The MARCH “Algorithm”, as it is often called, is an approach for performing a Primary Survey when dealing with a casualty. In a previous post we discussed a more advanced version of the Primary survey which build on the basic “DRABC” approach to give a advanced “DRCAcBCD“, where we add in additional aspects, predominately a concern for catastrophic bleeding. Whilst this new acronym is perfectly serviceable, some people may dislike it – one common complaint is “too many Cs” with Catastrophic Bleeding, C-Spine injuries, and Circulation all featured. Whilst this is unlikely to be a major concern for a trained responder, it might be frustrating during their initial training – since there’s so many acronyms to keep track of when you first get started with your learning.
This is one of the reasons that some people prefer the mnemonic “MARCH” as an alternative to “DRCAcBCDE”, in short there is little difference between the two in terms of what they cover and the order. Others may prefer it simply because it’s the one they were taught first!
The Primary Survey
The MARCH version of the primary survey has the following steps: Massive External Hemorrhage, Airway with c-spine, Respiration, Circulation, Head and Other Injuries. As with all of these algorithms, you might see variations, for example I’ve previously seen the final step given as “Head Injuries and Hypothermia” which is similar to how some people add “Environment/Exposure/Extraction” to the end of DRABCD.
Massive External Hemorrhage
The first step is a safe approach.
Whilst DRCABCD makes this explicit by having the mnemonic start with “Danger”, it’s still a critical first step to ensure that it is safe before approaching the casualty. Resisting the urge to rush in to help a casualty can be difficult, but you must ensure you do not become a casualty yourself.
Check for major bleeding that is an immediate threat to life. Catastrophic bleeding must be aggressively addressed as it can become lethal in minutes. A bleed can be as fast as 1 litre per minute and once a significant amount of bleeding has occurred, approximately 3 litres, methods to address blood loss such as a transfusion can become ineffective.
The signs of a major bleed are: obvious significant blood loss, rapidly pooling blood, anxiety or confusion, deteriorating conscious level or unconsciousness.
Bleeding can be controlled by applying pressure, wound packing, using haemostatic agents, or by applying a tourniquet.
Airway with C-Spine
First, consider the possibility of a spinal injury. If there is more than one responder, it may be possible to manually immobilise the neck whilst performing other aspect of the Primary Survey. If you are a manual responder it will be very difficult to prevent spinal movement during the assessment. There are options to restrict movement with equipment such as an adjustable cervical collar or bilateral head blocks with chin and forehead tapes. However, there is now considerable debate about the use of cervical collars, in part due to the potential for them to cause additional harm, and other equipment such as a vac-mat is considered better where available.
Clear, open, and maintain the airway. Even in a casualty that is visibly breathing and communicating it’s important to be aware of the risk of a partial airway, or for debris to enter the airway. So be aware of difficult or laboured breathing, hoarse voice, noisy breathing, or inability to speak. It may be possible to clear an obstructed airway with careful suction or by positioning the casualty to allow the material to fall out of the mouth.
Opening the airway can be performed via an airway manoeuvre, such as a head tile-chin lift or jaw-thurst. If a c-spine injury is suspected, a jaw-thrust should be used. If these manoeuvres are unsuccessful then an airway adjunct may be necessary. Examples of airway adjuncts are nasopharyngeal airways (NPA) and oropharyngeal airways (OPA). NPA can be used for unconscious or semi-unconscious casualties that does not have a risk of a basal skull fracture. The average female will require a 6mm and the average male will require a 7mm. An OPA can be used with an unconscious casualty and may be used in conjunction with an NPA.
Respiration
Listen, look, and feel for breathing. This can be done by placing an ear near to the casualty’s nose and mount to hear for breathing, with your head facing towards the chest to look for the rise of the chest. Place your hand on the stomach of the casualty and feel for breathing. Continue for 10 seconds to establish if the casualty is breathing. If they are not breathing, check for a pulse
If no signs of breathing and no palpable pulse, start CPR. If you have an assistant, tell them to prep an AED if there is one available. If you have an assistant available, prepare to take turns giving CPR. Do not stop CPR until help arrives or you become exhausted.
If not signs of breathing but there is a palpable pulse, consider supporting the casualty’s breathing such as with a Bag-Valve Mask (BVM).
If the casualty is breathing, check for 30 seconds to determine their respiratory rate. A normal rate is 12-20 breaths per minute. Check for respiratory distress, such as noisy breathing, use of accessory muscles, obvious distress.
Perform a thorough investigation of the chest for life-threatening injury. Examine from the larynx to the bottom of the rib cage for abnormalities. Observe the breathing pattern. Look at the chest wall (front, back, sides, and armpits) for uneven shape, bruising, lacerations, holes, or flail segment. Feel the chest for tenderness, emphysema, or deformity. Check for an abnormal breathing pattern. For puncture wounds, consider using a chest seal.
If an injury or condition is discovered at any stage, treat the issue and then restart the primary survey.
Circulation
Assess the pulse for rate, rhythm and strength.
Perform a capillary refill test, ideally on the forehead or centre of the chest. Hold for 5 seconds, 2 seconds or less refill time is normal.
Check for major internal or external haemorrhage. “One on the floor and four more”
External Haemorrhage (“One on the floor”): Check around the casualty for any major bleed but be aware of waterproof clothing which may hide a bleed. Additionally, check on the floor and be aware that blood might soak into soft ground or into clothing and appear less serious than it is. If a major bleed is found, control the bleed with pressure, wound packing with a haemostatic agent, or by applying a tourniquet.
Internal Haemorrhage (“Four more”: chest, abdomen, pelvis and long bones): Consider the possibility of a major internal bleed. Check the chest for major injuries, the abdomen for tenderness or if it is firm, if there is evidence of major pelvic trauma, or major trauma to the long bones. Major trauma may be visible in the long bones by shortening, abnormal leg position, thigh deformity, or a visible bone due to fracture,
If an injury or condition is discovered at any stage, treat the issue and then restart the primary survey.
Head and Other Injuries
Beware of any reduction in the level of consciousness, an “AVPU” assessment can be used to assess the casualty responsiveness. Other signs of head injury include obvious wounds wounds or deformity to the head, fluid coming from the head or nose, enlarged pupil in one eye, abnormal behaviour, or a low respiratory rate. Pupils can be checked with “PEARL”. There is little that responders can be do to manage traumatic brain injuries, but any casualties with an AVPU of “P” or “U” are time critical and will require rapid transfer to hospital where possible.
Other Injuries to consider are fractures, crush injuries, suspension trauma, abdominal injuries, and burns. The context of the rescue will likely disclose the potential for injuries such as suspension trauma and crush injuries.
If an injury or condition is discovered at any stage, treat the issue and then restart the primary survey.
Once you have completed your Primary Survey and you have addressed any conditions or injuries likely to present an immediate threat to life, you may continue to the Secondary Survey. Continue communicating with Control or Emergency Services, and prepare the casualty for hand over upon their arrival.