Understanding MARCH - The Role of Circulation

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From the MARCH Mnemonic Series – Tactical Trauma Care for EMS Providers

After addressing massive hemorrhage, airway, and respiration, the next priority is Circulation, the body’s ability to deliver oxygenated blood to vital organs and tissues.

In trauma, the circulatory system can be compromised by shock, internal bleeding, or poor perfusion, even when obvious external hemorrhage has already been controlled.

Within the tactical environment, circulation assessment focuses on recognition and management of shock, maintaining perfusion, and preventing secondary injury. The goal is to identify subtle but deadly deterioration before it progresses beyond recovery.

C – Circulation

In tactical casualty care, circulation assessment differs slightly from the traditional EMS approach. The emphasis is on speed, simplicity, and practicality in resource-limited or high-threat conditions.

Blood pressure cuffs and monitors may not be available, so providers rely on physical signs and simple indicators to evaluate perfusion. The presence of a radial pulse and normal mental status are key field markers of adequate circulation.

Principles of Circulatory Assessment and Management

1. Check for Pulse and Perfusion

• Radial Pulse: Presence suggests systolic blood pressure above roughly 80 mmHg, generally adequate for perfusion in tactical settings.

• Weak or Absent Pulse: May indicate hypovolemia or shock; assess for additional signs of poor perfusion such as pallor, clammy skin, or delayed capillary refill.

• Mental Status: A sudden change in consciousness (e.g., confusion, lethargy) is often an early sign of inadequate cerebral perfusion.

Remember: weak radial pulse + altered mental status = shock until proven otherwise.

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2. Identify and Manage Non–Life-Threatening Bleeding

Once major bleeding has been controlled, systematically check for and address secondary bleeding sites that may have been overlooked during the initial MARCH sequence. 

Apply direct pressure, pressure dressings, or hemostatic agents as needed.

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3. Treat for Shock

Shock - a state of inadequate tissue perfusion - can occur from blood loss (hypovolemic), cardiac injury, or tension pneumothorax.

In tactical medicine, hemorrhagic shock is the most common.

• Lay the casualty supine, if tactical conditions allow. 

• Keep the patient warm, hypothermia worsens coagulopathy and shock (addressed further in Part Five).

• Provide fluids only when indicated by TCCC or TECC guidelines

If in shock (weak/absent radial pulse or altered mental status):

• Administer whole blood if available; otherwise, 1:1:1 blood component therapy (plasma, platelets, red cells).

• If blood products are unavailable, give Hextend or Lactated Ringer’s solution, titrating only to restore a palpable radial pulse or improved mental status (per TCCC guidance).

If the casualty is not in shock and has a palpable radial pulse and normal mental status: no IV/IO fluids are indicated.

Avoid over-resuscitation, too much fluid can dislodge clots and worsen bleeding.

4. Establish IV/IO Access When Appropriate

In tactical field care, IV or intraosseous access is indicated for:

• Fluid resuscitation in shock
• Medication administration (e.g., analgesics, antibiotics, TXA).

If available, administer Tranexamic Acid (TXA) within three hours of injury for casualties at risk of significant hemorrhage. Early TXA administration has been shown to reduce mortality from bleeding.

5. Continuous Reassessment

Circulation is dynamic, especially in prolonged field care or delayed evacuation.

• Regularly recheck:
• Pulse quality and rate
• Mental status
• Skin color, temperature, and moisture
• Wound sites for renewed bleeding

Document all findings and interventions clearly for handoff to the next echelon of care.

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Key Takeaway for EMS and Tactical Providers

Circulation management is about detecting shock early, maintaining perfusion, and preventing deterioration. 

In the tactical environment, sophisticated monitoring tools are often unavailable, but trained observation remains powerful. 

The provider’s mindset should be:

Feel for the pulse, read the patient, and keep the blood where it belongs.

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Coming Up Next: Part Five – Hypothermia and Head Injury

The final step in the MARCH sequence focuses on protecting what you’ve fought to preserve, preventing hypothermia and managing head injuries to maintain survivability after initial stabilization.

In Part Five, we’ll discuss how temperature control, positioning, and neurologic assessment all play critical roles in keeping your casualty alive until evacuation and definitive care.

Because in tactical medicine, saving a life isn’t just about stopping the bleeding—it’s about keeping that life sustained.

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. 

Retrieved from https://pubmed.ncbi.nlm.nih.gov/28284483/ on October 8, 2025

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

Understanding MARCH - The Relevance of Respiratory Assessment

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From the MARCH Mnemonic Series – Tactical Trauma Care for EMS Providers

After controlling massive hemorrhage and ensuring a patent airway, the next priority in the MARCH sequence is Respiration. 

