Page 124 - JSOM Spring 2018

An Ongoing Series

Integrating Chemical Biological, Radiologic,
and Nuclear (CBRN) Protocols Into TCCC

Introduction of a Conceptual Model—TCCC + CBRN = (MARCHE) 2

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Devin R. DeFeo, 18D, NRP, FP-C ; Melissa L. Givens, MD, MPH *
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ABSTRACT
The authors would like to introduce TCCC [Tactical Combat MARCHE is an acronym used in TCCC to provide a struc-
Casualty Care] + CBRN [chemical, biological, radiological, tured approach to care of the trauma patient using a series
and nuclear] = (MARCHE) as a conceptual model to frame of steps for each letter in “MARCHE” (Table 1). This same
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the response to CBRN events. This model is not intended to acronym can be used in the care of a suspected CBRN-ex-
replace existing and well-established literature on CBRNE posed patient. Given that CBRN events may result in con-
events but rather to serve as a response tool that is an adjunct comitant trauma, the ability to apply the same memory tool
to agent specific resources. in the treatment algorithm allows for an orderly and simpli-
fied approach to an otherwise very complex tactical medical
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Keywords: MARCHE; (MARCHE) ; CBRN; CBRNE; triage; situation. (MARCHE) , pronounced “march squared,” will be
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casualties introduced as a means to integrate CBRN casualty care with
existing TCCC protocols. (MARCHE) combined with an in-
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formed CBRN mindset and understanding of CBRN casualties
Introduction can equip SOF Medics and providers to effectively respond to
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CBRN events**: TCCC + CBRN = (MARCHE) .
The approach to chemical, biological, radiological, and nuclear TABLE 1 MARCHE Acronym as Applied to TCCC
and explosive (CBRNE) events can seem overwhelming due to
the diverse nature of the CBRNE threat and risk of catastrophic M Massive hemorrhage control
outcomes. TCCC is a foundational program that can serve as A Airway management
1–3
a template for how to approach the response to CBRNE events R Respiratory management
in the prehospital and/or Role I level care. TCCC can even be C Circulation
further extended to higher echelons of care when mass casualty H Hypothermia, Head injury
(MASCAL) situations require a systematic approach to maxi- E Evacuate, Everything else (eye wounds, monitoring,
mize scarce resources. The authors would like to introduce analgesia, antibiotics, wound care, burns, fracture care,
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TCCC + CBRN = (MARCHE) as a conceptual model to frame communication, CPR, documentation)
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the response to CBRN events. There are excellent resources that
address response to specific categories of CBRNE events. This CBRN Mindset
model is not intended to replace existing and well-established In addition to application of a familiar acronym, creating a
literature. It is intended to serve as a response tool that is an healthy working mindset for CBRN events is critical. CBRN
adjunct to agent specific resources. CBRN, not CBRNE, is used events elicit a highly charged response. It is important to pro-
deliberately in this framework. Casualties with injuries that re- vide sound reasoning to deescalate heightened stress or emo-
sult from explosions do require special attention; however, this tion that may accompany responding to such events. Myths
is addressed in trauma protocols that cover explosion/blast inju- that can lead to compromised ability to care for CBRN ca-
ries. When referring to CBRN, nuclear events will be addressed sualties must be dispelled and replaced. A modern, rational,
in terms of the radiation exposure associated with the event. and systematic method that maximizes patient outcomes
Additionally, the word “agent” is meant to encompass chemi- while minimizing provider risk is needed (Table 2). The CBRN
cals, biologic toxins, infectious biologic agents, and radiologic mindset provides practical ideas that balance pragmatic care
materials to include those from a nuclear explosion. with provider safety.
*Address correspondence to melissa.givens@usuhs.edu
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1 SFC DeFeo is a a Senior Special Forces Medic, United States Army Special Operations Command, Fort Bragg, NC. COL Givens is an associate
professor, Uniformed Services University of the Health Sciences, Bethesda, MD.
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**The (MARCHE) approach is designed to answer the immediate threats associated with CBRN events. Because many CBRN agents, especially
biologic agents, can cause delayed effects, it is important to combine this approach with surveillance and response programs that address the
agents with insidious onset.
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