Emergency medical assessment
When someone collapses or is injured, the difference between a good outcome and a preventable death is often the order in which problems are addressed. Bystander cardiopulmonary resuscitation (CPR) survival rates for out-of-hospital cardiac arrest hover around 10–12% nationally — but trained bystanders who act in the first few minutes can triple those odds. The problem is not a lack of caring. It is a lack of a framework that works under pressure. Massive hemorrhage, Airway, Respiration, Circulation, Hypothermia (MARCH) and ABCDE are that framework: structured, fast, and field-proven across military and civilian contexts.
Educational use only
This page provides general educational information for emergency preparedness scenarios. It is not a substitute for professional medical training, diagnosis, or treatment. Patient assessment requires hands-on practice to execute effectively under stress. Always seek formal training through programs described in medical training and call emergency services when available.
Scene safety and initial approach
Every assessment begins before you touch the patient. Rushing to a downed person without evaluating the scene can turn a single casualty into two.
Scene size-up — run through this in 5–10 seconds:
- Is it safe to approach? Look for ongoing hazards: traffic, active threat, fire, downed power lines, structural collapse, toxic fumes. If the scene is unsafe, do not approach until the hazard is controlled.
- Mechanism of injury (MOI): What happened? A fall from 10 feet (3 m) implies spinal injury. A blast suggests multiple body regions affected. MOI guides what you look for before you find it.
- How many patients? One victim or several? If multiple, triage principles apply before individual assessment.
- Do you need help? Call emergency services (or dispatch a bystander to call) before beginning assessment. Send someone for an automated external defibrillator (AED) if cardiac arrest is possible.
- Personal protective equipment: Gloves before contact with any patient. Mask or barrier device if rescue breathing may be needed. If gloves are unavailable, use any barrier — plastic bag, clothing — between your hands and the patient's blood.
Approaching the patient: Move deliberately, not frantically. Announce yourself — "I'm here to help, don't move" — before touching a trauma patient. If the person is responsive, introduce yourself and ask what happened. Their answer tells you airway is open, breathing is present, and brain is perfused. Three problems ruled out in one sentence.
MARCH vs. ABCDE — choosing the right framework
Two protocols dominate prehospital assessment. They are not opposites — they reflect different threat environments.
MARCH (tactical and trauma)
Developed through Tactical Combat Casualty Care (TCCC) and adapted for civilian use by the Committee for Tactical Emergency Casualty Care (C-TECC) as TECC. MARCH prioritizes massive hemorrhage first because uncontrolled bleeding kills faster than airway obstruction in penetrating trauma.
| Letter | Step | Rationale |
|---|---|---|
| M — Massive hemorrhage | Identify and stop life-threatening external bleeding | Hemorrhage causes 30–40% of trauma deaths; most are preventable with early control |
| A — Airway | Open and maintain the airway | A patent airway is useless if the patient has bled to death before you reach it |
| R — Respirations | Assess breathing quality and treat thoracic injuries | Tension pneumothorax and open chest wounds must be treated here |
| C — Circulation | Check pulse quality, treat shock | Assess for internal bleeding signs; apply fluid resuscitation if available |
| H — Hypothermia/Head injury | Prevent or treat hypothermia; assess neurological status | Hypothermia accelerates coagulopathy; unrecognized head injury causes delayed deterioration |
Use MARCH when: The patient has penetrating trauma (gunshot, stab, blast), active external bleeding is visible, or the setting involves a high-threat environment where both you and the patient may be exposed to ongoing danger.