Effective breathing is critical for oxygen delivery and carbon dioxide removal. When trauma impairs the chest wall or lungs, hypoxia and shock can develop rapidly - even when the airway is clear.

In tactical or prehospital settings, respiratory compromise is often caused by thoracic injury, such as a gunshot, stab wound, or blast trauma. 

These injuries can lead to life-threatening conditions like tension pneumothorax or open chest wounds, both of which are preventable causes of death when identified and treated early.

This article - the third in a five-part series - will focus on that next critical step: 

R – Respiration

Respiration refers to the body’s ability to move air into and out of the lungs and to exchange gases at the alveolar level. 

Any disruption - mechanical, anatomical, or physiological - can cause hypoxia and threaten survival. 

The responder’s task is to rapidly assess, seal, decompress, and support breathing as needed.

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Principles of Respiratory Management

1. Assess the Casualty’s Breathing

Begin by evaluating rate, depth, and effort of respirations. Look, listen, and feel for:

• Asymmetrical chest rise or movement

• Difficulty speaking, gasping, or labored breathing

• Cyanosis around lips or fingertips

• Tracheal deviation, jugular venous distention, or subcutaneous emphysema

• Penetrating trauma to the chest or upper abdomen

If you’re operating in a tactical environment, conduct this assessment as efficiently as safety allows—rapid but systematic.

2. Expose and Inspect for Chest Injuries

Visually inspect the anterior, lateral, and posterior thorax for entry and exit wounds, contusions, or deformities. In low-light or confined spaces, gloved hands may detect what the eyes can’t.

• Sucking chest wounds (open pneumothorax) occur when air enters the pleural space through a chest wall defect.

• These must be sealed immediately with a vented or occlusive chest seal to prevent the progression to tension pneumothorax.

Modern products like the HyFin® Vent Chest Seal or FoxSeal™ are designed for field reliability and are standard in most tactical trauma kits.

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3. Manage a Tension Pneumothorax

A tension pneumothorax occurs when air becomes trapped in the pleural space and cannot escape, collapsing the lung and compressing the heart and great vessels.
Signs may include:

• Severe respiratory distress

• Decreased or absent breath sounds on one side

• Hypotension and tachycardia

• Tracheal deviation (a late sign)

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Intervention:

If tension pneumothorax is suspected and equipment/training allow, perform needle decompression:

• Use a 14-gauge, 3.25-inch (8.25 cm) needle or catheter.

• Insert into the 5th intercostal space, anterior axillary line (or 2nd intercostal space, midclavicular line if indicated).

• Listen for escaping air and observe for improvement in breathing and perfusion.

Always reassess, if symptoms recur, repeat decompression or prepare for chest tube insertion at higher care levels.

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4. Support Oxygenation and Ventilation

If available and appropriate, administer supplemental oxygen to maintain SpO₂ above 94%. 

For inadequate respirations, assist with bag-valve-mask (BVM) ventilation while maintaining airway alignment. In prolonged field care, consider monitoring SpO₂ and ETCO₂, if resources allow, to guide ongoing management.

5. Continue Monitoring and Reassessment

The chest is dynamic, bleeding, air leakage, or mechanical disruption can recur with movement or time. Reassess chest rise, breath sounds, and patient condition frequently during evacuation.

Key Takeaway for EMS and Tactical Providers

Thoracic trauma demands vigilance. While hemorrhage and airway compromise often draw attention first, unrecognized respiratory failure can kill just as quickly. The tactical provider must be proficient in identifying chest injuries, applying chest seals, and performing needle decompression when indicated.

In short: find the holes, seal the leaks, relieve the pressure, and keep the oxygen moving.

Coming Up Next: Part Four – Circulation

Once bleeding is controlled, the airway is secure, and breathing is restored, it’s time to assess circulation—the body’s ability to perfuse vital organs. 

In Part Four of our MARCH series, we’ll explore recognition and management of shock, fluid resuscitation strategies, and maintaining perfusion in both field and tactical environments.

Because after oxygen, the mission is to keep it flowing where it matters most.

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. 

Retrieved from https://pubmed.ncbi.nlm.nih.gov/28284483/ on October 8, 2025

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 

Healthcare News - Rocky Mountain Spotted Fever

Rocky Mountain Spotted Fever (RMSF), caused by Rickettsia rickettsii, is one of the most severe infectious diseases in the Americas.

The pathogen targets endothelial cells, leading to widespread microvascular damage, fluid leakage, and severe complications such as pneumonitis, myocarditis, kidney injury, and meningoencephalitis.

In advanced cases, RMSF can cause respiratory distress, cardiac abnormalities, coma, and peripheral gangrene, with high mortality rates if left untreated.

Timely diagnosis and immediate antibiotic administration are critical, as mortality can reach 50% within the first eight days of illness.

