What is the trauma assessment algorithm using MARCH (Massive transfusion, Airway, Respiratory, Circulation, Hypothermia) as a foundation?

MARCH Trauma Assessment Algorithm

The MARCH algorithm provides a systematic, priority-based approach to trauma assessment and management, addressing Massive hemorrhage, Airway, Respirations, Circulation, and Hypothermia/Head injuries in sequential order to reduce preventable trauma deaths. 1

Sequential Assessment and Intervention Priorities

M - Massive Hemorrhage (First Priority)

• Control massive bleeding immediately as the first priority, as hemorrhage remains the leading cause of preventable death in trauma, with mortality reduction from 45% to 27% when protocols are followed. 2

• Apply direct pressure, tourniquets, or hemostatic agents to external bleeding sources before proceeding to airway assessment. 2

• Activate massive transfusion protocols (MTP) early, targeting 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets. 3

• Administer tranexamic acid (TXA) before leaving the emergency room, as this is a key quality metric shown to reduce mortality. 2

• Time from injury to surgical intervention or embolization in hypotensive non-responders should be minimized, with a goal of reducing massive transfusion rates from 68% to 24%. 2

A - Airway (Second Priority)

• Assess airway patency and establish definitive airway control if needed, recognizing that prehospital intubation is strongly associated with developing hypothermia (OR 1.57,95% CI 1.45-1.69). 1

• Secure the cervical spine during airway management in all trauma patients until injury is excluded. 4

• Common pitfall: Prehospital intubation increases hypothermia risk significantly, so aggressive warming measures must be implemented simultaneously. 1

R - Respirations (Third Priority)

• Assess breathing adequacy, chest wall integrity, and bilateral breath sounds. 4

• Provide humidified, warmed oxygen to support respiratory function and prevent further heat loss. 2

• Identify and immediately treat life-threatening thoracic injuries (tension pneumothorax, massive hemothorax, flail chest). 5

C - Circulation (Fourth Priority)

• Define hemodynamic instability as: systolic blood pressure <90 mmHg with evidence of skin vasoconstriction (cool, clammy skin, decreased capillary refill), altered consciousness, and/or shortness of breath, OR blood pressure >90 mmHg but requiring bolus infusions/transfusions and/or vasopressor drugs. 5

• Administer warmed intravenous fluids to maintain circulation while preventing hypothermia. 2

• Obtain full blood count, PT, fibrinogen, and calcium levels rapidly, as time to availability is a quality metric. 2

• Implement goal-directed therapy guided by viscoelastic monitoring (TEG/ROTEM) or standard coagulation values, as this approach improves survival, reduces blood product use by reducing massive transfusion rates, and decreases costs. 2

H - Hypothermia/Head Injuries (Fifth Priority)

Hypothermia Management Algorithm

Temperature-Based Treatment Tiers:

• Mild Hypothermia (34-36°C): 5

  • Remove wet clothing immediately 5
  • Increase environmental temperature 2
  • Apply warm blankets 6
  • Continue monitoring every 5 minutes 2

• Moderate Hypothermia (32-34°C): 5

  • Continue all Level 1 interventions 6
  • Add forced-air warming blankets (increases rewarming rate to 2.4°C/hour vs 1.4°C/hour with passive blankets) 7
  • Apply heating pads and radiant heaters 6
  • Administer warmed IV fluids 2
  • Provide humidified, warmed oxygen 2

• Severe Hypothermia (<32°C): 5

  • Continue all Level 1 and 2 interventions 6
  • Implement active internal rewarming with warmed IV fluids 6
  • Consider peritoneal lavage with warmed fluids 6
  • Consider continuous arteriovenous rewarming (CAVR) 5

Critical Temperature Targets:

• Target minimum core temperature of 36°C before transferring patients between units. 5, 2

• Cease rewarming at 37°C, as temperatures above this threshold are associated with poor outcomes and increased mortality. 5, 2

• Hypothermia below 36.2°C is associated with significantly worse survival (91% vs 98%) and should trigger aggressive warming protocols. 1

• Every 1°C decrease in temperature below 36°C is associated with a 10% increase in blood product consumption during the first 24 hours. 8

Head Injury Management

• 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

• Monitor for progressive hemorrhagic injury, which is reduced with goal-directed therapy. 2

Critical Implementation Points

Protocol Adherence

• Institutions should implement evidence-based treatment algorithms with checklists to guide management, as adherence to trauma protocols reduces massive transfusion rates and mortality. 2

• Deviation from treatment pathways increases mortality three-fold, highlighting the critical importance of protocol adherence. 2

• Introduction of systematic algorithms significantly reduces time in the resuscitation room and reduces mortality in the most severely injured patients (ISS ≥25) from 33.3% to 16.7%. 9

Common Pitfalls to Avoid

• Hypothermia is often overlooked during initial resuscitation despite occurring in two-thirds of trauma patients and being associated with 43% vs 7% mortality. 5

• Current prehospital warming interventions are inadequate, as they were not associated with reduction in hypothermia risk in combat trauma populations. 1

• Emphasis should be on prevention first and treatment second, as it becomes increasingly difficult to rewarm patients once significant heat is lost. 6

• Temperatures below 34°C compromise blood coagulation, representing a critical threshold where coagulopathy begins to develop. 6

Temperature Monitoring

• Use oral or esophageal probes for accurate core temperature monitoring when pulmonary artery catheters are not warranted. 7

• Avoid axillary measurements as they consistently read 1.5-1.9°C below actual core temperature. 7

• Monitor core temperature every 5 minutes during active rewarming. 2