Trauma Care Basics: Bleeding, Shock & Airway

In a trauma emergency — vehicle accident, serious fall, penetrating wound — three things kill people fastest:

1. Uncontrolled bleeding (hemorrhage)
2. Airway obstruction
3. Shock

Everything else — fractures, burns, concussions — is serious, but these three are the ones measured in minutes. Understanding them, and having basic supplies and skills to address them, is the core of trauma preparedness.

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Understanding the Timeline

Severe arterial bleeding: A severed femoral artery can cause death in 3–5 minutes.

Airway obstruction: Brain damage begins after 4–6 minutes without oxygen. Death follows.

Shock: Progresses over minutes to hours depending on severity. Compensated shock can appear deceivingly stable before rapid decompensation.

What this means: In a mass casualty or grid-down scenario, you often won’t have 10 minutes for professional help to arrive. The first responder to many trauma emergencies is whoever is standing there.

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The MARCH Protocol

MARCH is the trauma response framework used by military and wilderness medicine. It provides a priority order for addressing life threats:

M — Massive hemorrhage (control life-threatening bleeding first) A — Airway (ensure the airway is open and maintained) R — Respiration (address chest injuries affecting breathing) C — Circulation (address shock, secondary circulation problems) H — Hypothermia/Head injury (prevent heat loss; monitor consciousness)

This guide covers M, A, and C — the three most immediately life-threatening.

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M: Massive Hemorrhage — Controlling Severe Bleeding

The Stop the Bleed program, developed with the Hartford Consensus and widely deployed to civilian first responders, identifies three techniques for hemorrhage control, in order:

1. Tourniquet (Limb Injuries)

For severe bleeding from an arm or leg, a tourniquet is the most effective intervention and the current standard of care in emergency medicine and military trauma.

When to use a tourniquet:

• Bleeding from a limb that cannot be controlled by direct pressure
• Amputation
• Any limb wound with spurting or rapidly soaking blood loss

How tourniquets are taught to work (per Stop the Bleed and TCCC training):

• Apply 2–3 inches above the wound (not on a joint)
• Tighten until bleeding stops — this requires firm pressure; mild discomfort is expected
• Note the time of application
• Do not remove once applied — removal requires medical assessment

The CAT (Combat Application Tourniquet) and SOFTT-W are the most studied and widely validated civilian tourniquets. Purchase genuine, certified products — counterfeits exist.

2. Wound Packing with Hemostatic Gauze (Junction and Torso Wounds)

Wounds at junctions — groin, armpit, neck — and torso wounds cannot have a tourniquet applied. For these, wound packing is the technique taught in hemorrhage control training:

• Pack hemostatic gauze directly into the wound, as deep as possible
• Apply continuous firm pressure — this requires real physical effort
• Maintain pressure for a sustained period (3–5 minutes minimum per training)
• Apply an Israeli bandage or pressure dressing over the packing to maintain pressure

QuikClot (kaolin-impregnated) gauze and Combat Gauze are the standard hemostatic products validated for wound packing.

3. Direct Pressure (Minor-to-Moderate Bleeding)

For wounds that are not immediately life-threatening:

• Apply firm, continuous pressure with a clean dressing
• Do not remove and check — maintain continuous pressure for a minimum of 5–10 minutes
• Add dressings on top if soaking through; do not remove the original dressing

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A: Airway — Keeping the Passage Open

An unconscious person loses muscle tone, and the tongue can fall backward and obstruct the airway. Airway obstruction is silent and fast — it can happen without the dramatic choking presentation most people expect.

Positioning for an Unconscious, Breathing Person

If a person is unconscious but breathing, and has no suspected spinal injury:

• Recovery position: Roll them onto their side, support with the bent upper knee, tilt the head back slightly to keep the airway open.
• This prevents the tongue from blocking the airway and prevents choking on vomit.

Head-Tilt Chin-Lift

For an unresponsive person with no suspected neck injury:

• Place one hand on the forehead, two fingers under the chin
• Tilt the head back, lift the chin forward — this extends the airway and lifts the tongue off the back of the throat

Rescue Breathing

If a person is not breathing adequately, CPR guidelines (American Heart Association / American Red Cross) provide the current evidence-based approach. Hands-only CPR — chest compressions without rescue breathing — is currently recommended for bystanders in cardiac arrest situations and is highly teachable.

If you have not taken a CPR course recently, the American Red Cross and American Heart Association both offer widely available courses and online refreshers.

Nasopharyngeal Airway (NPA)

An NPA is a flexible tube inserted through the nostril to maintain airway patency in an unconscious patient. It’s significantly easier to use correctly than an oral airway and is included in many advanced first aid kits. Its use requires training to understand correct sizing and insertion technique.

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C: Circulation — Recognizing and Managing Shock

Shock is a state of inadequate tissue perfusion — the body is not getting enough oxygen to its tissues. In trauma, hemorrhagic shock (from blood loss) is the primary concern.

Signs of Shock

• Rapid, weak pulse
• Pale, cool, clammy skin
• Rapid breathing
• Altered mental status (confusion, anxiety, unresponsiveness)
• Dizziness or fainting

These signs can appear even when external bleeding is controlled — internal bleeding causes shock without visible blood loss.

What You Can Do

Position: Lay the patient flat. If blood pressure is low, some training references describe elevating the legs — though current TCCC guidance focuses on treating the underlying cause and keeping the patient warm rather than positioning as a primary intervention.

Keep warm: Hypothermia worsens shock significantly. A hypothermic, shocked patient deteriorates faster. Cover with a blanket, emergency bivy, or whatever insulation is available.

Prevent further blood loss: Ensure all identified bleeding is controlled before addressing other injuries.

Reassess: Shocked patients can deteriorate quickly. Monitor breathing, pulse, and responsiveness continuously.

Transport: Shock requires definitive medical care. All interventions are supportive bridges to hospital treatment. If there is any possibility of getting professional medical care, pursue it.

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When to Prioritize Evacuation

All of these interventions are temporary stabilization measures. The goal is always to get the patient to definitive medical care as quickly as possible.

Evacuate immediately for:

• Chest wounds (potential pneumothorax)
• Penetrating abdominal injury
• Head trauma with altered consciousness
• Suspected internal bleeding
• Shock that doesn’t respond to stabilization measures
• Any injury beyond your training and equipment to manage

Knowing when something is outside your capability is as important as knowing how to act.

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Building the Trauma Skill Set

The knowledge in this article is a starting point. The skills require hands-on practice:

Course	Provider	Focus
Stop the Bleed	stopthebleed.org	Hemorrhage control (free/low cost)
First Aid / CPR	Red Cross, AHA	General first aid and CPR
CERT	FEMA / local fire	Community emergency response
Wilderness First Responder (WFR)	NOLS, SOLO, others	Extended care, no-evac scenarios

The Wilderness First Responder certification is particularly relevant for preparedness — it specifically addresses managing medical emergencies when definitive care may be delayed or unavailable. It’s a multi-day intensive course widely offered by outdoor education organizations.