ABCDE (civilian primary survey)
The Advanced Trauma Life Support (ATLS) primary survey and standard civilian EMS framework. Appropriate for blunt trauma, medical emergencies, and any setting where massive hemorrhage is not the primary threat.
| Letter | Step | Key thresholds |
|---|---|---|
| A — Airway | Open? Clear? Maintained? | Jaw thrust for suspected spinal injury; head-tilt/chin-lift otherwise |
| B — Breathing | Rate, depth, equality, effort | Normal: 12–20 breaths/min (adult); >30 or <8 = critical |
| C — Circulation | Pulse rate, quality, skin color/temperature | No radial pulse = systolic BP likely below 80 mmHg |
| D — Disability | Level of consciousness, pupils | Use AVPU or GCS; unequal pupils suggest brain herniation |
| E — Exposure | Full-body exam for hidden injuries; prevent heat loss | Undress to assess, then cover to preserve temperature |
Use ABCDE when: The patient has blunt trauma (fall, vehicle collision), a medical emergency (chest pain, stroke, overdose), an unknown mechanism, or you are operating in a stable civilian environment.
Field note
In practice, MARCH and ABCDE are not mutually exclusive. Many experienced providers run MARCH for the first pass on any trauma patient — because missing life-threatening hemorrhage while assessing an airway kills patients — then convert to ABCDE thinking for systematic secondary survey. If you only learn one framework for trauma, learn MARCH.
Massive hemorrhage control (the M in MARCH)
Before doing anything else in a trauma patient with visible external bleeding: stop the bleeding.
Decision sequence:
- Is it a limb injury? If the extremity is bleeding severely and a tourniquet can be placed, apply it 2–3 inches (5–7.5 cm) proximal to the wound. Tighten until bleeding stops. Record the time. See bleeding control for full tourniquet technique.
- Is it junctional (groin, armpit, neck)? A tourniquet cannot be placed here. Apply hemostatic gauze packed directly into the wound and maintain sustained direct pressure for at least 3 minutes.
- Is it truncal? You cannot tourniquet the torso. Pack the wound, apply a pressure dressing, and prioritize rapid transport.
Threshold for action: If blood is pooling rapidly, soaking through clothing, or pulsing with heartbeats, the hemorrhage is life-threatening. Act immediately. You do not wait for an assessment to complete before stopping a femoral artery from bleeding.
Airway assessment
A compromised airway is fatal within minutes. Check it second in MARCH, first in ABCDE.
Is the airway open?
- Conscious, talking normally → airway is open
- Gurgling → fluid (blood, vomit, secretions) in the airway — suction or finger-sweep and position
- Snoring → tongue partially occluding — open with head-tilt/chin-lift or jaw thrust
- Stridor (high-pitched wheeze on inhalation) → partial upper airway obstruction — urgent intervention needed
- Silent — no airway sounds, no chest movement → complete obstruction or respiratory arrest
Opening maneuvers:
| Technique | When to use | How |
|---|---|---|
| Head-tilt/chin-lift | No suspected spinal injury | Place one hand on forehead, two fingers under chin bony prominence, tilt head back while lifting chin |
| Jaw thrust | Suspected spinal injury (trauma mechanism) | Two hands on jaw angles, push jaw forward and up without moving the neck |
| Recovery position | Unconscious, breathing, no spinal concern | Roll to side, support head, position to drain secretions |
Airway adjuncts (Tier 3 kit): Nasopharyngeal airway (NPA) — a soft rubber tube inserted through the nostril — maintains the airway in unconscious patients who may still have a gag reflex. Contraindicated in suspected skull base fracture.
Respiratory assessment
Breathing rate and quality give you more information faster than almost any other assessment.
Normal respiratory rates by age group
| Age group | Normal range | Concerning |
|---|---|---|
| Adult (≥18) | 12–20 breaths/min | < 8 or > 30 |
| Child (1–12) | 18–30 breaths/min | < 10 or > 40 |
| Infant (<1 year) | 30–60 breaths/min | < 20 or > 60 |
Assessment technique: Watch the chest rise for 30 seconds, multiply by 2 to get breaths per minute. Simultaneously assess:
- Depth: Are both sides of the chest rising equally? Unequal movement suggests pneumothorax, hemothorax, or splinting from pain.
- Effort: Is the patient using neck or shoulder muscles to breathe? Labored breathing at any rate is concerning.
