First Aid for Burns, Breaks, and Bleeding: Field Emergency Guide

Step-by-Step Instructions

1. 01

   Controlling life-threatening bleeding: the MARCH protocol and tourniquet application

   The military MARCH protocol (Massive hemorrhage, Airway, Respiration, Circulation, Hypothermia) starts with bleeding control because major hemorrhage kills faster than airway obstruction in most trauma situations. A patient can bleed out from a severed femoral artery in 3–5 minutes. Sequence for major bleeding: (1) Expose the wound — cut clothing away using trauma shears; do not try to remove clothing over a suspected fracture. (2) Assess: is this arterial (bright red, spurting, pulsing) or venous (dark red, flowing)? Arterial bleeding requires tourniquet immediately. (3) Tourniquet first for extremity arterial bleeds — apply 2–3 inches above the wound (proximal to the wound, toward the torso). The CAT tourniquet: route through the buckle, pull tight, secure the buckle, twist the windlass rod until bleeding stops and the patient's distal pulse disappears. Lock the windlass in the clip. Write the time on the strap. (4) For non-tourniquet locations (neck, groin, armpit, shoulder): pack the wound with hemostatic gauze — press in with your fist and hold direct pressure for 3 minutes minimum. Do not release pressure to check; timer-only. Then apply a pressure dressing over the packed wound. (5) Reassess: is bleeding controlled? Is the patient conscious? What is their mental status — alert (A), responds to voice (V), responds to pain (P), or unresponsive (U)? (6) Keep the patient warm and flat — hemorrhagic shock is worsened by cold and by standing.

   Warning: A tourniquet left in place for less than 2 hours virtually never causes permanent nerve or vascular damage in a healthy adult. The fear of "losing the limb from a tourniquet" is outdated and not supported by modern combat medicine data. A tourniquet left in place too long (6+ hours) can cause damage; a tourniquet not applied to an arterial bleed causes death. Apply it. Write the time. Evacuate. Do NOT loosen a tourniquet once applied except under direct physician supervision.
2. 02

   Field fracture assessment and splinting — stabilize before you move

   The primary goal of fracture management in the field is to prevent a closed fracture from becoming an open fracture (bone breaking through skin), to reduce pain and spasm, and to enable safe movement of the patient. You do not need to reduce (reset) a fracture in the field. Splint it where it lies. Assessment steps: (1) Check the Six P's distal to the fracture site: Pain (present?), Pallor (is the skin pale or white?), Paresthesia (is there tingling or numbness?), Pulse (can you feel a pulse distal to the injury?), Pressure (is the skin tight or bulging?), Paralysis (can they move fingers or toes?). Loss of pulse or paralysis = vascular or nerve involvement = urgent evacuation immediately. (2) Expose the limb and check for open fractures — bone visible, severe angulation, skin tenting. Do not push bone back in. Cover open wounds with clean dressings, immobilize in position found. (3) Splinting with a SAM splint: mold the SAM splint to the uninjured limb first (or to the natural resting position), then apply to the injured limb. Immobilize the joint above AND the joint below the fracture. Secure with elastic bandages — firm but not tight enough to cut circulation. Check pulse and sensation distal to the splint every 15–30 minutes. (4) Sling and swathe for upper-extremity fractures: fold a triangular bandage into a sling, support the arm at 90 degrees, tie behind the neck. Swathe (bind the arm to the torso) if the shoulder itself is injured.

   Warning: Pelvic fractures and femur fractures are life-threatening even when closed because of the volume of internal bleeding possible. A femur fracture can cause 1–2 liters of internal blood loss. A pelvic ring fracture can cause 3–4+ liters. If you suspect either, stabilize immediately, treat for shock (keep warm, flat), and expedite evacuation. A traction splint for femur fractures (if available) reduces pain and internal hemorrhage significantly — improvise with two rigid poles and cordage if no commercial traction splint is available.
3. 03

