Managing Patients in the Austere Environment Utilizing the M.A.R.C.H Algorithm- R: Respiratory Management

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Managing Patients in the Austere Environment
utilizing the M.A.R.C.H algorithm
R. Respiratory Management



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 life saving interventions utilizing the M.A.R.C.H. algorithm in managing patients with traumatic injuries.

R. or Respiratory Management needs to be recognized immediately and managed aggressivelyonce we have managed the control of massive hemorrhage. Once again, we need to understand that we are managing the effects and mitigating the negative effects of 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 meaning the first trained hands applied to a patient at the point of wounding starts the cascade of success through Damage Control in Surgery. Recognizing and applying the 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.   


Respiratory compromise is the 2nd leading cause of preventable death secondary to trauma both in combat and in America. If a  victim's inability to breath adequately goes unrecognized and is not mitigated immediately than your patients chances of survival diminishes greatly every minute

Respiratory compromises can be managed by positioning and simple tools while keeping in mind where you are in a tactical situation. Position is the simplest form of respiratory management and patients will typically try to best position themselves to breathe. In the Care Under Fire phase of an tactical operation, Fire superiority, Cover, and managing massive Hemorrhage are the priorities while in the Hot Zone. If we have an opportunity to place a patient in a recovery position during this phase is acceptable as well as in the Tactical Field Care phase of an operation.  This position combined with simple airway position and clearing usually is all that is needed to manage Respiratory compromise.

Victims with penetrating trauma to the chest area from the neck to the navel should have anocclusive dressing applied.  There are many types of dressings available and the provider should have an intimate knowledge of the product that your team uses.  Look for signs and symptoms in difficulty breathing that maybe leading to a tension pneumothorax or hemothorax.  Providing a needle decompression to the effected side or bilaterally can be life saving medical procedure.  There are more complex ways to provide relief to a tension by utilizing chest tubes but they're not something we see being preformed by lower level providers and is not part of most civilian pre-hosptial provider skill sets.  

As we move our patient through the phases of care into the Tactical Extrication Phase of care we can start to provide our patient with supplemental Oxygen, SPo2 and Co2 monitoring as well as a BVM or other mechanical tools to breath for a patient. Critically thinking through the tactical situation, applying proper body positions and utilizing airway and respiratory adjuncts to a victim is not only imperative to tactical mission success, but to the outcome of our patient.  

VAMS provides its students with the education and skills required to support respiratory management through practical experience base training.


 In conclusion, by recognizing the Method of Injury, following the M.A.R.C.H. trauma treatment protocol and systematically managing your patients Bleeding, Airway and Breathing is instrumental to your patients outcomes in the DCS system.  Preventing shock and mitigating the Trauma Triad of traumaCritical thinking through the tactical medical problem and being aggressive with your life saving interventions as well getting your patient extricated and headed to an appropriate treatment facility.  This supports our efforts to advocate your patient through Damage Control process and provides for the best survival outcomes for your patient.

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