← PROTOCOLS
🩹 Trauma Assessment
MARCH • ABCDE • NEXUS • Load & Go
MARCH Protocol — Priority Order
M
Massive Hemorrhage
A
Airway
R
Respiration
C
Circulation
H
Hypothermia

⚠ Step 1 — Scene Size-Up & MOI

MOI Selector
Select mechanism type:
🚗
Blunt Trauma
MVA, fall, assault
🩸
Penetrating
GSW, stabbing, impalement
⬇️
Low Energy
Ground-level fall, slow speed
⚡
High Energy
High speed, rollover, ejection
↓

🦠 Step 2 — Primary Survey (ABCDE)

A
Airway + C-Spine
  • Manual inline stabilization for unknown/trauma mechanism
  • Open with jaw thrust (NOT head-tilt in trauma)
  • Suction blood/vomit — clear and maintain
  • OPA if unconscious with absent gag; NPA if gag intact
  • Assess: phonation, stridor, gurgling
B
Breathing
  • Rate, depth, effort, symmetry of chest rise
  • Paradoxical movement → flail chest
  • Absent unilateral sounds → tension PTX / hemothorax
  • Open chest wound → seal 3-sided (occlusive dressing)
  • SpO2 — O2 if < 94%; BVM if inadequate respirations
C
Circulation & Hemorrhage Control
  • External hemorrhage: Direct pressure immediately → wound packing → tourniquet
  • Pulse: rate, rhythm, quality (radial present = SBP ~80+)
  • Skin: pale/cool/diaphoretic = shock
  • Estimate blood loss — class per shock table below
  • Pelvic instability (gentle compression once) — pelvic binder if available
D
Disability (Neuro)
  • AVPU: Alert / Verbal / Pain / Unresponsive
  • Pupils: equal, reactive to light?
  • Motor: move all extremities? Focal deficit?
  • GCS if time permits (Eyes 1-4, Verbal 1-5, Motor 1-6)
E
Expose & Environment
  • Expose to assess injuries — cut away clothing if necessary
  • Look for hidden wounds: axilla, groin, back
  • Hypothermia prevention: Cover immediately after exposure — Lethal Triad (hypothermia + acidosis + coagulopathy)
  • Warm blankets, warm IV fluids (ALS), heated compartment
↓

🚨 Step 3 — Life Threat Recognition

⚠ Tension Pneumothorax
CRITICAL
Absent unilateral BS + JVD + hypotension + tracheal deviation (late)
🔴 ALS — Needle decompression 2nd ICS MCL. Seal open wounds. Rapid transport.
🩸 Massive Hemorrhage
CRITICAL
Active uncontrolled external bleeding, hemorrhagic shock signs
🔵 BLS — Direct pressure, wound packing, tourniquet for extremity. Pelvic binder.
💨 Open Pneumothorax
CRITICAL
Sucking chest wound — air moving through wound with respirations
🔵 BLS — 3-sided occlusive dressing (vented preferred). Seal 3 sides, leave 1 open to vent. Monitor for tension PTX development.
🦴 Flail Chest
CRITICAL
Paradoxical chest movement — segment moves opposite to rest of chest. Multiple rib fractures.
🔴 Positive pressure ventilation (ALS). Minimize splinting (may worsen). O2 high-flow. ALS intercept.
❤️ Cardiac Tamponade
CRITICAL
Beck's Triad: JVD + muffled heart sounds + hypotension. Penetrating chest trauma.
🔴 ALS — Pericardiocentesis (hospital). BLS: rapid transport, IV access, fluid if hypotensive (ALS).
↓

📉 Hemorrhagic Shock Classification

Class Blood Loss HR BP RR Mental Status
I <750mL
<15%		 <100 Normal 14-20 Normal/Anxious
II 750-1500mL
15-30%		 100-120 Normal/↓ 20-30 Anxious
III 1500-2000mL
30-40%		 120-140 ↓ 30-40 Confused
IV >2000mL
>40%		 >140 Critically ↓ >35 Lethargic/Unresponsive
Class III-IV = aggressive hemorrhage control + ALS intercept + rapid transport

🩹 Tourniquet Application

🔴 Tourniquet — Extremity Life-Threatening Hemorrhage
1. Apply 2-3 inches above wound (not over joint)
2. Pull tight, secure, twist windlass until bleeding stops
3. Lock windlass, secure with keeper strap
4. Write time on patient with marker/tape
5. Do NOT remove once applied
6. Notify receiving hospital of time and location
Tourniquet Time Applied:

🦴 Step 4 — Spinal Motion Restriction (NEXUS)

NEXUS Low-Risk Criteria
If ANY criteria present → full spinal motion restriction required. Check ALL that apply:
○
Midline cervical tenderness
Palpation along C-spine midline elicits pain
○
Focal neurological deficit
Weakness, numbness, tingling in extremities
○
Altered level of consciousness
GCS < 15, AVPU below Alert
○
Intoxication
Alcohol, drugs — unreliable examination
○
Distracting injury
Painful injury elsewhere distracting from C-spine assessment
5
Secondary Survey — DCAP-BTLS Head-to-Toe
DCAP-BTLS: Deformity • Contusion • Abrasion • Penetration • Burns • Tenderness • Lacerations • Swelling
  • Head/Skull: Deformity, lacerations, Battle's sign, raccoon eyes, CSF
  • Face/Neck: Tracheal deviation, JVD, subcutaneous emphysema
  • Chest: Stability, breath sounds, crepitus, paradoxical movement
  • Abdomen: Rigidity, guarding, distension, evisceration
  • Pelvis: Gentle compression (once) — instability = binder
  • Extremities: PMS distal to each injury (Pulse, Motor, Sensation)
  • Back: Logroll to assess posterior — if time permits
⚠ Only if time permits en route or scene time allows — don't delay transport for secondary survey
↓

🚑 Step 6 — Transport Decision

🏃 Load & Go — Immediate Transport
Unstable vitals, hemodynamic compromise, penetrating trunk trauma, uncontrolled hemorrhage, airway compromise, Glasgow < 14, any life threat identified
🏥 Stay & Play — Stabilize on Scene
Stable vitals, isolated extremity injury, no life threats identified, extended transport where ALS interventions will improve outcome
⏱
Golden Hour Concept: Trauma patient survival improves dramatically with definitive surgical care within 60 minutes of injury. Do not delay transport for extended field stabilization.
Splinting & Special Considerations
🦵
BLS Traction splint: Isolated mid-shaft femur fracture with NO hip, knee, ankle injury. Apply to relieve pain and reduce blood loss (femur fracture = 1-1.5L loss).
🩹
BLS General splinting: Immobilize joint above and below fracture. Check PMS before and after. Padded, firm. No traction for joint injuries.
🧊
BLS Hypothermia prevention: Cover with blankets. Warm environment. Wet clothing = remove. Lethal trauma triad: hypothermia + coagulopathy + acidosis.
🩸
ALS IV access en route (2 large bore IVs). Judicious fluid resuscitation — permissive hypotension for penetrating trauma (SBP ~80-90 target until surgical control).