MARCH Algorithm: Massive Hemorrhage, Airway, Respiration, Circulation, Hypothermia
The MARCH algorithm from Tactical Combat Casualty Care: why it treats massive bleeding before the airway, what each letter covers, and how it lines up with XABCDE in civilian EMS.
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MARCH is the order of treatment for an injured patient taught in Tactical Combat Casualty Care (TCCC) and in many civilian tactical and trauma courses. It stands for Massive hemorrhage, Airway, Respiration, Circulation, and Hypothermia and Head injury. Its defining feature is that it treats catastrophic bleeding before the airway, because a patient can bleed to death from a limb wound in a few minutes, faster than most airway problems kill.
Where MARCH comes from
TCCC is the set of trauma care guidelines developed for the US military and maintained by the Committee on Tactical Combat Casualty Care (CoTCCC), which revises them as evidence changes. It grew out of military casualty studies that found hemorrhage to be the leading cause of potentially preventable death on the battlefield, and bleeding from the limbs to be among the most preventable of those deaths. Civilian guidelines adapted from it, Tactical Emergency Casualty Care (TECC), apply the same thinking to active-violence incidents and other civilian high-threat scenes.
| TCCC phase | TECC name | What happens |
|---|---|---|
| Care under fire | Direct threat care | The threat is still active. Move to cover and control massive limb bleeding, usually with a tourniquet. Little else is done here. |
| Tactical field care | Indirect threat care | The immediate threat is suppressed. This is where the MARCH sequence is worked through in full. |
| Tactical evacuation care | Evacuation care | The casualty is being moved to definitive care. MARCH is repeated and care continues with more equipment and people. |
The five letters
| Letter | Stands for | What you check | What you do, in principle |
|---|---|---|---|
| M | Massive hemorrhage | Life-threatening external bleeding: spurting or pooling blood, a soaked dressing or clothing, an amputation | A tourniquet for limb bleeding; wound packing and firm pressure for a junctional wound (the neck, armpit or groin); direct pressure everywhere else |
| A | Airway | Is the airway open? Is the casualty talking? Blood, broken teeth or facial injury in the way? | Let a conscious casualty sit up or take whatever position best protects their own airway where spinal motion restriction is not needed, per protocol. Position and a nasopharyngeal airway for an unconscious casualty whose airway is at risk. A surgical airway (cricothyrotomy) is a paramedic skill in systems whose protocols include it, and is not within EMT scope. |
| R | Respiration | Chest injury, open chest wounds, breathing rate and effort, signs of a tension pneumothorax | Seal open chest wounds, with a vented chest seal where available, and support ventilation if breathing is inadequate. Decompressing a tension pneumothorax is within paramedic scope under protocol in many systems and is not an EMT skill; an EMT recognizes it, burps a chest seal and requests ALS. |
| C | Circulation | Every tourniquet and bleeding site again, other bleeding, signs of shock: mental status, radial pulse, skin | Reassess and tighten or add to bleeding control. Bind the pelvis for a suspected pelvic fracture. Vascular access and resuscitation as your protocol directs; TCCC favors blood products over other fluids where they are available. |
| H | Hypothermia and head injury | Exposure to cold, wet clothing, the ground; level of consciousness and signs of a head injury | Keep the casualty warm from the start, even in a warm climate. For a head injury, prevent low oxygen and low blood pressure, both of which worsen brain injury. |
Under A, in a suspected basilar skull fracture or major midface injury, see the caution in our Airway Adjuncts guide before placing a nasopharyngeal airway; your protocol decides.
Some versions split the last letter into two, H1 for hypothermia and H2 for head injury, and some courses add other letters. The core five are the same in all of them.
Why massive bleeding goes before the airway
The traditional order of ABC, airway, breathing and circulation, puts the airway first because a blocked airway kills in minutes. A severed artery in a limb can kill faster than that, and controlling it takes seconds with a tourniquet or firm pressure. MARCH moves massive bleeding to the front for that reason. It does not mean the airway matters less. On a patient with no catastrophic bleeding, the M takes a moment to clear and you move straight on to the airway.
