What Changed in TCCC for 2026

The Committee on Tactical Combat Casualty Care published the current TCCC Guidelines on May 1, 2026. CoTCCC does not update on a calendar. Changes drop when the evidence supports them, and this cycle brought a meaningful set. The published guidelines explicitly call out airway management and traumatic brain injury management in tactical field care as the focus areas for this update. If you teach TCCC, run a tactical medicine program, or stock kits for an agency, the protocols you trained on in 2024 are no longer current in several places that matter.

Here is the working summary of what changed, why it changed, and where it lands in real-world practice. This is a high-level reference. Always train against the current published guidelines from the Joint Trauma System.

A note on scope: TCCC is the military standard

TCCC is the U.S. military prehospital trauma standard, written for combat casualties under battlefield conditions. The civilian equivalent is TECC, Tactical Emergency Casualty Care, maintained by the Committee for Tactical Emergency Casualty Care. TECC tracks TCCC closely but is purpose-built for civilian operational environments, including law enforcement tactical teams, fire-based rescue task forces, EMS, and active threat response.

Some 2026 TCCC updates translate cleanly to civilian practice. Others do not. A patrol officer is not a Combat Lifesaver. An EMS agency operates inside a state scope of practice and a medical director's standing orders, not a DoD scope. Pediatric considerations, which TCCC does not address, sit at the center of civilian work. Drug availability, controlled substance handling, and documentation requirements all differ from the military environment.

If you work on the civilian side, treat TCCC changes as a leading indicator of where TECC and your local protocols are likely to move, not as something you can adopt unilaterally tomorrow. The pattern is consistent: TCCC moves first, TECC follows after CoTECC review, and individual state and agency protocols update on their own schedules after that.

Standing orders and protocol updates take time

Even when a change is clearly indicated, the path from a published guideline to a signed standing order is not fast. Medical directors review the evidence. Regional EMS councils weigh in. State EMS offices issue scope-of-practice clarifications. Agencies update SOPs, retrain staff, restock kits, and document the change. None of that happens overnight, and none of it should.

Until your medical director signs off and your protocol is updated, you operate under your current standing orders. That is the correct answer even when the new guideline is better. Knowing what is coming is part of being prepared for the update. Acting outside your protocol because a military guideline changed is not.

For agency leaders reading this: the time to start the protocol revision conversation with your medical director is now, not after the next training cycle. The 2026 changes are substantial enough that some of them will take months to work through a properly governed update process.

Why these changes happened

Most of what shifted in 2026 traces back to two pressures. The first is data from the Russo-Ukrainian War, which produced years of casualty observations under prolonged evacuation timelines that look almost nothing like the early GWOT golden-hour assumption. The second is accumulated trial evidence on TXA, ceftriaxone, and TBI management that has matured since the previous guideline cycle.

The throughline across most of the 2026 updates is prolonged casualty care. When evacuation may take hours rather than minutes, decisions about tourniquets, fluids, antibiotics, and analgesia look different. The guidelines are catching up to that reality.

A note on numbering

The section headers below match the numbering in the published TCCC Guidelines so this article can be used as a reference alongside the source document. Sections 1, 5, 7, 10, and 13 through 20 contain no substantive 2026 changes and are not addressed here in detail. Tactical situational awareness, tension pneumothorax management, hypothermia prevention, monitoring, abdominal evisceration, burns, fractures, CPR, communication, documentation, and evacuation preparation all remain operationally as they were in 2024. If you teach against the full guideline, those sections still belong in your curriculum unchanged.

The full TCCC Guidelines document published 01 May 2026 is available for download at the end of this article.

2. Triage and Weapons

The 2024 statement directing removal of weapons and communications equipment from casualties with altered mental status has been replaced by a reference to Supplement A, which contains more refined Role 1 triage recommendations. The principle of disarming an altered casualty is unchanged in operational practice. The guideline language now points to a more comprehensive document rather than living as a single line.

3. Massive Hemorrhage

The 2026 guidelines tighten the language on initial limb tourniquet application. Apply the tourniquet directly to the skin 2 to 3 inches above the bleeding site. If bleeding is not controlled with the first tourniquet, apply a second side-by-side with the first. Both elements are now explicit in the published text rather than implied by training convention.

The skin-application language carries operational weight. Tourniquets applied over uniform fabric, pouches, cargo pockets, or thigh rigs are far more vulnerable to slippage and inadequate pressure than tourniquets applied directly to skin. The 2024 guideline allowed over-the-uniform application during Care Under Fire and required reposition during Tactical Field Care. The 2026 update keeps that structure but makes the skin-application standard for TFC tourniquets unambiguous.

The side-by-side second tourniquet language is also worth noting. Some training programs have historically taught second tourniquet placement proximal to the first. The published guideline now specifies side-by-side, which preserves the closest-to-wound principle established elsewhere in the 2026 update.

4. Airway Management

The 2026 guidelines explicitly identify airway management as one of the two major change areas in this cycle. The shifts are operational, not philosophical.

