Understanding MARCH - A Tactical Approach to Massive Hemorrhage

In prehospital medicine, chaos is a constant. Whether in combat zones, tactical operations, or austere environments, responders need an effective method to prioritize lifesaving interventions.

The MARCH mnemonic provides that structure.

Used in Tactical Combat Casualty Care (TCCC) and increasingly adapted into Tactical Emergency Casualty Care (TECC), MARCH guides providers through the sequence of treating trauma in order of urgency:

M – Massive Hemorrhage
A – Airway
R – Respiration
C – Circulation
H – Hypothermia/Head Injury

Each step addresses a preventable cause of death, beginning with what kills fastest.

This article – the first in a five-part series – focuses on the first and most critical step:

M – Massive Hemorrhage.

Massive hemorrhage is the leading cause of preventable death in trauma. Life can be lost in minutes from uncontrolled bleeding, making rapid identification and intervention paramount. Clinically, a massive hemorrhage may be defined as the loss of more than 50% of circulating blood volume within three hours, but in the field, it’s simpler: if it looks bad, treat it fast.

Principles of Care

Control the Bleed Immediately

Identify and manage life-threatening external bleeding before addressing airway or breathing. In tactical settings, hemorrhage control often occurs under fire or while the threat is active, emphasizing the importance of speed and training.
Direct Pressure

Apply firm, targeted pressure directly over the bleeding source using a gloved hand and dressing. Direct pressure remains the most reliable method of hemorrhage control and should be maintained until bleeding stops or another intervention takes effect.
Tourniquet Application

If the bleeding is from an extremity and direct pressure fails, apply a commercially approved tourniquet as high and tight as possible, proximal to the wound. Tighten until the bleeding stops and document the time of application. Avoid improvised or untested devices—equipment failure can cost lives.
Hemostatic and Pressure Dressings

For junctional or compressible areas (e.g., the groin, axilla, or neck), use a hemostatic dressing and apply continuous firm pressure for at least three minutes or as directed by the manufacturer. Secure with a pressure dressing and reassess frequently.
Reassess Constantly

Bleeding control is not a one-and-done task. Reassess interventions after movement, transport, or environmental changes. Tourniquets can loosen, and pressure dressings can shift during casualty movement or extraction.

Key Takeaway for EMS and Tactical Providers

Massive hemorrhage is fast, silent, and deadly – but also the most preventable cause of battlefield and tactical death.
Responders must adopt a mindset of “Stop the bleed, then everything else.” Consistent training, reliable equipment, and disciplined reassessment make the difference between life and loss in tactical trauma care.

Coming Next: Part Two – Airway

Once life-threatening bleeding is controlled, the next critical step is ensuring the casualty can breathe.

In Part Two of our MARCH series, we’ll examine airway management in tactical and prehospital settings—covering essential assessment, manual maneuvers, airway adjuncts, and when to escalate to advanced interventions.

Because once the bleeding stops, oxygen is your next priority!

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