The ABCs of Trauma Care: Airway, Breathing, Circulation Under Fire

In emergency medicine, the ABCs—Airway, Breathing, and Circulation—are the foundation of trauma care. These priorities guide EMTs, paramedics, and first responders in treating critical injuries. However, in tactical situations where danger remains, the standard approach must change. Tactical medics don’t throw out the ABCs; they adapt them to match the urgency and unpredictability of real-world threats.

When trauma care has to happen in the middle of an active threat, traditional protocols aren’t always enough. That’s where frameworks like TCCC (Tactical Combat Casualty Care) and TECC (Tactical Emergency Casualty Care) come in. They provide medics with strategies to deliver life-saving treatment while staying safe and supporting the team.

A Quick Recap: The Traditional ABCs

In typical EMS settings, trauma care begins with:

• A: Airway – Make sure the airway is open and protected.

• B: Breathing – Support adequate ventilation.

• C: Circulation – Stop bleeding and maintain blood flow.

This sequence is designed to address the most significant threats first. If someone’s airway is blocked, time is of the essence. If they’re losing blood, every second counts. In a safe environment, providers can follow this sequence in a calm and controlled manner.

Tactical Environments Call for MARCH

In tactical medicine, the priorities shift. The model becomes MARCH:

• M: Massive Hemorrhage

• A: Airway

• R: Respiration

• C: Circulation

• H: Head Injury/Hypothermia

Why the change? Massive bleeding is the leading cause of preventable death in tactical settings. If it isn’t handled immediately, nothing else matters.

Tourniquets, pressure dressings, and hemostatic agents take top billing here. They're fast, simple tools that stop bleeding before it becomes fatal.

Care Under Fire: First, Survive

Real-World Scenario: During a nighttime SWAT operation, a team member was hit in the leg by shrapnel from an explosive breach. With rounds still flying and visibility low, the tactical medic crawled under cover, applied a tourniquet one-handed over the pants, and dragged the casualty behind a barrier. Only once the area was secure did they begin further treatment. It wasn’t picture-perfect, but it saved the officer’s life.

In a high-risk environment, such as a firefight, raid, or mass casualty event, the primary priority is survival. Tactical medics constantly ask: Can I treat this person without putting myself or others in danger?

During the Care Under Fire phase:

• The focus is on cover and movement, not full treatment.

• Medics apply tourniquets fast, often one-handed and typically in under 30 seconds, even through clothing.

• Airway and breathing support wait until the scene is safer.

This isn’t about doing less. It’s about doing what’s possible when every second and every movement matters.

Airway: Fast, Simple, Effective

In tactical settings, airway management sticks to what works quickly:

• If the person is talking, the airway is open.

• If the person is unconscious but breathing, use a nasopharyngeal airway (NPA).

• Use the recovery position or jaw thrust as needed.

Advanced airways, such as surgical crics, are only used later, in safer conditions.

Breathing: Watch the Chest

Once the airway is clear, medics check for chest trauma. Gunshot or blast injuries can lead to tension pneumothorax, which requires immediate attention.

Tactical medics:

• Look for entry and exit wounds.

• Apply chest seals front and back as needed.

• Watch for uneven chest rise or difficulty breathing.

• Use needle decompression when necessary.

Again, timing is everything. If the area isn’t safe, some treatments may need to wait.

Circulation: Beyond the Obvious

With major bleeding under control, medics shift focus to less visible threats:

• Suspect pelvic injuries; use a binder.

• Check for abdominal bleeding (swelling, tightness).

• Stabilize long bone fractures when there’s time.

Fluids are limited. The goal is permissive hypotension to keep blood pressure just high enough to maintain organ function without worsening internal bleeding.

Hypothermia and Head Injuries

Two silent killers that tactical medics are always watching for:

• Hypothermia: Trauma patients lose body heat fast. Blood doesn’t clot well if it’s cold. Medics insulate with wraps, blankets, or even gear.

• Head injuries: Look for confusion, sluggish pupils, or strange behavior. These signs may point to a traumatic brain injury and call for urgent evacuation.

From Training to Action: Be the One Who's Ready

Tactical medicine isn’t about textbook perfection. It’s about calm, confident action under pressure. Medics learn to think clearly, act fast, and adapt to the situation without losing focus.

At TAC-MED, we train responders to do just that. Our programs include:

• The complete MARCH sequence, hands-on

• Realistic scenarios with stress-based decision-making

• Hemorrhage control, airway support, and casualty movement

• Practical tools for field care under extreme conditions

We don’t just teach skills. We train the judgment and mindset to use them.

If you’re just getting started, our Self-Aid / Basic Tactical Aid course is a great way to build confidence. It’s designed for civilians, first responders, and anyone who wants to be ready when it matters most.

Ready to take the next step? Explore our tactical medical training programs today. Whether you're in EMS, law enforcement, military service, or want to be better prepared, TAC-MED provides you with the tools and training to act when every second counts.

Contact us to learn more.