- Sounds: Crackling = fluid in lungs. Wheezing = lower airway constriction. Absence of breath sounds on one side = pneumothorax until proven otherwise.
Life threats to identify during respiratory assessment:
- Tension pneumothorax: Absent breath sounds one side + tracheal deviation away + hypotension + distended neck veins. Requires needle decompression if trained; evacuate immediately if not.
- Open chest wound: Sucking chest wound — seal with a commercial vented chest seal or improvised occlusive dressing taped on three sides (leave fourth side open to allow air escape, prevent tension).
- Flail chest: Three or more adjacent ribs fractured in two places. Visible paradoxical movement of chest wall — that segment moves in during inspiration, out during expiration. Stabilize with bulky padding; positive pressure ventilation if available.
Circulation assessment
Pulse assessment:
Check the radial pulse (wrist) first. A palpable radial pulse indicates systolic blood pressure is approximately 80 mmHg or above. No radial pulse but carotid pulse present suggests systolic BP is 60–80 mmHg — shock is established.
Normal vital signs by age group
| Parameter | Adult | Child (1–12) | Infant (<1 yr) |
|---|---|---|---|
| Heart rate (beats/min) | 60–100 | 70–120 | 100–160 |
| Systolic BP (mmHg) | 90–140 | 80–120 | 70–100 |
| Respiratory rate (breaths/min) | 12–20 | 18–30 | 30–60 |
| Temperature | 97–99°F (36.1–37.2°C) | 97–99°F | 97–99°F |
| SpO2 (pulse oximetry) | ≥95% | ≥95% | ≥95% |
Shock indicators — the triad of poor perfusion:
- Skin: pale, cool, clammy (peripheral vasoconstriction diverting blood to core)
- Mentation: anxious, confused, or combative (decreased cerebral perfusion)
- Pulse: rapid and weak ("thready")
For full shock assessment and treatment protocol, see shock management.
Disability — level of consciousness
Two standardized scales. Use both.
AVPU scale
Fast, one-minute assessment. Use it during primary survey.
| Letter | Meaning | Clinical significance |
|---|---|---|
| A | Alert — fully awake and oriented | Normal |
| V | Responds to Voice — opens eyes or responds when spoken to | Altered consciousness — investigate cause |
| P | Responds to Pain — responds only to painful stimulation (sternal rub, nail bed pressure) | Significant impairment — protect airway |
| U | Unresponsive — no response to any stimulus | Critical — airway at immediate risk |
A patient who was A on your first contact and is now V or P has deteriorated. This is an urgent sign — reassess immediately.
Glasgow Coma Scale (GCS) overview
Used in hospital and advanced field settings for more precise tracking. Scores three domains:
| Domain | Range | Normal |
|---|---|---|
| Eye opening | 1–4 | 4 (spontaneous) |
| Verbal response | 1–5 | 5 (oriented conversation) |
| Motor response | 1–6 | 6 (obeys commands) |
Total score: 3–15. GCS ≤8 = severe impairment; intubation considered in hospital settings. In the field, GCS 13–15 = minor, 9–12 = moderate, ≤8 = severe. Record the score and recheck every 15–30 minutes — trend is more important than a single number.
Pupils: Check with a penlight. Normal: round, equal, reactive to light (constrict when light shines in). Abnormal: - Unequal (anisocoria) + altered consciousness: suspect brain herniation from head injury or stroke - Both fixed and dilated: severe brain injury, cardiac arrest, or certain drug exposures - Pinpoint: opioid overdose, pontine bleed
Patient positioning
Positioning prevents secondary injury and manages immediate problems.
