClot Combat Gauze   Kaolin (mineral activates    NONE (Safe)
                           Factor XII intrinsic cascade)
   
   Celox Gauze /           Chitosan (positively charged NONE (Safe)
   ChitoGauze              crustacean polymer binds 
                           negatively charged RBCs)
   
   Standard Gauze          Mechanical mesh only         NONE
   (Non-hemostatic)        (relies on natural clot)
   ─────────────────────────────────────────────────────────────────

Step-by-Step Wound Packing Technique:

1. Wipe away pooled blood: Rapidly sweep fingers inside the wound cavity to clear clots, identifying the exact deep bleeding source (arterial pulsation or tear against bone).
2. Anchor the gauze: Unroll the hemostatic gauze. Take the working end, form a small ball with fingers, and pack it directly against the bleeding vessel deep against the bone.
3. Pack tightly to bone: Continue feeding gauze into the cavity incrementally, maintaining constant downward pressure with the opposing hand. The cavity must be packed tightly until the entire wound space is filled above the level of the skin.
4. Apply direct manual pressure: Once the cavity is packed, apply continuous, uninterrupted, firm manual pressure directly over the wound for a minimum of 3 minutes when using hemostatic gauze (QuikClot Combat Gauze). If standard non-hemostatic gauze is used, manual pressure must be held for a minimum of 5 minutes.
5. Secure with pressure bandage: Without releasing manual compression, wrap an elastic pressure bandage (such as the Emergency Bandage / Israeli Bandage) firmly over the packed site, anchoring the pressure bar directly over the wound packing to maintain continuous tension.

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5. A — Airway Management: Assessment and Primary Interventions

Once massive hemorrhage is arrested, the responder immediately shifts focus to the casualty's airway. An obstructed airway rapidly leads to hypoxia, hypercapnia, and terminal cardiac arrest.

Airway Patency Assessment

• Check responsiveness: Assess the casualty using the AVPU scale (Alert, Verbal, Pain, Unresponsive). Ask a direct question: "Soldier, are you hit? Where does it hurt?"
• Vocal response present: If the casualty answers clearly and coherently, their airway is patent, ventilation is adequate, and brain perfusion is preserved. Reassess frequently.
• Snoring, gurgling, or stridor: Audible snoring indicates upper airway collapse (tongue occluding the posterior pharynx). Gurgling indicates fluid, vomit, or blood in the airway. Stridor indicates high-grade laryngeal obstruction.

Manual Airway Maneuvers

• Conscious / Non-Trauma Casualty: Perform the head-tilt chin-lift maneuver.
• Suspected Cervical Spine or Blast Trauma: Perform the modified jaw-thrust maneuver. Rescuers place fingers behind the angles of the casualty's mandible and displace the jaw anteriorly without extending the cervical spine.
• Clear the oral cavity: Inspect the mouth and perform a sweeping finger sweep to clear dislodged teeth, bone fragments, blood clots, or vomit. Never perform a blind finger sweep into the hypopharynx.

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6. Nasopharyngeal Airway (NPA) Insertion Mechanics

The Nasopharyngeal Airway (NPA) (typically a 28 French flexible tube in military IFAKs) is the primary tactical airway adjunct for soldiers in the field. It is exceptionally well-tolerated and can be placed in both unconscious casualties and semi-conscious casualties who retain an intact gag reflex.

   NASOPHARYNGEAL AIRWAY (NPA) CLINICAL SUMMARY
   ─────────────────────────────────────────────────────────────────
   Indications:       • Unconscious casualty with spontaneous respirations
                      • Conscious casualty with airway compromise or snoring
                      • Inability to maintain airway independently
   
   Contraindications: • Severe midface trauma with suspected basilar skull
                        fracture (risk of cranial vault penetration)
                      • Clear cerebrospinal fluid (CSF) leaking from nose/ears
   ─────────────────────────────────────────────────────────────────

Step-by-Step NPA Placement Procedure:

1. Position the casualty: Place the casualty supine with the head in a neutral position.
2. Lubricate the tube: Liberally apply water-soluble surgical lubricant or the casualty's own saliva to the outside of the NPA tube.
3. Select nostril and align: Select the right nostril first (anatomically larger and straighter in 85% of adults). Orient the NPA so that the bevel faces the nasal septum (the flat, angled opening faces the midline of the nose).
4. Advance along the nasal floor: Insert the tip into the naris and advance the tube straight back along the floor of the nasal passage, perpendicular to the face, following the natural curve of the hard palate. Never push upward toward the eyes or brain.
5. Overcoming resistance: If mild resistance is encountered, gently rotate the tube between thumb and forefinger. If significant resistance persists, withdraw the NPA, re-lubricate, and attempt insertion into the left nostril (orienting the bevel to face the septum, which may require rotating the tube 180 degrees upon entering the pharynx).
6. Seat the flange: Advance the tube until the flared flange rests flush against the outer nostril opening. Secure with tape or a safety pin if necessary.

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7. Positioning: The Lateral Recumbent Recovery Position

Any unconscious or semi-conscious casualty breathing spontaneously who does not require active airway intervention should immediately be placed in the lateral recumbent recovery position (turned onto their side):

• Mechanism: Gravity pulls the tongue forward, preventing it from occluding the hypopharynx.
• Aspiration Protection: Vomitus, saliva, and blood drain freely out of the dependent corner of the mouth rather than being aspirated into the trachea and lungs.
• Tactical Advantage: Allows the provider to monitor breathing while maintaining hands-free security or attending to other casualties.

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8. Worked Clinical Scenario: Point-of-Injury Hemostasis and Airway Control

To understand how these protocols integrate seamlessly under operational conditions, consider the following combat vignette:

Tactical Scenario

During an urban clearing operation, a squad comes under sniper fire from an elevated compound. Specialist Davis sustains a penetrating high-velocity gunshot wound to the proximal right medial thigh. Specialist Davis collapses behind a low cinderblock retaining wall while the squad suppresses the sniper.

   STEP-BY-STEP CLINICAL WORKFLOW AT POINT OF INJURY
   ─────────────────────────────────────────────────────────────────
   Phase 1: CUF      • Specialist Davis drags himself behind the wall.
                     • Rescuer confirms no effective hostile fire at wall.
                     • Squad achieves local fire superiority.
   
   Phase 2: TFC      • Provider cuts away bloody right ACU trouser leg.
   (Massive          • Identifies high femoral wound with spurting arterial bleed.
    Hemorrhage)      • Places deliberate CAT tourniquet 2 inches above wound.
                     • Rotates windlass 3 full turns; bleeding ceases;
                       distal dorsalis pedis pulse completely abolished.
                     • Fastens strap; writes 'T = 0942' on white band.
   
   Phase 2: TFC      • Provider checks groin: secondary blast fragment wound
   (Junctional        in right inguinal crease actively pooling blood.
    Packing)         • Packs QuikClot Combat Gauze tightly into inguinal void
                       directly against pubic ramus.
                     • Holds continuous manual compression for 3 minutes.
                     • Anchors with Emergency Bandage pressure dressing.
   
   Phase 2: TFC      • Davis becomes unresponsive; provider notes loud snoring.
   (Airway)          • Performs modified jaw-thrust; snoring resolves.
                     • Inspects oral cavity; clears small blood clot.
                     • Lubricates 28 Fr NPA; inserts along floor of right naris
                       with bevel facing septum until flange rests on naris.
                     • Rolls Davis into lateral recumbent recovery position.
                     • Rechecks femoral tourniquet: stable, no bleeding.
   ─────────────────────────────────────────────────────────────────