Massive Hemorrhage First

Why this matters

Airway, breathing, and circulation were the old order. In catastrophic bleeding, that order can kill the patient. An artery can empty the patient of blood while you set up airway equipment. That blood loss can kill the patient before low oxygen does.

MARCH means massive hemorrhage, then airway, then respirations, then circulation, then hypothermia and head injury. Some crews say XABC. The X means bleeding out, before airway, breathing, and circulation. The idea is the same. Stop the bleeding that will kill the patient first. This is not permission to ignore the airway. It is the order for this patient.

Clinical sequence

1. If the bleeding is catastrophic, stop it first. MARCH puts massive hemorrhage before the airway.
2. For an extremity artery, place a tourniquet so arterial flow actually stops. Write the time.
3. If it still spurts, add a second tourniquet closer to the trunk, or side by side with the first. Do not loosen the first one to check.
4. For a junctional wound at the groin, axilla, or neck, pack to the bleeding source and hold real pressure. A limb tourniquet will not reach those sites.
5. If you cannot see the bleeding, treat shock and move. You cannot pack a spleen. Use a pelvic binder only if your protocol still uses one.

MARCH

1. M — Massive hemorrhage
   • Put pressure on the wound with your hands. Then pack gauze down to the bleeding source and hold that pressure.
   • Pack the groin, the axilla, and some neck wounds the way you were trained. Do not pack an open chest wound the way you pack a groin.
   • Use a tourniquet for an extremity that is losing blood fast. Place it high enough and tight enough. Note the time. Recheck it after every move.
   • Use a junctional device only if you carry it, it fits, and protocol allows it.
   • Do not rock the pelvis. A binder, if your protocol still uses one, goes at the greater trochanters, with the legs inward and the feet together. NAEMSP 2025 asks systems to reconsider routine binders. Protocol still decides. Shock is often not in the pelvic ring.
2. A — Airway — open it, suction, and protect it. Use adjuncts or an advanced airway after the catastrophic bleeding is controlled, or at the same time if you have enough hands.
3. R — Respirations — oxygenate and ventilate. If the patient is breathing on their own, a vented chest seal is reasonable for an open chest wound. Needle only for tension physiology. Do not needle a simple pneumothorax.
4. C — Circulation — check pulses and shock, and get access as indicated. Give blood or fluid only as your protocol writes it. Keep stopping the bleeding.
5. H — Hypothermia and head injury — cold patients clot poorly. Remove wet clothes and keep them warm. The lethal triad is hypothermia, acidosis, and coagulopathy, which means blood that will not clot. Damage-control teaching often adds low calcium as a fourth factor, a lethal diamond, when blood products are used. Protect a traumatic brain injury with oxygen and blood pressure. Do not delay those for a board.

Tourniquets and packing

• Tourniquets save lives on an extremity artery. Apply them so they work. Lock the windlass. If bleeding continues, add a second tourniquet or reposition. Do not loosen a working tourniquet to look, unless you have a plan and protocol allows conversion.
• Write the time on the tourniquet and in the chart. Say it at the trauma bay.
• Wound packing is for the groin, the axilla, and some neck wounds. Use the gauze you are trained to pack with. Hold pressure afterward. Do not pack an open chest wound the way you pack a groin.
• Commercial versus improvised: use the device you train with. A working improvised tourniquet is still better than a light dressing on a stump that is still bleeding.

Key points

• Do not delay bleeding control for a full set of vitals, a complete undressing, or a long secondary survey while the wound is still bleeding.
• Internal bleeding still needs shock recognition and a short scene. You cannot pack a ruptured spleen. Use a pelvic binder only if your protocol still includes one (see pelvic binder thinking). For uncontrolled bleeding without traumatic brain injury, many systems limit crystalloid until blood and surgical control are available. Do not copy a low blood-pressure target onto a traumatic brain injury.
• TXA and blood products do not replace a tourniquet. Use them only if you carry them and the patient meets your protocol. See the TXA lesson for the NAEMSP 2025 frame: after life-saving interventions, clinical shock, and inside 3 hours. This site does not publish a milligram or mixing recipe.
• Prevent hypothermia. Remove wet clothes. Warm the patient compartment. Cold blood does not clot well.
• Teamwork: one provider holds pressure while another prepares the tourniquet or the airway.
• Scene safety still comes first. You cannot stop bleeding if you become a patient.

Common errors

• Going to the airway first while an extremity artery is still losing blood fast.
• A tourniquet that is only tight enough to block veins, so bleeding continues or gets worse.
• Loosening a working tourniquet at the hospital door to see if the patient still needs it.
• A long scene for a patient with internal bleeding who needs an operating room.
• Forgetting to recheck the wound after you package and move.

Practice

See also

• Pelvic binderTrochanters, legs inward, feet together — only if your protocol still uses one. Do not rock the pelvis.
• Open chestVented seal if the patient is breathing. Do not pack the chest. Needle only for tension physiology.
• TXA framingAfter life-saving hemorrhage control, clinical shock, inside 3 hours. Not a substitute for a tourniquet. No milligrams on this site.
• Shock categoriesName the shock you can see, then move. Internal bleeding still needs a surgeon.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

• NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; your protocol decides
• TCCC guidelines (Committee on TCCC)
• Tactical Emergency Casualty Care (TECC)
• NAEMSP / ACEP / ACS-COT 2025: Tranexamic Acid in Trauma — after life-saving interventions, clinical hemorrhagic shock, within 3 hours of injury; protocol owns whether you carry it
• MARCH, tourniquets, wound packing, and hypothermia prevention are the field hemorrhage framework. TXA and blood products only if your system carries them.
• Your trauma, TXA, blood-product, and pelvic-binder protocols.