MARCH — Mountain First Aid Algorithm (vs ABCDE)

The MARCH algorithm is a first-aid protocol adapted from combat medicine (Tactical Combat Casualty Care) to mountain rescue. It differs from classic ABCDE by priority — massive hemorrhage first, because in alpine or avalanche terrain arterial limb bleeding kills in 3 minutes, faster than airway obstruction. This article: what MARCH is, when to use it instead of ABCDE, and how to perform each element step by step.

MARCH expanded

• M — Massive haemorrhage — stop first
• A — Airway — clear
• R — Respiration — ensure gas exchange
• C — Circulation — pulse assessment, volume replacement
• H — Hypothermia — prevent further heat loss

Why MARCH, not ABCDE in the mountains

Classic ABCDE (Airway, Breathing, Circulation, Disability, Exposure) works great in hospital and ambulance — with equipment, staff, time. In mountains priorities differ:

• Arterial limb hemorrhage = death in 3 min (thigh can lose 1 L blood per minute). In tactical medicine #1
• Airway obstruction = 4–6 min before irreversible brain damage
• Hypothermia = silent danger added to any other trauma in terrain

In avalanche debris or after a fall the patient may have all three problems simultaneously. MARCH provides the correct intervention order giving best statistical survival chance. Historically from US Navy SEALs experience, then TCCC (Tactical Combat Casualty Care) more broadly, in the last 15 years also in mountain and expedition rescue.

M — Massive haemorrhage

Identification

• Arterial bleeding — bright, pulsating, spurting
• Continuous venous bleeding — dark, flowing steadily
• Blood pool >500 mL around patient
• Soaked dressings or clothing over significant area

Interventions in order

1. Direct pressure — firm at bleeding site for minimum 3 min, don’t lift to check
2. Pressure dressing — rolled gauze or clean cloth + elastic bandage; add more layers if soaked through
3. Tourniquet — when arterial limb bleeding doesn’t stop with pressure. Use CAT (Combat Application Tourniquet), SWAT-T, or improvised wide-tape (min. 4 cm, NOT wire/string). Apply 5–8 cm above wound on bare skin, twist until bleeding stops, record time of application.
4. Junctional bleeding (groin/armpit) — sites unreachable for tourniquet. Strong pressure with knuckle for 3–5 min, then external hemostatic (QuikClot, Celox, Combat Gauze) if available.

Tourniquet can be left up to 2 hours without irreversible damage. With longer application: crush syndrome risk and limb necrosis below tourniquet rise. DO NOT remove tourniquet in the field — rebleeding risk and embolism. Record time and inform hospital staff.

A — Airway

Assessment

Patient speaks calmly and answers questions = airway is clear. Snoring, gurgling, silence = airway compromised. In avalanche specifically: remove snow from mouth and nose, check tongue position.

Interventions

1. Remove foreign bodies — hooked finger sweep, jaw thrust (with suspected cervical spine injury) or head tilt (no suspicion)
2. Recovery position — if unconscious and breathing spontaneously, side position (unless spinal injury suspicion — log-roll)
3. Nasopharyngeal airway (NPA) — if available, insert nasally; better tolerated than OPA in semi-conscious
4. Oropharyngeal airway (OPA) — only in unconscious without gag reflex

R — Respiration

Assessment

Observe chest movement for 10 seconds: rate (normal 12–20/min), symmetry (chest trauma — pneumothorax), depth, respiratory effort. Auscultate (if stethoscope available) — silence in lung field suggests pneumothorax. Palpation — pain, crepitus (rib fractures, subcutaneous emphysema).

Interventions

• Oxygen if available (reservoir mask 15 L/min)
• Open chest wound — three-sided foil dressing (leave one side unsealed as one-way valve) or Asherman chest seal
• Tension pneumothorax (cyanosis, falling pulse, tracheal deviation) — needle decompression 2nd intercostal space mid-clavicular line or 4th/5th anterior axillary line (newer guidelines)
• Chest stabilization — for rib fractures, compression hurts but improves ventilation

C — Circulation

Assessment

• Pulse at carotid (conscious patient — at wrist) — rate, regularity, strength
• Skin color — pale/gray/cyanotic = ischemia
• Capillary refill — nail compression 5 s, count seconds until redness (>2 s = shock)
• Consciousness — disturbances = cerebral hypoperfusion

Interventions

• Trendelenburg position — supine with legs elevated 30–45° if no spinal injury
• IV fluids (if access) — Ringer’s lactate or 0.9% NaCl, 250–500 mL bolus, then 500 mL/h (target: palpable radial pulse)
• Maintain warmth — hypothermia worsens shock (see H below)
• Stop all bleeding before volume replacement (“dilutes” blood)

H — Hypothermia

Last MARCH element — but equally critical. Every trauma patient in mountains is at hypothermia risk, even in warm season, because combination: lying still, blood loss, metabolic stress, wind exposure = rapid heat loss. Hypothermia added to trauma >3× increases mortality.

Interventions

• Insulate from ground — backpack, pad, branches
• Wind-proof cover — emergency blanket, bothy bag, tarp
• Replace wet clothing with dry (cut with scissors if needed)
• Chemical warmers — centrally (chest, armpits, groin); NEVER on extremities
• Warm drinks — only in conscious, able to safely swallow, NOT in abdominal trauma (surgery risk)
• Monitor core temperature — if rectal thermometer available

Practical workflow: MARCH in 60 seconds

1. Seconds 0–10: Look, listen — is there massive hemorrhage? If YES, apply tourniquet/dressing (15–30 s). If NO, move on.
2. Seconds 10–20: Open airway — remove blockages, recovery position if unconscious
3. Seconds 20–30: Assess breathing — chest movement, rate, symmetry. Pneumothorax/open wound intervention if visible.
4. Seconds 30–45: Pulse, skin color, consciousness. Anti-shock position.
5. Seconds 45–60: Thermal insulation — emergency blanket under back, windbreak.
6. After first minute: Detailed secondary assessment, call for help, evacuation prep.

Frequently asked questions

References

• Committee on Tactical Combat Casualty Care (TCCC). Tactical Combat Casualty Care Guidelines, 2024 update. deployedmedicine.com.
• Butler FK, Holcomb JB, Giebner SD, et al. Tactical Combat Casualty Care 2007: evolving concepts and battlefield experience. Mil Med. 2007;172(11 Suppl):1–19.
• Zietlow JM et al. Prehospital Use of Hemostatic Bandages and Tourniquets: Wilderness Medical Society Practice Guidelines. Wilderness Environ Med. 2015;26(3):411–416.

Disclaimer: Full MARCH application requires medical training. Courses: Wilderness First Aid (WFA), Wilderness First Responder (WFR). This article is educational.