Managing Patients in the Austere Environment utilizing the M.A.R.C.H algorithm: M - Massive Bleeding Control

In our last post, we presented the importance of a systematic approach to patient assessment and treatment in the trauma patient. In the next several posts we will break down the life-saving interventions utilizing the M.A.R.C.H. algorithm in managing patients with traumatic injuries. M. or Massive Hemorrhage needs to be recognized immediately, managed aggressively, and extricated the trauma system. Lets first take a look at the Lethal Triad of Trauma. The three components that make up the triad are Hypothermia, Acidosis, and Presenting Coagulopathy.  Our job as providers is to mitigate this triad by applying Damage Control measures as soon as possible thus, It starts with the first trained hands applied to a patient at the point of wounding that starts the cascade of success through Damage Control in Surgery.  By recognizing and applying the appropriate life-saving interventions to your wounded patient provides for the best outcomes for survival moving through the trauma system.  Whether you are a level one provider in the military or a pre-hospital provider, your ability to critical think and manage your patient greatly reduces the effects of the triad of death.

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Massive Hemorrhage is the leading cause of death both in combat and in America.  If bleeding goes on recognized and is not mitigated immediately than your patient's chances of survival diminishes greatly every minute. 

Massive extremity bleeding can be managed by applying a tourniquet. Understanding how to apply a tourniquet and knowing that this is the best practice for managing massive bleeding greatly enhances your patient's survival.  Tourniquets have come a long way over the past 50 years with the greatest improvements in the past 15 years. Improvements in design like one-handed application, having tourniquets readily available to deploy, has lead to many lives being saved both in combat and on our streets of America.  VAMS has provided our student's  education with many different types of tourniquets.  Each manufacturer has their special features or application technique, so understanding the specific tourniquet you utilize in the field is very important and must be practiced regularly.  Junctional and axillary bleeding can be managed utilizing junctional and auxular tourniquets systems.  Again there are many types that are manufactured so, learn, practice and understand theirs and cons of these devices.  New to the tourniquet family are abdominal tourniquets that are showing good success.  

Wound packing is a best practice in massive hemorrhage control utilizing both gauze and hemostatic agents has been proven to having great success in controlling bleeding in areas of the body that can not be managed using tourniquets.  Recognizing the need to wound pack saves lives and reduces mortality when tourniquets can't be used or in addition to tourniquets.

Direct pressure has been used to control bleeding for hundreds of years and still is a great skill to have when managing trauma.  Knowing when and how to apply direct pressure can save lives.   As mentioned about other medical equipment and supplies, there are many manufactured products that work very well for applying pressure to a wounding site. So understanding the products you carry is vital to success in managing your patients.

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In conclusion, by recognizing the Method of Injury, recognizing massive hemorrhage, and understanding the pros, and cons of your equipment and medical supplies will enhance your ability as a responder to saves lives. Combining all three methods of bleeding control may be required to stop a hemorrhage. Critical thinking and being aggressive with your life-saving treatment interventions as well as exciting the extrication of your patient to the appropriate treatment facility is all part of damage control providing for the best survival outcomes for your patient.

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