MARCH Algorithm
The treatment priority sequence used in tactical medicine, prioritizing the leading preventable causes of death in a deliberate order: Massive Hemorrhage, Airway, Respiration, Circulation, Hypothermia/Head Injury.
In the Field
MARCH is the checklist that keeps you from getting distracted by a loud injury that is not actually killing the patient. Trauma scenes produce visual chaos. There is blood, there is screaming, there is something that demands attention because it looks worst. MARCH forces the discipline of working the algorithm in order. Massive hemorrhage gets fixed before you even look at the airway. Once you can recite MARCH and apply it under stress, you have the foundation of every other tactical medical skill.
Common Mistake
Skipping ahead in the algorithm to address a visually dramatic injury before completing the higher-priority steps that are actually killing the patient.
Technical Detail
The MARCH algorithm is the structured assessment and treatment priority sequence taught in Tactical Combat Casualty Care (TCCC), Tactical Emergency Casualty Care (TECC), and most modern tactical medical training programs. The algorithm replaces the older civilian ABC (Airway, Breathing, Circulation) sequence with a priority order that reflects the actual leading causes of preventable death in tactical and battlefield trauma.
The MARCH sequence:
M - Massive Hemorrhage. Stop life-threatening external bleeding first. This is addressed before airway because uncontrolled extremity hemorrhage kills faster than airway compromise in most tactical trauma. Interventions include tourniquet application, hemostatic wound packing, pressure dressings, and direct pressure. See the Tourniquet, Hemostatic Agent, and Pressure Dressing entries.
A - Airway. Establish or maintain a patent airway. Interventions range from simple positioning (head tilt, jaw thrust, recovery position) and adjuncts (nasopharyngeal airway, oropharyngeal airway) to provider-level interventions (supraglottic airway, surgical cricothyroidotomy). See the Surgical Airway and Cricothyroidotomy entries.
R - Respiration. Assess and address breathing. The primary trauma focus is penetrating chest trauma and tension pneumothorax. Interventions include chest seal application for penetrating wounds and needle decompression for tension pneumothorax. See the Chest Seal, Open Pneumothorax, Tension Pneumothorax, and Needle Decompression entries.
C - Circulation. Assess and address circulation beyond the massive hemorrhage already managed. Interventions include reassessment of bleeding control, IV or IO access, fluid or blood product resuscitation per protocol (with attention to permissive hypotension principles), TXA administration where authorized, and pulse and perfusion reassessment. See the Shock, Radial Pulse, Permissive Hypotension, and TXA entries.
H - Hypothermia / Head Injury. The H is taught with two parallel meanings depending on the curriculum. Hypothermia management addresses the active prevention of body temperature loss, recognized as a contributor to the Lethal Triad. Head injury assessment addresses traumatic brain injury, which is a major source of mortality and requires specific monitoring and (in advanced care settings) modified resuscitation targets. See the Hypothermia and Lethal Triad entries.
Why the order matters. The MARCH order reflects time-to-death from each preventable cause and the proportion of preventable battlefield deaths attributable to each:
Extremity hemorrhage can kill in minutes. Stopping it first preserves the patient long enough to address everything else.
Airway compromise kills in approximately 4 to 6 minutes. Once massive bleeding is addressed, airway is the next time-critical priority.
Tension pneumothorax kills over a longer window, but is identifiable and treatable in the field.
Circulation issues beyond the immediate hemorrhage become addressable once the immediate threats are managed.
Hypothermia and head injury affect long-term outcomes more than minute-to-minute survival, so they appropriately come last in the priority order, while still being part of the standard sequence.
Variations and extensions. Some training programs use extended versions of the algorithm:
MARCH-PAWS. Adds Pain management, Antibiotics, Wounds (dressing of non-life-threatening injuries), and Splints to the basic MARCH sequence for prolonged field care.
MARCHE. Adds Evacuation as a final step.
The basic MARCH sequence is universal across TCCC, TECC, and major civilian tactical trauma programs.
In application. MARCH is intended to be applied in a deliberate, sequential order, but providers may need to manage multiple priorities simultaneously when team size allows. A multi-provider response to a casualty might have one team member managing massive hemorrhage while another manages airway, with both feeding into the broader MARCH-driven sequence.
The discipline of MARCH is what makes tactical trauma response replicable, teachable, and effective under stress. It is the framework that holds nearly every other tactical medical concept together.
The MARCH sequence:
M - Massive Hemorrhage. Stop life-threatening external bleeding first. This is addressed before airway because uncontrolled extremity hemorrhage kills faster than airway compromise in most tactical trauma. Interventions include tourniquet application, hemostatic wound packing, pressure dressings, and direct pressure. See the Tourniquet, Hemostatic Agent, and Pressure Dressing entries.
A - Airway. Establish or maintain a patent airway. Interventions range from simple positioning (head tilt, jaw thrust, recovery position) and adjuncts (nasopharyngeal airway, oropharyngeal airway) to provider-level interventions (supraglottic airway, surgical cricothyroidotomy). See the Surgical Airway and Cricothyroidotomy entries.
R - Respiration. Assess and address breathing. The primary trauma focus is penetrating chest trauma and tension pneumothorax. Interventions include chest seal application for penetrating wounds and needle decompression for tension pneumothorax. See the Chest Seal, Open Pneumothorax, Tension Pneumothorax, and Needle Decompression entries.
C - Circulation. Assess and address circulation beyond the massive hemorrhage already managed. Interventions include reassessment of bleeding control, IV or IO access, fluid or blood product resuscitation per protocol (with attention to permissive hypotension principles), TXA administration where authorized, and pulse and perfusion reassessment. See the Shock, Radial Pulse, Permissive Hypotension, and TXA entries.
H - Hypothermia / Head Injury. The H is taught with two parallel meanings depending on the curriculum. Hypothermia management addresses the active prevention of body temperature loss, recognized as a contributor to the Lethal Triad. Head injury assessment addresses traumatic brain injury, which is a major source of mortality and requires specific monitoring and (in advanced care settings) modified resuscitation targets. See the Hypothermia and Lethal Triad entries.
Why the order matters. The MARCH order reflects time-to-death from each preventable cause and the proportion of preventable battlefield deaths attributable to each:
Extremity hemorrhage can kill in minutes. Stopping it first preserves the patient long enough to address everything else.
Airway compromise kills in approximately 4 to 6 minutes. Once massive bleeding is addressed, airway is the next time-critical priority.
Tension pneumothorax kills over a longer window, but is identifiable and treatable in the field.
Circulation issues beyond the immediate hemorrhage become addressable once the immediate threats are managed.
Hypothermia and head injury affect long-term outcomes more than minute-to-minute survival, so they appropriately come last in the priority order, while still being part of the standard sequence.
Variations and extensions. Some training programs use extended versions of the algorithm:
MARCH-PAWS. Adds Pain management, Antibiotics, Wounds (dressing of non-life-threatening injuries), and Splints to the basic MARCH sequence for prolonged field care.
MARCHE. Adds Evacuation as a final step.
The basic MARCH sequence is universal across TCCC, TECC, and major civilian tactical trauma programs.
In application. MARCH is intended to be applied in a deliberate, sequential order, but providers may need to manage multiple priorities simultaneously when team size allows. A multi-provider response to a casualty might have one team member managing massive hemorrhage while another manages airway, with both feeding into the broader MARCH-driven sequence.
The discipline of MARCH is what makes tactical trauma response replicable, teachable, and effective under stress. It is the framework that holds nearly every other tactical medical concept together.