The first step in the strategy we just reviewed was to reassess bleeding control measures from massive hemorrhage management. Hemorrhage control in combat casualties takes precedence over fluid resuscitation, even when treating a casualty who is in shock.

If a tourniquet was applied in the CARE UNDER FIRE phase or earlier in your MARCH sequence, assess for effectiveness. If ineffective, replace any limb tourniquet placed over the uniform with one applied directly to the skin 2-3 inches above the bleeding site. Ensure that bleeding is stopped. If a deliberate tourniquet that was placed in TFC is ineffective, apply a second tourniquet side-by-side with the first.

If the wound was packed, consider repacking the wound and reapplying the pressure bandage or moving to a tourniquet for definitive management. If a tourniquet has already been applied to a wound or previously packed and bandaged but is still bleeding, then tighten the original tourniquet, or if that fails to stop the bleeding and eliminate the distal pulse, consider applying a second tourniquet side-by-side, proximal to the original.