From the MARCH Mnemonic Series – Tactical Trauma Care for EMS ProvidersPreserve and Protect After Stabilization
The
final step in the MARCH sequence - Hypothermia & Head Injury -
focuses on two conditions that can rapidly worsen outcomes if not addressed
early.
After
bleeding is controlled, the airway secured, respiration managed, and
circulation assessed, providers must work to preserve core body temperature and
protect neurological function.
Uncontrolled
heat loss accelerates shock, impairs clotting, and undermines every prior
intervention. Likewise, traumatic brain injury can progress quickly without
vigilant monitoring and early management.
Protecting
a patient from heat loss and preserving the brain is essential for preventing
secondary injury and supporting long-term survival and neurological recovery.
Image retrieved from tccc.org.ua
H –
Hypothermia
Trauma-induced
hypothermia is a major contributor to mortality in both military and
civilian trauma.
Even in warm
climates, a patient can quickly lose body heat through evaporation,
convection, and exposure.
Hypothermia
worsens the “lethal triad” of trauma - acidosis, coagulopathy & hypothermia - impairing clotting and promoting continued bleeding.
Image retrieved from tccc.org.ua
Recognition
of Hypothermia
Look for early
indicators, especially when there is significant blood loss or environmental
exposure:
- Shivering or muscle tremors (may
disappear as hypothermia worsens)
- Pale, cool, or mottled skin
- Slurred speech or confusion
- Slowed respirations or heart rate
- Core temperature below 95°F
(35°C)
Environmental
factors such as wind, wet clothing, cold ground, or prolonged evacuation time
accelerate heat loss, even in mild weather.
Image retrieved from tccc.org.uaHypothermia
Prevention and Management
- Remove wet clothing when
tactically feasible and replace with dry layers.
- Insulate from the ground using
a poncho, sleeping pad, or casualty blanket.
- Cover the casualty completely,
including the head, to reduce radiant heat loss.
- Use hypothermia prevention kits (e.g.,
Blizzard Survival Blanket, Ready-Heat™ Active Warming Blanket) if
available.
- Warm IV fluids or blood products when
resources allow.
- Monitor core
temperature if devices are available, especially in prolonged field care
scenarios.
Image retrieved from tccc.org.uaKey Point: Preventing heat loss is just as vital as stopping bleeding - once the casualty is cold, outcomes worsen rapidly.
Image retrieved from tccc.org.ua
H – Head
Injury
The “H” in
MARCH also stands for Head Injury, emphasizing early recognition and management
of traumatic brain injury (TBI), a leading cause of preventable death and
long-term disability in prehospital trauma.
Image retrieved from tccc.org.ua
Recognizing
Head Trauma
Watch for the
following signs and symptoms:
- Decreasing level of consciousness
or responsiveness
- Unequal or dilated pupils
- Repetitive questioning, confusion,
or agitation
- Persistent vomiting or seizures
- Irregular breathing patterns
(Cheyne-Stokes or slow respirations)
- Obvious penetrating or blunt trauma
to the skull or face
Image retrieved from tccc.org.ua
Management Principles
- Maintain airway and oxygenation. Keep SpO₂ > 90% and avoid hypoxia, which worsens secondary brain injury.
- Prevent hypotension. Maintain systolic BP ≥ 90 mmHg to ensure cerebral perfusion.
- Positioning: If spinal injury is not suspected, elevate the head 30° to promote venous drainage.
- Avoid hyperventilation unless there are signs of herniation (e.g., blown pupil, rapid deterioration).
- Control external bleeding with gentle pressure; do not compress depressed skull fractures or insert dressings into open cranial wounds.
- Monitor for changes in mental status using tools like AVPU or GCS if time and environment allow.
In the tactical environment: head injuries often coexist with blast or penetrating trauma. Managing hypoxia and hypotension early has been shown to double the odds of survival in severe TBI (Eastridge et al., 2012).
Image retrieved from tccc.org.ua
Key Takeaway
for EMS and Tactical Providers
The 'H' in MARCH is about preservation and protection - maintaining the physiological stability of a
casualty who has already survived the most immediate threats.
Hypothermia
prevention and head injury management require vigilance, insulation, and gentle
handling. In tactical medicine, saving a life doesn’t end with hemorrhage
control, it continues with keeping that life viable during evacuation.
In short: preserve
the heat, protect the brain
Image retrieved from tccc.org.ua Conclusion of the MARCH Series
The MARCH sequence - Massive Hemorrhage, Airway, Respiration, Circulation, and Hypothermia/Head Injury - originated in Tactical Combat Casualty Care and remains the foundation of modern field trauma management.
This structured approach guides responders to address the most preventable causes of death in the order they matter most. In this series, each component of MARCH is explored in turn, offering practical guidance for EMS and tactical providers operating in dynamic, resource-limited environments.
From controlling catastrophic bleeding to protecting core temperature and neurological function, the series outlines a clear, evidence-informed pathway for stabilizing trauma patients and improving survivability in the prehospital setting.
Train Hard. Stay Prepared. Save Lives.
Further Reading:
American College of Surgeons Committee on Trauma. (2022) Advanced Trauma Life Support (10th Ed). Chicago, IL: American College of Surgeons.
Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, MA: Pearson Education
Butler, F. K. (2017) Tactical Combat Casualty Care: Beginnings. Wilderness & Environmental Medicine 28 (2S): S12-S17.
Butler, F. K., Bennett, B., & Wedmore, C. I. (2017) Tactical Combat Casualty Care and Wilderness Medicine: Advancing Trauma Care in Austere Environments. Emergency Medicine Clinics of North America 35 (2): 391-407. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28411934/ on October 8, 2025
Committee on Tactical Combat Casualty Care (2023) Tactical Combat Casualty Care (TCCC) Guidelines for Medical Personnel. Defense Health Agency, Joint Trauma System. Retrieved from https://jts.health.mil on October 8. 2025
National Association of Emergency Medical Technicians NAEMT (2020) TECC: Tactical Emergency Casualty Care Course Book (2nd Ed). Burlington, MA: Jones & Bartlett Learning
National Association of Emergency Medical Technicians NAEMT (2023) Tactical Emergency Casualty Care (TECC) Guidelines. NAEMT Education Division
National Association of Emergency Medical Technicians NAEMT (2025)
PHTLS: Prehospital Trauma Life Support, Military Edition eBook (10th Ed). Burlington, MA: Jones & Bartlett Learning