MARCH and XABCDE
Civilian trauma teaching made the same change. Many curricula now teach life-threatening external bleeding before the airway, and PHTLS uses the order XABCDE, with X for exsanguinating hemorrhage. MARCH's M and XABCDE's X are the same idea. The two sequences then differ mainly in how they divide the rest, as the table shows. Check the order your program and the NREMT trauma skill sheet expect, and use it consistently; our Scene Size-Up and Primary Assessment guide covers XABCDE step by step.
| MARCH | XABCDE | Traditional ABC |
|---|---|---|
| M: massive hemorrhage | X: exsanguinating hemorrhage | Bleeding is handled under circulation, after the airway and breathing |
| A: airway | A: airway | A: airway |
| R: respiration | B: breathing | B: breathing |
| C: circulation | C: circulation | C: circulation |
| H: hypothermia and head injury | D: disability, and E: exposure, then cover to prevent heat loss | Disability and exposure follow in most versions |
Controlling massive bleeding
These are principles taught in TCCC, TECC and public bleeding control courses. Which devices you carry and exactly how you use them are set by your protocol and your training.
Tourniquets
- Use a tourniquet for life-threatening bleeding from an arm or a leg, or an amputation, as soon as you recognize it.
- Under threat, or when you cannot quickly find the wound, place it high on the limb. Otherwise place it on the limb above the wound, not over a joint, following your protocol.
- Tighten it until the bleeding stops and the pulse below it is gone. A loose tourniquet can make bleeding worse by blocking the veins and not the arteries.
- If one tourniquet does not stop the bleeding, apply a second above the first.
- Write the time it went on, on the tourniquet or the patient, and tell the receiving team.
- Do not loosen it to check the wound, and do not cover it so it cannot be seen. Whether and when a tourniquet is loosened or converted to another method is a decision for trained providers under protocol and for the receiving team.
- A tourniquet hurts. That is not a reason to loosen it.
Wound packing and pressure
- Bleeding from the neck, armpit or groin cannot take a limb tourniquet. These are junctional wounds, and they are packed.
- An open wound of the neck is also covered with an occlusive dressing, because an open neck vein can draw in air.
- Find the source of bleeding, then pack gauze tightly into the wound against it, filling the wound cavity. Hemostatic gauze, which helps blood clot, is used where it is carried; plain gauze also works.
- Hold firm direct pressure over the packed wound. TCCC teaches at least three minutes of pressure after packing a hemostatic dressing.
- Then apply a pressure dressing, and reassess for bleeding through it.
- Junctional tourniquets, devices designed to compress the groin or armpit, exist and some services carry them.
- For bleeding that is serious but not massive, firm direct pressure is usually enough, and it is the first thing anyone can do.
After MARCH: PAWS
TCCC continues the sequence after MARCH with PAWS: Pain, Antibiotics, Wounds and Splinting, often written MARCH-PAWS. It is a military sequence for prolonged field care. Pain control is part of civilian EMS care too, under your protocol; battlefield antibiotics are not part of most civilian EMS protocols. Wound care and splinting belong in any secondary assessment.
MARCH in civilian EMS
- Tactical EMS teams, and EMS working with law enforcement at active-violence incidents, commonly use MARCH because the injuries and the scene resemble the ones TCCC was written for.
- In a mass-casualty incident with penetrating injuries, stopping massive bleeding is one of the few treatments given during triage. Our START triage guide and tool cover sorting patients.
- Public bleeding control training, such as Stop the Bleed, teaches the M of MARCH to bystanders: pressure, packing and tourniquets.
- Most civilian EMS curricula, and the NREMT trauma skill sheet, use an XABCDE or ABC order. The principle is the same; use the order your program teaches.
The short version
- MARCH: Massive hemorrhage, Airway, Respiration, Circulation, and Hypothermia and Head injury. It comes from Tactical Combat Casualty Care.
- It treats catastrophic bleeding first, because a limb bleed can kill faster than most airway problems. XABCDE's X is the same idea in civilian teaching.
- Limb bleeding: a tourniquet, tight enough to stop the bleeding and the distal pulse, with the time written down. Junctional bleeding: pack tightly and press hard.
- Respiration: seal open chest wounds and watch for tension pneumothorax.
- Circulation: reassess every bleeding site and look for shock.
- Hypothermia and head injury: keep the patient warm, and prevent low oxygen and low blood pressure.