RMSF is transmitted through various tick species, with Rhipicephalus sanguineus (brown dog tick) playing a significant role in Mexico, while Amblyomma species contribute to transmission in Brazil and North America.

The disease is endemic across Canada, the United States, Mexico, and South America, with an increasing number of urban outbreaks linked to poor sanitation, high tick populations, and free-roaming dogs.

A One Health approach has identified three primary ecological zones for RMSF transmission: sylvatic (wildlife-based), peridomestic (domesticated animal involvement), and urban (densely populated regions).

Control efforts require vector management, improved veterinary care, environmental modifications, and public health initiatives.

The brown dog tick presents a particular challenge due to its resistance to acaricides, necessitating integrated pest management strategies, including the use of isoxazolines and environmental barriers.

RMSF remains a serious public health concern, demanding coordinated intervention.

Preventative strategies - such as early recognition, vector control, sterilization programs, and public awareness - are essential to reducing transmission and improving patient outcomes.

Healthcare professionals must remain vigilant in identifying and managing suspected cases to mitigate the disease’s increasing burden.

For more information access this Medtigo link .

References: Foley J., López-Pérez A.M., Álvarez-Hernández G (2025) A Wolf at The Door: The Ecology, Epidemiology & Emergence of Community & Urban-Level Rocky Mountain Spotted Fever in The Americas. American Journal of Veterinary Research 86(3):368-378. https://doi.org/10.2460/ajvr.24.11.0368 Accessed March 10, 2025

EMS Emergencies - Pediatric Patients

EMS providers need to be well-prepared to handle pediatric emergencies as they require specialized knowledge and skills due to the unique needs of children.

Here are some key points they should know:

1. Respiratory Distress: Children commonly present with respiratory distress due to conditions such as asthma, bronchiolitis, or croup. EMS providers should be proficient in assessing respiratory status, administering oxygen, and managing airway obstructions.

2. Febrile Seizures: Febrile seizures are common in young children and are often frightening for caregivers. EMS providers should know how to assess and manage febrile seizures, including ensuring adequate ventilation and preventing injury during the seizure.

3. Trauma: Children are at risk for various types of trauma, including falls, burns, and motor vehicle accidents. EMS providers should be skilled in assessing and managing pediatric trauma, including immobilization techniques and pain management.

4. Sepsis: Sepsis can be challenging to recognize in children, as symptoms may be nonspecific. EMS providers should be vigilant for signs of sepsis, such as fever, tachycardia, and altered mental status, and be prepared to initiate early treatment.

5. Anaphylaxis: Allergic reactions, including anaphylaxis, can occur in children due to food allergies, insect stings, or medications. EMS providers should be trained in recognizing anaphylaxis and administering epinephrine as needed.

6. Dehydration: Children are at increased risk for dehydration due to factors such as vomiting, diarrhea, or fever. EMS providers should be skilled in assessing hydration status and administering fluids as needed, especially in cases of severe dehydration.

7. Seizures: Seizures can occur in children due to various causes, including epilepsy or febrile illnesses. EMS providers should know how to assess and manage seizures, including protecting the child from injury and administering appropriate medications if necessary.

8. Poisoning: Accidental poisoning is a common pediatric emergency. EMS providers should be familiar with common toxins and their effects on children, as well as appropriate decontamination and treatment measures.

9. Cardiac Arrest: While less common in children than in adults, cardiac arrest can still occur due to various causes, including congenital heart defects or respiratory failure. EMS providers should be proficient in pediatric CPR and advanced life support techniques.

10. Communication & Family Support: Effective communication with caregivers is essential in pediatric emergencies. EMS providers should be skilled in providing clear and compassionate communication, as well as offering support to families during stressful situations.

By being knowledgeable about these common pediatric emergencies and having the necessary skills to assess and manage them effectively, EMS providers can play a crucial role in providing optimal care for children in emergency situations.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS Particular Patient Populations - Geriatric Emergencies

EMS providers play a crucial role in managing geriatric emergencies, as the elderly population often presents with unique medical challenges.

Here are some key considerations, common presentations, and possible treatment plans for geriatric emergencies in the prehospital setting:

Key Considerations:

Physiological Changes: Aging leads to physiological changes, such as decreased organ function, altered drug metabolism, and reduced reserve capacity. Be mindful of these changes when assessing and treating elderly patients.

Atypical Presentations: Geriatric patients may present with atypical symptoms, making diagnosis challenging. For example, myocardial infarction may manifest as confusion or weakness rather than classic chest pain.

Polypharmacy: Elderly individuals often take multiple medications, increasing the risk of drug interactions and adverse effects. Obtain an accurate medication history and be alert to potential complications.

