Trauma Assessment MARCH

MARCH

There are several common mnemonics in trauma assessments. All have the same principle, which is to find and treat all major life threats as quickly as possible. For this text, we will be using MARCH which is adopted from Tactical Combat Casualty Care (“T-Triple-C ”), as it is the most up-to-date assessment tool as of the writing of this text. MARCH stands for:

• Massive hemorrhage
• Airway
• Respirations
• Circulation & C-spine
• Head injury / Hypothermia

We will use the MARCH mnemonic for all trauma with a significant Mechanism of Injury “MOI” or where we determine the patient may be suffering from life-threatening injuries. The MOI is a combination of scene clues and patient assessment that increase index of suspicion for injury patterns and potential hazards. The MOI does not always perfectly match the injury found but can give us clues to update our mental model and triage or appreciate the severity. Our mental model as we approach our patient points to a general impression of the patient’s condition. The general impression is one or two words to describe the severity of the patient and can be anywhere from mild distress as would be the case in a broken toe, to critical in the case of GSW to the chest. There is little scientific about our general impression however, it is a step in our assessment that highlights our awareness of the patient’s condition.

As you approach the patient, introduce yourself in a calm and reassuring voice. Something like “My name is Jada. I’m here to help. Where are you hurt?”. The patient response, or lack thereof tells us the patient’s Level of Responsiveness (LOR). LOR is measured using the mnemonic AVPU, standing for Alert, Verbal, Painful, and Unresponsive, more on this in a second. The patient’s LOR gives us an indication of severity, further developing our Mental Model.

Getting closer, observe for Massive Hemorrhage and control obvious life-threatening bleeding. Remember, as the team lead you can choose to delegate this task to a member of your team. Sometimes massive hemorrhage is obvious as it may be spurting or in the form of a pool of blood. However, don’t forget about the blood you cannot see; there are massive internal hemorrhaging signs to look for too. These come in the form of swelling, contusion, pt stating thirst, and of course skin signs such as diaphoresis.

As resources allow the next step in MARCH is to assess and manage Airway. This step can be done simultaneously with massive hemorrhage control if resources allow. The team leader should be to quickly assess the airway. The airway may be intact as is the case when they verbally respond to your introduction or may be obstructed by the tongue, blood, teeth or vomit.

When massive hemorrhage and airway have been assessed and addressed by the team, the next task is to assess and manage Respirations. Say this out loud, “One instance of hypoxia a major trauma patient significantly increases the risk of mortality.”

After respirations, the next priority is Circulation & C-Spine. At this step, the team lead or other delegate will “cut and cover” to expose an appropriate amount of a critical trauma patient. We “cut” to remove clothing to inspect and palpate for additional bleeding. Certain cases of including entrapment, remote cold-weather rescue, active shooter, or potentially unsafe scenes may limit the EMS team’s ability to remove clothing. This should be the exception, not the rule.

Every red blood cell matters in major trauma. Our patient needs every hemoglobin cell to carry Oxygen and remove carbon dioxide. Remember, one instance of hypoxia (or in the case of hemorrhagic shock, relative hypoxia) in a major trauma patient significantly increases the risk of mortality.

C-Spine is short for “cervical spine”. In this step the team leader will also evaluate the need and delegate tasks to begin the process of spinal immobilization.

To assess for major bleeding, we need to take a systematic approach, moving from head to toe, exposing and re-covering sections of the body. Some instructors will refer to this process as a “blood sweep”, “trunk check”, or “rapid trauma” but they all refer to the same step in the assessment process.

The blood sweep can be done in several appropriate ways. However, the authors of this text believe in the following order as it focuses on areas where large, life-threatening bleeding is most possible and is easy to remember. If life-threatening injuries are discovered and they are treatable within the EMT scope of practice. The team leader should immediately delegate appropriate treatments.

• Head – run fingers through hair looking for bleeding.
• Neck – palpate the neck, look for bleeding.
• Chest – expose and assess for equal rise/fall by placing the sides of the hands below the nipple line during respirations, look for bleeding, sucking chest wounds and flail segments.
• Abd – expose and look for major bleeding.
• Pelvis & genitals – assess for major bleeding, priapism, and pelvis stability.
• Legs – Expose femurs for bleeding and assess for isolated femur fractures.
• Arms – assess for major bleeding.
• Back – assessed as the patient is positioned for transport.

