Massive Hemorrhage First

Why This Is Hard

Classic ABC was drilled for years. In catastrophic bleeding, checking the airway while arterial blood pools can be the wrong first move. Modern trauma education often uses MARCH or XABC: stop massive external hemorrhage first. Seconds of arterial spurting can empty a patient before you ever open an airway kit.

This is not “ignore the airway forever.” It is order of operations when life-threatening external bleeding is present.

MARCH (Teaching Order)

1. M — Massive hemorrhage
   • Direct pressure with both hands and effective packing materials.
   • Wound packing for deep/junctional bleeding per training (approved gauze, proper depth, pressure).
   • Tourniquet for extremity exsanguination — high and tight enough to stop arterial flow; note time; reassess.
   • Junctional strategies and pressure devices only as trained and authorized.
   • Pelvic binder when indicated by mechanism/protocol (unstable pelvis suspicion).
2. A — Airway — open, suction, protect; adjuncts and advanced airway as indicated after catastrophic bleed is controlled or simultaneous if resources allow.
3. R — Respirations — oxygenate/ventilate; seal open chest wounds per protocol; decompress tension if indicated.
4. C — Circulation — pulses, shock recognition, IV/IO access as indicated; fluid/blood products per protocol; prevent further blood loss.
5. H — Hypothermia / head — prevent cooling (trauma triad of death: hypothermia, acidosis, coagulopathy); protect TBI per protocol (oxygenation, avoid hypotension when possible).

Tourniquets and Packing — Street Notes

• Tourniquets save lives in extremity arterial bleeding. Apply effectively per training; windlass locked; still bleeding → second tourniquet or reposition per training — do not “loosen to check” repeatedly in the field without a plan.
• Note the time on the tourniquet and in the PCR; tell the receiving team.
• Wound packing for junctional bleeds (groin, axilla, neck contexts per training) is a practiced skill — use approved materials and continuous pressure afterward.
• Commercial devices vs improvised: use what you are trained and equipped to use.

Key Points for Paramedics

• Do not delay bleeding control for nonessential diagnostics, full undressing rituals, or perfect vital signs while hemorrhage is active.
• Internal bleeding still needs shock recognition, limited scene time, pelvic binder when indicated, and rapid transport with ongoing care — you cannot pack a ruptured spleen in the field.
• TXA and blood products — only if your system carries them and criteria are met; not a substitute for mechanical hemorrhage control.
• Prevent hypothermia — wet clothes off, warm environment, prevent further heat loss when possible; cold patients clot poorly.
• Teamwork: one provider can hold pressure while another prepares tourniquet/airway — parallel processing wins.
• Scene safety still comes first — you cannot stop bleeding if you become a patient.

Field Pitfalls

• Airway-first habit with obvious arterial extremity bleeding uncontrolled.
• Tourniquet too loose (venous only) so bleeding continues or worsens.
• Removing a working tourniquet in the field without a higher-level plan.
• Long scene times for internal hemorrhage patients who need an OR.
• Forgetting to reassess bleeding after packaging and movement.

Practice

Skills bay: timed tourniquet application to stop simulated flow; then simultaneous pressure + tourniquet with a partner while a third manages verbal airway tasks. Related: Shock categories.

Sources & Further Study

• TCCC / TECC educational concepts; local trauma protocols and tourniquet/packing training.
• Your TXA, blood product, and pelvic binder protocols if carried.