| Situation | Position | Rationale |
|---|---|---|
| Unconscious, breathing, no spinal concern | Recovery position (lateral, stable side-lying) | Keeps airway draining; prevents aspiration of vomit |
| Suspected spinal injury | Supine, in-line stabilization | Minimize movement; logroll only if airway management required |
| Suspected shock (hypotension without respiratory distress) | Supine, legs elevated 6–12 inches (15–30 cm) | Improves venous return to core; do not elevate if head injury suspected |
| Chest injury, respiratory distress | Semi-recumbent (45°), injured side down | Reduces work of breathing; allows unaffected lung to expand fully |
| Pregnant patient (>20 weeks) in shock | Left lateral tilt (15–30°) | Prevents aortocaval compression by uterus |
| Alert trauma patient, stable | Position of comfort | Reduces pain; patient's own guarding often optimizes their mechanics |
Exposure and secondary survey
Exposure: Identify hidden injuries by exposing the body — cut away clothing if necessary. Use trauma shears along seams to avoid moving the patient more than needed. Look for entrance and exit wounds, bruising patterns (seatbelt sign across abdomen = internal injury concern), deformity.
Hypothermia prevention: Every exposed trauma patient loses heat. After examination, cover with a space blanket or any dry insulation. Wet clothing against skin accelerates heat loss. The trauma triad — hypothermia, acidosis, coagulopathy — is self-reinforcing and causes many patients who survive the initial injury to deteriorate and die.
Secondary survey: Head-to-toe assessment after life threats are addressed. Scalp (palpate for depressed skull fracture), face, neck (tracheal position, JVD, crepitus), chest (equal expansion, rib tenderness), abdomen (guarding, rigidity, distension), pelvis (stability — compress gently), extremities (pulse, motor, sensation in each), back (log-roll to examine).
Handoff report — SBAR and MIST
When emergency services arrive or you transfer care, a structured verbal report prevents information from being lost. Two formats are standard:
MIST (trauma handoff)
Preferred for trauma patients:
| Letter | Content | Example |
|---|---|---|
| M — Mechanism | How was the patient injured? | "GSW to the right thigh, approximately 20 minutes ago" |
| I — Injuries | What injuries have you identified? | "Through-and-through wound, controlled with tourniquet at 14:23" |
| S — Signs | Vital signs and level of consciousness | "HR 110, RR 20, alert and oriented, GCS 15, pale and diaphoretic" |
| T — Treatment | What have you done? | "Tourniquet applied, one liter NS infused, oxygen via NRB at 15 L/min" |
SBAR (medical/non-trauma handoff)
| Letter | Content |
|---|---|
| S — Situation | "I have a 62-year-old male with sudden onset chest pain and shortness of breath" |
| B — Background | "History of hypertension, takes metoprolol. Pain onset 30 minutes ago, radiates to left arm" |
| A — Assessment | "Vital signs: HR 98, RR 22, SpO2 91%. Diaphoretic, pale. Concerned for ACS" |
| R — Recommendation | "Requesting ALS intercept. Patient needs 12-lead ECG and nitrates" |
Write it down: Record the time of injury, time of each intervention, vital sign trends, and medications given with times and doses. Emergency responders use this information to make treatment decisions. A card in a medical kit with fields for time, HR, RR, GCS, interventions, and medications is worth carrying.
Assessment readiness checklist
- Memorize the MARCH sequence: Massive hemorrhage → Airway → Respirations → Circulation → Hypothermia/Head injury
- Memorize ABCDE and normal adult vital sign ranges
- Practice head-tilt/chin-lift and jaw thrust maneuvers on a CPR mannequin or willing adult
- Know the AVPU scale — you can assess level of consciousness in 10 seconds
- Practice counting respiratory rate: 30-second count × 2
- Build a MIST handoff habit — write down mechanism, injuries, signs, and treatment for every drill
- Review bleeding control for hemorrhage management details
- Review shock for circulation assessment and treatment
- Review training options to practice assessment in a structured course
Assessment frameworks only work if they have been practiced before the emergency. A MARCH or ABCDE protocol read from a card under stress is far slower and less reliable than one that has been drilled until it is automatic. The investment is a weekend course and quarterly 15-minute household practice — return on that investment is a potentially saved life.