For this part of the assessment, we are only looking for life-threats that our team can manage on scene. We may discover distracting injuries, such as a deformity to an extremity or a bone protruding from the skin. Keep in mind that secondary injuries, or non-life-threatening injuries should not be managed on scene. These secondary injuries, such as deformities or deglovings to name a few, should be addressed only after all major life threats have been addressed and preferably during transport, and not while on scene.

Head injury assessments come along with talking to the patient. Key first interactions should include introducing yourself, asking what happened, and what hurts. Their responses should lead you to a quick AVPU assessment. AVPU stands for Alert, Verbal, Painful, and Unresponsive. The details of their response will be further articulated in a GCS assessment in the back of the ambulance. While on scene, simply talking your patient about their condition and through what is happening next is sufficient.

Next, we will control/treat/prevent hypothermia by keeping the patient warm by keeping them covered with a blanket and taking appropriate steps to move to the back of the ambulance where we can turn on the heat. One instance of hypothermia in major trauma results in a significant increase risk of morbidity and mortality.

As we move to the back of the ambulance our priorities expand to additional information collection.

As the team loads the patient into the ambulance the team lead can begin to assign roles for the next phase of patient care. Many of these items happen simultaneously as team members work on their designated tasks.

Let’s tackle History Taking first.

1. Obtain baseline vital signs (must include BP, P, & RR)
   1. Direct one of your crew to obtain vital signs for you. “Crew-member, please get me a set of vitals, BP, Pulse and Respiratory Rate and report back to me your findings” Remember to use closed-loop communications!
   2. This step happens in the back of the ambulance, during transport. Do not get vital signs on a critical trauma scene. It is a waste of time; time your patient does not have. The EMT cannot fix most issues discovered by VS in the field; the fix is at the hospital. Within the EMT scope of practice, vital signs in trauma are for identifying trends that can later be used to dictate treatment by paramedics and the hospital.
2. Obtain a SAMPLE history.
   1. If the patient is responsive, ask for a SAMPLE history.
      1. Signs & Symptoms
      2. Allergies, Medications
      3. Past medical history
      4. Last oral intake
      5. Events leading up to the incident.
      6. Here is where you will clarify the story of the call. “So, let me get this straight, you and your buddies were drinking Milwaukee Ice and cleaning your guns when you thought it’d be funny to point it at your own foot and pull the trigger? Got it.”
   2. If the patient isn’t responsive, check with bystanders or family members prior to leaving the scene.

Now on to the Secondary Assessment.

Here is where the team lead begins to address some of the issues likely discovered in the blood sweep. The team lead will move from head to toe identifying additional injuries and direct a crew member to fix ones identified earlier. Find a fracture? Have a partner get a splint. Find minor bleeding – bleeding control.

1. Start at the head palpating and inspecting for injuries.
   • Scalp -“checking for DCAP-BTLS” (Deformities, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations, Swelling)
   • Ears – “Looking for CSF” (cerebral spinal fluid)
   • Eyes – “Looking for PERRL” (Pupils, Equal, Round, Reactive to Light)
   • Mouth, Nose facial area
     1. “Looking for blood in mouth and/or loose teeth”
     2. “Nasal fractures”
     3. “DCAP-BTLS on the face”
2. Continue your assessment on the neck.
   • “Looking for Jugular Venous Distention (JVD)/Tracheal deviation”
   • Palpate the posterior neck if you haven’t done so already.
3. Next move to the chest.
   • Inspect the chest.
   • Palpate the sternum and clavicles. Check for equal rise/fall.
   • Listen to lung sounds.
4. Assess the abdomen and pelvis for internal bleeding.
   • Inspect and palpate the 4-quadrants of the abdomen.
   • Assess for stability of pelvis if not done so already (push down, then in)
   • Verbalize checking genitalia for priapism/bleeding “I’m checking the genitalia.“
5. Lower extremities – Inspect and palpate, CMS (circulation, motor, and sensation).
6. Upper extremities – Inspect and palpate, CMS.
7. Posterior thorax, lumbar and buttocks
   • If you did this during the transport stage, you don’t need to do it again.
   • Use your fingers, and walk down the spine feeling for DCAP-BTLS

Reassessment

The team lead is responsible for managing any injuries and treatments throughout transport. For this step, the team lead will go back and re-check any injuries/interventions (i.e., reassess the tourniquet to ensure bleeding is still controlled). Vital signs should be repeated every 5 min for critical patients and 10-15 min on non-critical patients.