What is the breakdown of the MARCH (Massive transfusion, Airway management, Respiratory support, Circulation, and Hypothermia/Head injury) algorithm for trauma care?

MARCH Algorithm for Trauma

The MARCH algorithm is a systematic, priority-based approach to trauma care that addresses life-threatening conditions in order: Massive hemorrhage, Airway, Respirations, Circulation, and Hypothermia/Head injury. 1

M - Massive Hemorrhage (First Priority)

Control of massive bleeding takes absolute precedence over all other interventions, as hemorrhage remains the leading cause of preventable death in trauma. 2

Immediate Actions:

• Apply direct pressure and tourniquets to control external hemorrhage before addressing airway or breathing 1
• Initiate massive transfusion protocol (MTP) immediately when indicated - defined as replacement of more than 4 red cell units within one hour 3
• Target transfusion ratio of 1:1:1 (packed red blood cells : fresh frozen plasma : platelets) to approximate whole blood and prevent dilutional coagulopathy 4, 3, 5
• Administer tranexamic acid (TXA) before leaving the emergency room - this is a key quality metric 2

Surgical Control:

• Time from injury to surgical intervention or embolization in hypotensive non-responders should be minimized - this is a critical quality standard 2
• Use damage control surgical techniques for severely injured patients 2

A - Airway Management (Second Priority)

Secure the airway only after controlling massive hemorrhage, but before addressing respiratory issues. 1

Critical Caveat:

• Prehospital intubation is strongly associated with increased hypothermia risk (OR 1.57) - be prepared to aggressively manage temperature when intubating 1
• Maintain cervical spine precautions during airway management in trauma patients 1

R - Respirations (Third Priority)

Address respiratory support after airway is secured, focusing on adequate oxygenation and ventilation. 1

Key Interventions:

• Provide humidified, warmed oxygen to support respiratory function and prevent further heat loss 6
• Treat tension pneumothorax, hemothorax, and other breathing-impairing injuries 1
• Monitor oxygen saturation and adjust ventilation accordingly 1

C - Circulation (Fourth Priority)

Restore circulatory volume and maintain perfusion after controlling hemorrhage and securing airway/breathing. 1

Management Approach:

• Administer warmed intravenous fluids to maintain circulation while preventing hypothermia 7, 6
• Monitor and correct hypocalcemia, which commonly occurs with massive transfusion 4
• Obtain full blood count, PT, fibrinogen, and calcium levels rapidly - time to availability is a quality metric 2
• Consider viscoelastic testing (ROTEM/TEG) if available to guide hemostatic resuscitation 2, 8

H - Hypothermia/Head Injury (Fifth Priority)

Hypothermia prevention and management is critical throughout resuscitation, as it exacerbates coagulopathy and increases mortality. 2

Hypothermia Classification and Treatment:

• Mild hypothermia (34-36°C): Remove wet clothing, increase environmental temperature, apply warm blankets 2, 7
• Moderate hypothermia (32-34°C): Add active external rewarming with heating pads, radiant heaters, and forced warm air blankets 7, 6
• Severe hypothermia (<32°C): Implement active internal rewarming with warmed IV fluids, humidified oxygen, and consider peritoneal lavage 7, 6

Temperature Targets:

• Target minimum core temperature of 36°C before transferring patients between units 7, 6
• Cease rewarming at 37°C, as higher temperatures are associated with poor outcomes 7, 6
• Monitor core temperature every 5 minutes during active rewarming 6

Head Injury Considerations:

• Maintain goal-directed physiologic parameters, as deviations correlate with worse neurologic outcomes and mortality in traumatic brain injury 2
• Avoid hypotension, hypoxia, and hyperthermia in patients with head injuries 2

Critical Implementation Points

The Lethal Triad:

The MARCH algorithm specifically addresses the "lethal triad" of hypothermia, acidosis, and coagulopathy that drives trauma mortality. 4, 3, 5

Protocol Adherence:

• Institutions should implement evidence-based treatment algorithms with checklists to guide management 2
• Adherence to trauma protocols has been shown to reduce massive transfusion rates from 68% to 24% and mortality from 45% to 27% 2
• Deviation from treatment pathways increases mortality three-fold 2

Common Pitfall:

Hypothermia is often overlooked during initial resuscitation despite occurring in two-thirds of severe trauma patients - emphasis must be on prevention first, as rewarming becomes increasingly difficult once significant heat is lost 2, 7