   Burn assessment and treatment: cool it, cover it, don't contaminate it

   Burns are assessed by depth and total body surface area (TBSA). Depth: (1) Superficial (first degree) — red, painful, no blisters (sunburn); heals in 3–5 days without treatment beyond cool water and moisturizer. (2) Partial thickness (second degree) — blisters, weeping, extremely painful; requires proper wound care to prevent infection, heals in 2–3 weeks. (3) Full thickness (third degree) — white, brown, or black; painless because nerve endings are destroyed; requires surgical treatment. TBSA: use the "Rule of Nines" — each arm is 9%, each leg is 18%, the torso front is 18%, torso back is 18%, head is 9%, genitals 1%. A second-degree burn over more than 10% TBSA, or any third-degree burn, requires hospital care. Treatment protocol: (1) Remove the heat source immediately. (2) Cool the burn with cool (not cold, not ice) running water for 20 full minutes. This is the most important step and dramatically reduces burn depth if done within 3 hours of injury. Do not use ice — it causes additional tissue damage. (3) Remove jewelry, watches, and tight clothing near the burn before swelling begins. (4) Cover with a non-adherent burn dressing or clean plastic wrap (cling film — do not use cotton or fluffy material, it sticks). Water-Jel dressings add cooling gel and reduce pain while protecting the wound. (5) Do NOT apply butter, toothpaste, oil, egg white, yogurt, or any home remedy — all increase infection risk and trap heat. (6) Give pain relief (ibuprofen) if available and not contraindicated.

   Warning: Inhalation burns are more dangerous than surface burns. Signs: singed nasal hair or eyebrows, soot around the mouth and nose, hoarse voice, stridor (high-pitched breathing), coughing up carbon. Any suspected inhalation burn is an immediate evacuation emergency — airway swelling can close the airway completely within hours. Seat the patient upright to reduce airway swelling. Administer supplemental oxygen if available.
4. 04

   Shock recognition and field treatment

   Shock is the failure of the circulatory system to deliver adequate oxygen to tissues. In a trauma context, the most common cause is hemorrhagic shock (blood loss). Early recognition of shock is critical because patients can be deceptively alert in early shock and deteriorate rapidly. Signs and stages: (1) Compensated (early) shock — patient is anxious, slightly pale, skin cool and clammy, heart rate elevated (>100 bpm), blood pressure normal or slightly low, mental status normal. The body is compensating. This patient looks "okay" but is not. (2) Decompensated (late) shock — patient is pale or mottled, cold and clammy, heart rate very high (>130 bpm) or paradoxically slowing (very bad sign), blood pressure dropping, altered mental status (confusion, agitation, or stupor). This patient is dying. The decompensation threshold is the point where the body can no longer compensate — it happens suddenly. Field treatment: (1) Control all visible bleeding — the source of the shock. (2) Position: lay the patient flat; elevate the legs 6–12 inches if no suspected spinal, pelvic, or lower extremity fractures. (3) Keep warm — hypothermia accelerates coagulation failure and cardiac arrhythmias in hemorrhagic shock. Use emergency blankets, sleeping bags, anything. The "lethal triad" in trauma is hypothermia + acidosis + coagulopathy — all three worsen shock. (4) Do NOT give food or water to a patient in shock — they may need surgery; an empty stomach reduces complications. (5) Continuous reassessment of mental status and pulse.

5. 05

   When to evacuate vs. manage in the field

   The most critical decision in field medicine: does this patient need hospital care within hours, or can they wait? Evacuate immediately (life threat): arterial bleeding not controlled by tourniquet, suspected inhalation burns, open fractures, pelvic or femur fractures, signs of decompensated shock, any fracture with absent distal pulse, suspected spinal injury, head injury with altered consciousness, any burn >10% TBSA or all third-degree burns, respiratory distress of any cause. Evacuate urgently (within 4–6 hours): open wounds with high infection risk in contaminated environments, fractures of lower extremities in non-ambulatory patients, moderate burns with intact blisters. Manage in field until evacuation available: superficial burns (first degree), closed fractures of arms with intact circulation and sensation, lacerations controlled with pressure and bandaging, sprains and strains. Decision rule: when in doubt, evacuate. You cannot diagnose internal injuries, internal bleeding, or occult fractures in the field. The downside of unnecessary evacuation is a wasted trip. The downside of failing to evacuate a serious injury is death.