Page 76 - 2023 SMOG Digital

CBRN

2
MARCHE

After initial assessment of casualty in CBRN-threat environment for the presence or absence of CBRN symptoms using
the CRESS algorithm, the integrated assessment and management of TCCC and CBRN injuries can proceed. MARCHE 2
integrates the TCCC MARCH algorithm with the priorities of CBRN treatment. MARCHE 2 is further broken down into
phases similar to TCCC. The “Hot Zone” should be considered as care under fire, addressing only immediate life threats,
“Warm Zone” is tactical field care and “Cold Zone” as tactical evacuation care.
MARCHE 2 Algorithm
TCCC MARCH CBRN MARCHE 2
MASSIVE HEMORRHAGE CRESS Assessment Mask
H
R
• HASTY tourniquets in the HOT ZONE Consciousness: • MASK or CHECK MASK SEAL as immediate
• Transition to DELIBERATE tourniquets during Conscious, Unconscious, depressed HOT ZONE treatment
DECON in WARM ZONE consciousness, AMS, seizures,
agitation, normal Antidote
AIRWAY Respirations: • Utilize CRESS to differentiate chemical agent
• Assess–excessive secretions indicate Normal, increased, decreased, exposure RAPID IDENTIFICATION OF
CHEMICAL WARFARE AGENT
NERVE AGENT distress, delayed onset, apneic, • ATNAA (x3)/CANA (x1) for NERVE AGENT
• Defer most interventions–consider risks in tachypnea, wheezing, immediate • NALOXONE (2mg IM) for OPIOID
O
X
O
L
N
active HOT ZONE of remove mask to access irritation INCAPACITATING AGENT
airway
Eyes: • Can consider Cyanokit® in HOT ZONE for
BLOOD AGENT if symptoms are severe, first
Respirations Normal, constricted (Miosis), dilated action should be removal from area of exposure
(Mydriasis), irritated, painful, and rapid spot decontamination
• Increased respirations consider ATNAA/CANA
NERVE AGENT GUIDELINE Secretions:
L
• Depressed respirations consider NALOXONE None, Increased, Decreased Copious Rapid Spot Decontamination
X
INCAPACITATING AGENT GUIDELINE Secretions (salivation, lacrimation, • Indicated for gross contamination on skin and/
• Other than antidotes–respiratory interventions rhinorrrhea, bronchorrhea), or wounds or if protective gear is breached
is best deferred to WARM ZONE • Rapid exposure and decontamination of
Skin: contaminated wounds is necessary lifesaving
Circulation Normal, Dry and Hot, Flushed, procedure in the HOT ZONE
Erythema, Diaphoresis, Cyanotic, • Apply RSDL, M100, M295, Sorbent, tech wipe,
• Circulation intervention should be deferred to Blisters, Pain etc.
WARM ZONE
• Assess for shock CRESS must be reassessed Countermeasures
regularly, during zone transitions
• IV/IO GUIDELINE and at each transfer, to monitor for
• HYPOTENSION/SHOCK GUIDELINE • Appropriate therapy based on type of agent
delayed onset of life threatening exposure, post initial antidote administration
symptoms, and analyze antidote or • Deferred to WARM ZONE
countermeasure effectiveness

Hypothermia Prevention & Head Injury
O
T
P
• Protect from lethal triad: HYPOTHERMIA, acidosis and coagulopathy through HOT/WARM/COLD ZONES
H
Y
E
R
M
H
I
A
• Active warming or HPMK post decontamination and packaging for further evacuation
B

I
Y
/
T
L
E
N
I
U
G
D
I
E
A
D
• Determine if altered mental status is due to chemical agent or trauma, if trauma HEAD INJURY/TBI GUIDELINE E

H
J
U
R
N
I

Extricate and Evacuate
• EXTRICATE: egress patient from threat, agent contact, HOT ZONE
• Evacuate: to WARM ZONE–Dirty CCP for decontamination
• COUNTERMEASURES and appropriate supportive care starts in WARM ZONE and continues during Evacuation/COLD ZONE
CBRN
Pearls:
• Treatment goals of CBRN is give antidote, extricate from exposure area, conduct spot
decontamination, provide airway support.
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