Treat every casualty in MARCH order. Do not move to the next letter until the current one is controlled.

1. M, massive hemorrhage: stop the bleeding.
2. A, airway: open it and keep it open.
3. R, respiration: check the chest, seal it, decompress it.
4. C, circulation: pulse, CPR, AED.
5. H, head injury and hypothermia: consciousness, then pain and fractures.

Soldiers use the short form, the 3 Bs: Bleeding, Breathing, Beating. Related guides: Drugs, CBRN, MIST report, CASEVAC, Evacuation.

CLS keeps the casualty alive with non-invasive tools and pre-dosed meds until a Medic arrives.

• You do: everything a soldier does, plus trauma dressings, NPA/OPA, suction bag, chest seal, needle decompression, pulse oximeter, AED in AED mode, autoinjectors and inhalers, SAM splint.
• You do not: IV or IO access, fluids or blood, vial medications, i-gel, surgical airway, thoracostomy, manual AED, fracture realignment, casualty conversion.
• Work in order: bleeding, airway, breathing, circulation, then fractures and pain.

• Tourniquets, pressure bandages, emergency trauma dressings, elastic wraps
• NPA, OPA, emergency suction bags
• Chest seals, NCD kits
• Pulse oximeter, AED
• Paracetamol, Penthrox, naloxone spray, ammonia inhalant
• ATNA and midazolam autoinjectors when a chemical threat is briefed
• SAM splints

Quantities are not set yet.

Stop all external bleeding before anything else.

Tourniquet, emergency trauma dressing, elastic wrap:

1. Limb with many wounds: tourniquet.
2. Body part with many wounds: emergency trauma dressing. It is slower to apply and cannot be used on yourself.
3. Single wounds: pressure bandage.
4. Once stable: elastic wrap over bandaged and clotted wounds.

• Bruising on a body part with a falling blood pressure means internal bleeding. That needs TXA and fluids. Call the Medic.
• A long bleed uses up platelets. After that, wounds stop clotting and bleed faster.
• Tourniquets block IVs on that limb. Take them off once the wounds under them are bandaged.

Every unconscious casualty needs the airway held open, by hand or with an adjunct.

NPA, OPA, suction bag:

• NPA and OPA only go in when the airway is clear. Suction first.
• NPA and OPA do not manage collapse. Only hand maneuvers and the i-gel do.
• Head-tilt chin-lift is an active action. You hold it and do nothing else.
• The recovery position blocks most other treatment.
• A patient vomits a set number of times. Expect to suction more than once.

Seal every penetrating chest wound, then re-assess.

Check breathing (unconscious casualties):

Inspect chest (casualty flat on back, airway clear):

Treatment:

1. Pneumothorax: chest seal. It stops the injury getting worse.
2. Tension pneumothorax: chest seal, then needle decompression with the NCD kit.
3. Hemothorax: chest seal and call the Medic. It needs TXA and a chest tube.

Chest seal, NCD kit, pulse oximeter:

• A pneumothorax worsens for as long as the casualty breathes. Do not leave it.
• Pulse oximeter: under 80 unconscious, under 67 cardiac arrest, under 55 death.
• The reading is less reliable at low blood volume. With systolic under 90 it can be off by up to 30%.

No carotid pulse means cardiac arrest: connect the AED or start CPR at once.

Cardiac arrest drill:

1. Check for a cause you can fix: tension pneumothorax (seal and decompress), blocked airway (clear it).
2. If the casualty has had morphine or fentanyl, give naloxone now. Opioids more than double the time to get a pulse back.
3. Connect the AED and select AED mode. It analyzes, shocks when needed and tells you when to do CPR.
4. CPR for 2 minutes or until the AED prompts, then let it re-analyze. Repeat.
5. No AED: CPR for 2 minutes, carotid pulse check, repeat.

The full flow. The medication box is the Medic's part:

• Signs the pulse is back: cyanosis fades, carotid pulse returns.
• Arrest from blood loss will not resolve with CPR alone. It needs fluids from the Medic.
• Oxygen saturation falls during CPR even at full blood volume. The Medic carries the BVM.

The ACM wiki overview lists no head injury or hypothermia mechanics, so H is the consciousness check, then pain and fractures.

• Unconscious with stable vitals: ammonia inhalant.
• Still unconscious: go back through M, A, R, C. Saturation under 80 keeps a casualty out.
• Conscious: manage pain, then fractures.

CLS gives pre-dosed meds only: pills, inhalers, sprays and autoinjectors.

Paracetamol, Penthrox, naloxone, ammonia:

• Penthrox lowers heart rate. Do not use it on a casualty with a chest injury, slow breathing, low blood volume or altered mental status.
• Naloxone wears off in about 6 minutes. Opioids last longer. Watch the casualty and re-dose.
• Midazolam lowers heart rate and blood pressure.
• Morphine autoinjector is not issued. The unit medication notes treat it as unsafe.

Splint the limb so the casualty can move, and leave realignment to the Medic.

1. Apply a SAM splint.
2. Wrap the splint with an elastic wrap.

• A splint without realignment lets the casualty jog. Realignment plus splint restores sprint.
• Broken legs cause limping. Broken arms increase weapon sway.
• Fractures can worsen over time or with more damage.

Give the Medic the state of the casualty in the order you treated it.

1. Bleeding: where the tourniquets are, what is bandaged, any bruising.
2. Airway: what is in, how often you suctioned.
3. Breathing: chest seals, NCD done or not, last oximeter reading.
4. Circulation: pulse, time in arrest, shocks given.
5. Meds: what, how much, when. Opioids and naloxone above all.
6. Fractures: which limbs are splinted and not realigned.

Send it as a MIST report. See the MIST guide.