Frailty and Fall Risk: Falls are a common geriatric emergency. Assess for frailty, perform fall risk assessments, and address environmental factors that may contribute to falls.

Cognitive Impairment: Cognitive conditions like dementia can complicate patient assessment and communication. Collaborate with family members or caregivers for additional information.

Common Presentations:

Falls: Assess for injuries, especially head injuries and fractures. Consider the possibility of syncope, medication-related issues, or environmental factors contributing to the fall.

Chest Pain and Cardiac Issues: Look beyond classic symptoms; consider fatigue, shortness of breath, or altered mental status. Monitor for signs of heart failure or arrhythmias.

Respiratory Distress: Evaluate for pneumonia, chronic obstructive pulmonary disease (COPD) exacerbation, or heart failure. Be aware of potential complications related to decreased respiratory reserve.

Altered Mental Status: Determine the cause, considering infectious, metabolic, or neurological etiologies. Hypoglycemia, infections, and medication side effects are common contributors.

Abdominal Pain: Assess for gastrointestinal issues, urinary tract infections, or other abdominal pathologies. Consider the possibility of atypical presentations.

Common Treatment Plans:

Airway Management: Be prepared for airway management challenges, especially if the patient has altered anatomy or decreased respiratory reserve.

Pain Management: Manage pain appropriately, considering the potential for undertreatment due to fears of side effects or drug interactions.

Medication Administration: Administer medications cautiously, considering altered pharmacokinetics and potential drug interactions. Be aware of medications that may cause or exacerbate falls.

Fluid Management: Monitor fluid status carefully, especially in patients with heart failure. Adjust fluid administration based on the patient's hemodynamic status.

Transport to Appropriate Facilities: Consider transporting geriatric patients to facilities with expertise in the care of the elderly, as they may have specialized resources and staff.

Collaboration with Family and Caregivers: Communicate effectively with family members or caregivers to gather crucial information and involve them in the decision-making process.

Prevention Strategies: Provide education on fall prevention, medication management, and strategies to maintain overall health and well-being.

Conclusion:

EMS providers should approach geriatric emergencies with a comprehensive understanding of the unique challenges associated with the elderly population.

By considering the physiological changes, atypical presentations, and specific needs of geriatric patients, EMS providers can deliver more effective and tailored prehospital care.

Ongoing education and training in geriatric emergency medicine are essential for improving outcomes in this vulnerable population.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS Pediatric Populations - Pediatric Emergencies

EMS providers should have knowledge and skills to effectively manage pediatric emergencies.

Here are some key points they should know:

1. Pediatric Assessment: Understanding the differences in anatomy, physiology, and vital signs between adults and children is crucial. Providers should be skilled in performing a thorough pediatric assessment, including assessing airway, breathing, circulation, disability, and exposure (ABCDE).

2. Airway Management: Pediatric airways are smaller and more easily obstructed than adult airways. Providers should be proficient in managing pediatric airway emergencies, including using appropriate airway adjuncts and techniques such as bag-mask ventilation and endotracheal intubation.

3. Respiratory Distress: Common respiratory emergencies in children include asthma, bronchiolitis, and croup. Providers should be familiar with respiratory assessment, oxygen therapy, and administering nebulized medications.

4. Cardiac Arrest and CPR: Pediatric cardiac arrest requires prompt recognition and intervention. Providers must be skilled in pediatric cardiopulmonary resuscitation (CPR), including chest compressions, ventilation, and the use of automated external defibrillators (AEDs).

5. Fever and Sepsis: Fever is a common presentation in pediatric patients. EMS providers should recognize signs of serious bacterial infections, sepsis, and know how to provide appropriate supportive care during transport.

6. Allergic Reactions: Anaphylaxis and severe allergic reactions can be life-threatening. Providers should be trained in recognizing and managing allergic emergencies, including the administration of epinephrine.

7. Trauma: Pediatric trauma may present differently than adult trauma. Providers should know how to assess and manage common pediatric injuries, including fractures, head injuries, and burns. They should also consider the psychological needs of the child and provide age-appropriate support.

8. Seizures: Seizures can occur in children due to various causes. Providers should be familiar with seizure recognition, seizure management, and appropriate administration of anti-seizure medications.

9. Dehydration: Children are more prone to dehydration due to their smaller fluid reserves. Providers should be able to assess and manage pediatric patients with suspected dehydration, including fluid resuscitation if necessary.

10. Communication and Psychological Support: Effective communication with both the child and their parents or caregivers is vital. Providers should use age-appropriate language, provide reassurance, and involve parents or caregivers in the decision-making process.

These are general considerations, and ongoing training and education in pediatric emergency care are essential for EMS providers to ensure optimal care for children in emergencies.