Page 127 - JSOM Spring 2018

TABLE 4 (MARCHE) 2
M 2 Massive hemorrhage Massive blood loss is the most likely rapid killer of casualties even in the CBRN environment.
Mask Help casualty don mask or ensure proper seal if protective mask already in place. If a powered air purifying
respirator (PAPR) or self-contained breathing apparatus (SCBA) in place, ensure it is functional.
A 2 Airway Determine if it makes sense to unmask casualty for airway intervention in a contaminated environment.
Determine appropriate airway device that will allow casualty to be re-masked if indicated. Is resuscitator
device individual chemical (RDIC) indicated?
Antidotes If casualty will die before decontamination (i.e., nerve agent exposure or cyanide), administer antidotes
®
(ATNAA, CANA, or Cyanokit ).
R 2 Respirations Determine if respiratory symptoms are caused by agent or trauma.
Rapid spot RSD indicated if agent can be seen on skin or there is a breach in PPE. Apply RSDL, M295, Sorbent, tech
decontamination wipe, or plain irrigation. Rapid decontamination of the eyes with water or normal saline is imperative due to
(RSD) eye sensitivity.
C 2 Circulation Determine if circulation issues are caused by agent or trauma.
Countermeasures Nebulized medications, IV/IO drips, chelation therapy, airway maintenance (suctioning, intubation,
ventilator settings, etc.)
H 2 Hypothermia Prevent hypothermia, especially in setting of decontamination.
Head wounds Determine if altered mental status (AMS) is due to agent or trauma.
E 2 Evacuate Determine evacuation asset. Assess need for further decontamination. Dirty evacuation to a robust
doctrinally complete and fully manned decontamination site may be the best choice if it is available,
especially for extremely deadly agents such as nerve or biological agent. Fill out the CBRN Casualty Card.
Begin prolonged field care and treat “Everything else” if required.
Extraction Every CBRN casualty will require an extraction to effect rescue. The hot line or dirty CCP may be hundreds
of meters or more away from the hot zone. Be cognizant of risk of heat injury to those carrying casualties in
PPE. The nature of the CBRN environment almost always presents casualty extraction problems through the
phases of care (e.g., confined space, vehicle, high angle, etc.).

TABLE 5 TCCC + CBRN = (MARCHE)² Priorities and Phases of Care Summary
Zone Priorities (MARCHE) 2
• Sometimes the agent is like the bullet, think Care Under Fire. M: Massive hemorrhage
• Always ask yourself, “What is killing the casualty now, is it the agent or the wound?” The answer M: Mask check, (PAPR/tank)
to this question dictates your treatments. A: Antidote (ATNAA/CANA)
• Triage
• Only expose what is needed to save life, follow with RSD. A: Airway
Hot • Protect yourself and the casualty from the threat: time, distance, shielding; upwind, uphill, R: Respirations
Zone upstream. R: Rapid spot decontamination
• Heat casualties from operating in PPE is a common injury and may not be agent related. E: Extraction
• Anticipate casualty extraction problem: confined space, vehicle, high angle, etc.
• Getting to the warm zone may require prolonged movement of the casualty.
• Dirty medic (contaminated and cannot cross to cold zone with patient until decontaminated).
• Think Tactical Field Care MAR reassessment
• Always ask yourself, “What is killing the casualty now, is it the agent or the wound?” The answer C: Circulation and shock status
to this question dictates your treatments. C: Countermeasures (drips)
• Triage
• Minimal lifesaving care, get them to the cold zone for definitive care. H: Hypothermia
Warm H: Head wounds
Zone • Replace dirty dressings and tourniquets, and decontaminate indwelling equipment (IV ports, ET
tubes, etc.) or replace as indicated.
• May require advanced airway management (cricothyroidotomy, endotracheal intubation, etc.).
• Cutout and thorough decontamination.
• Do treatments while decontamination is being conducted. “Expose to treat.”
• Hypothermia is a big threat due to exposure during the time it takes to decontaminate.
• Think prolonged field care MARCH reassessment
• Always ask yourself, “What is killing the casualty now, is it the agent or the wound?” The answer E: Evacuation
to this question dictates your treatments.
Cold • Triage
Zone • Hypothermia
• Receiving medical personnel may have little to no experience with CBRN, anticipate fear, misun-
derstanding, requiring another unneeded decontamination process and/or an unwillingness to treat.
• Clean medic (remains on cold zone side of hot line and not exposed to contaminated casualties).

is to quickly transition the patient to the cold zone for defini- personnel when the provider deems it in the best interest of the
tive care. The focus should be on medical interventions nec- casualty to remove the casualty’s PPE in order to provide life-
essary to preserve life while simultaneous decontamination is saving medical intervention. In this circumstance, the mask is
being conducted. removed and the head, face, and chest is quickly decontami-
nated so that the provider can ventilate the patient with an
Decontamination and treatment can be synchronous processes. RDIC (resuscitation device, individual, chemical) and insert
Medical personnel will need to clearly communicate with a sternal IO if countermeasures are immediately indicated.
nonmedical personnel responsible for decontamination. “Ex- Please note that if the provider is on filtered air, the casualty
pose to treat” can be used as a command to decontamination should be as well. It would also be appropriate to prioritize

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