Framework: MARCH → then Secondary Injury Management 🩸 M — Massive Hemorrhage (FIRST, ALWAYS) Fractures love to bleed—especially femur, pelvis, open fractures. - Look for life-threatening bleeding - Apply: Tourniquet (high & tight if needed) Pressure dressing Wound packing if open + bleeding - Do not splint before bleeding is controlled 👉 Remember: A broken bone can kill via blood loss. 🫁 A / R — Airway & Respiration Usually intact with isolated fractures, but: - High-energy trauma = reassess - Rib fractures? Watch for: Shallow breathing Increasing pain Signs of pneumothorax 🩸 C — Circulation / Shock Fractures can cause internal bleeding. - Check: Skin (cool, pale, clammy) Mental status Radial pulse - Treat for shock: Lay flat (if safe) Keep warm Control pain if within scope 🧠 H — Hypothermia / Head Injury - Exposed patients lose heat fast - Use: Emergency blanket Jackets / vehicle heat - Head injury + fracture = higher priority 🦴 FRACTURE IDENTIFICATION Suspect a fracture if you see: - Deformity or unnatural angle - Swelling / bruising - Pain with movement - Loss of function - Bone visible = open fracture (medical emergency) ⚠️ If it looks broken, treat it as broken. 🔒 SPLINTING: THE GOLD STANDARD Rule: Immobilize the injury and the joints above and below Steps: 1. Expose the injury 2. Check CSM (Circulation, Sensation, Movement) 3. Realign only if needed to restore circulation (and trained to do so) 4. Pad generously 5. Splint & secure 6. Recheck CSM 🧠 Field-expedient splints: - Rifles (safe & unloaded) - Tourniquet windlass rods - Sticks / trekking poles - Cardboard / magazines - SAM splint = king 👑 🚫 WHAT NOT TO DO - ❌ Don’t ignore bleeding - ❌ Don’t force realignment unless circulation is compromised - ❌ Don’t leave jewelry on (swelling risk) - ❌ Don’t forget reassessment 🎯 SCENARIO (Think It Through) You respond to a vehicle vs pedestrian. Patient has: - Obvious lower leg deformity - Bleeding controlled with pressure - Complains of severe pain

Why “C” Matters You can stop the bleeding and manage airway/breathing—but if circulation fails, shock kills quietly. “C” is about keeping blood moving, organs perfused, and preventing preventable death. What “C” Covers (Plain Language) Circulation focuses on: - Identifying shock - Managing bleeding you may have missed - Supporting blood flow until higher care arrives Think: “Is blood moving where it needs to go?” Step-by-Step: Circulation Check 1️⃣ Recheck for Bleeding (You WILL miss things) - Quickly sweep head-to-toe - Look under clothing, behind legs, armpits, groin - Check tourniquets: Still tight? Bleeding stopped? Time noted? 👉 Rule: If you see blood, fix it before moving on. 2️⃣ Assess for Shock (This Is the Silent Killer) Early signs: - Pale, cool, clammy skin - Fast pulse - Anxiety, restlessness - Thirst Late signs (bad): - Confusion - Weak or absent pulse - Loss of consciousness 👉 You don’t need a BP cuff—use your eyes and hands. 3️⃣ Treat Shock (Simple, Effective Actions) - Lay them flat (if no contraindication) - Keep them warm (blanket, jacket, space blanket) - Control pain & anxiety (calm voice matters) - Do NOT give food or drink - Rapid evacuation / EMS activation 🧠 Cold + blood loss = clot failure. 4️⃣ Capillary Refill & Mental Status (Quick Field Checks) - Press fingernail → refill >2 seconds = poor perfusion - Ask simple questions: “What’s your name?” “Where are we?” “What happened?” Changes = worsening circulation. Common Mistakes to Avoid 🚫 - ❌ Assuming bleeding control = circulation handled - ❌ Ignoring temperature management - ❌ Letting patients sit or walk unnecessarily - ❌ Focusing on gear instead of reassessment Real-World Mindset Shift: Tourniquets save lives—but shock management keeps them alive long enough to matter. Circulation isn’t flashy. It’s discipline, reassessment, and calm control.

Once massive bleeding is controlled, air in and out matters—now. Respiration focuses on life-threatening chest injuries that prevent effective breathing. 🔍 What you’re looking for: - Penetrating chest wounds (front or back) - Sucking chest wounds - Unequal chest rise - Rapid, labored, or shallow breathing - Chest pain or worsening respiratory distress 🛠️ Immediate actions: - Seal open chest wounds with a vented chest seal(If unvented: burp it if breathing worsens) - Expose and check the back—missed exit wounds kill - Monitor breathing continuously - Be alert for tension pneumothorax signs: Increasing difficulty breathing Anxiety / restlessness Diminished breath sounds on one side Worsening despite treatment - 🧠 Mindset shift: Respiratory problems can deteriorate fast. A patient who’s “okay right now” may not stay that way.

A: Airway Why it matters: No airway = no oxygen = no life. What to Look For - Snoring, gurgling, choking - Blood, vomit, broken teeth - Inability to speak clearly What to Do 1. Position patient 2. Jaw thrust / head tilt–chin lift 3. Clear visible obstructions 4. NPA / OPA as appropriate (if trained) Tactical Considerations - Facial trauma = airway risk - Secure airway without losing scene awareness Note: Most airway failures are positioning failures.

MARCH: Massive Hemorrhage – Reassessment Matters 🔴 Scenario You arrive first on scene of a vehicle vs pedestrian crash. A bystander applied a tourniquet to the patient’s left thigh. EMS is 6–8 minutes out. The patient is conscious, pale, and anxious. M – Massive Hemorrhage ✅ What To Do - Reassess the tourniquet Is it high and tight? Is bleeding fully controlled? - If bleeding continues: Tighten the tourniquet until bleeding stops Apply a second tourniquet above the first if needed - Check for hidden bleeding Groin, buttocks, armpits, behind knees - If a tourniquet can’t be placed: Pack the wound and apply direct pressure 👀 What To Look For - Blood soaking through clothing or bandages - Pooling blood beneath the patient - Pale or clammy skin - Fast pulse or increasing anxiety (early shock signs) 🆚 Civilian vs Law Enforcement Response 🧍‍♂️Civilian Focus - Prioritize personal safety - Call 911 early - Use commercial or improvised tourniquets - Apply direct pressure if unsure - Reassess only if safe to do so Goal: Stop the bleeding until help arrives Law Enforcement / First Responder Focus - Ensure scene security - Apply rapid hemorrhage control - Carry and use department-issued TQs and hemostatic gauze - Perform systematic MARCH reassessments - Prepare for handoff to EMS Goal: Stabilize, reassess, and maintain control until transport 👨‍🏫 Instructor Note Tourniquets fail more often from poor placement or hesitation than from overuse. Pain is expected. Bleeding control always comes first. Reassess after movement, stress, or time passes. 🔑 Key Takeaway The first tourniquet isn’t the finish line — reassessment saves lives.