Recovery position is now first-line for unconscious casualties without obstruction. The guidelines direct: place an unconscious casualty in the recovery position with head tilted back and chin away from chest. NPA insertion is no longer the default opening move. NPAs and BVM ventilation now appear in the algorithm as the response when measures fail and oxygen saturation falls below 90 percent, or below 92 percent in moderate or severe TBI.

The bag-valve-mask is specified as a 1000 mL resuscitator. Kit builders should confirm what is on the shelf and replace anything smaller.

Surgical cricothyroidotomy remains the only invasive airway authorized in Tactical Field Care. Supraglottic and extraglottic airways are not in the TFC algorithm. The cric guidance was expanded:

Two techniques are now explicitly listed: bougie-aided open surgical, and standard open surgical. The cannula specifications are stated: less than 10 mm outer diameter, 6 to 7 mm internal diameter, and 5 to 8 cm of intratracheal length.

Continuous EtCO2 capnography is now mandated to verify cric placement. This is a documentation and equipment standard, not a recommendation.

Lidocaine is explicitly indicated for conscious casualties undergoing cric.

Continuous EtCO2 and SpO2 monitoring is called for to assess airway patency over time. SpO2 alone is no longer enough.

For agency kit builders and training officers, the practical implications are straightforward. Confirm BVMs are 1000 mL. Confirm capnography is in every kit that contains a cric setup. Update training scenarios to lead with positioning and recovery position rather than reflexive NPA placement. If your protocols still include SGAs as a step in tactical airway management, that is a TECC and local protocol question rather than a TCCC alignment question.

6a-c. Bleeding Control and Tourniquet Reassessment

This is the operational change with the broadest impact for non-medical responders.

The 2026 guidelines now expect All Service Member and Combat Lifesaver level personnel to perform tourniquet reposition and tourniquet conversion under defined conditions. Reassessment of every applied tourniquet is now stated as an absolute requirement, not a best practice. All tourniquets must be reassessed for continued indication and proper placement.

The language also shifted. A high-and-tight or over-the-uniform tourniquet is now repositioned, not replaced. Place a second tourniquet directly on skin two to three inches above the wound, confirm hemorrhage control, then loosen the first. This protects against the gap-in-coverage failure mode that "replace" implied.

Conversion criteria remain familiar: casualty not in shock, wound can be monitored, and the tourniquet is not controlling an amputation. The new operational safeguard is that ASM and CLS personnel should generally not attempt conversion beyond two hours post-application without higher-level medical direction.

This update reflects field evidence of unnecessary tourniquet application, ischemic complications from prolonged use, and the hard reality that conversion gets more dangerous the longer a limb has been occluded. It also introduces a clean scope-of-practice escalation: the first two hours belong to the responder on scene, beyond that belongs to a medic.

6d. TXA

TXA has been in TCCC since 2012, originally with a one-gram loading dose followed by a one-gram infusion.

The current dosing is a single two-gram slow IV/IO push, administered as soon as possible but not later than three hours after injury. The three-hour window remains in the published 2026 guidelines, contrary to some secondary reporting that has circulated.

Indications are: a casualty likely to need a blood transfusion (hemorrhagic shock, one or more major amputations, penetrating torso trauma, or evidence of severe bleeding), or a casualty with signs or symptoms of significant TBI or altered mental status associated with blast injury or blunt trauma. The TBI indication is the meaningful expansion. TXA for TBI is now a stand-alone indication, not just a co-treatment for hemorrhage.

The simplified single-dose format is operationally significant. One dose, one route. The time-of-injury window still applies.

6e. Circulation: Pelvic Binders, Blood Products, and Calcium

Pelvic binder application is now spelled out with specific indications. Apply for suspected pelvic fracture in cases of severe blunt force or blast injury with one or more of the following: pelvic pain, any major lower limb amputation or near amputation, exam findings suggestive of pelvic fracture, unconsciousness, or shock.

The calcium addition is operationally significant for any kit carrying blood products. If blood products are transfused, administer one gram of calcium IV/IO after the first transfused product. The dosing is 30 mL of 10 percent calcium gluconate or 10 mL of 10 percent calcium chloride. This is a kit content and protocol authorization question for any agency operating prehospital blood programs.

The transfusion endpoint is unchanged: continue resuscitation until palpable radial pulse, improved mental status, or systolic BP of 100 mmHg is present. Reassess after each unit.

8. Traumatic Brain Injury

TBI management received the most substantial clinical revision in 2026.

Mild TBI and concussion are now separated from moderate and severe TBI in the guidelines. Suspected moderate or severe TBI is defined as inability to follow simple instructions beyond ten minutes after injury with suspected head injury and no alternative cause. Evacuation should target neurosurgical capability within five hours when possible.

The numbers that changed:

The oxygen saturation target moved from greater than 90% to at least 92%. Ventilatory support is indicated for moderate or severe TBI when saturation falls below 92%.

The blood pressure target shifted from a narrow window of SBP 100 to 110 mmHg to SBP greater than 100 mmHg, or a normal radial pulse if BP cannot be measured.

For isolated TBI without evidence of hemorrhage, crystalloid bolus guidance was replaced with one to two units of plasma.

Ventilation now targets EtCO2 35 to 45 mmHg, or 10 breaths per minute when capnography is unavailable.

Penetrating TBI and open skull fracture care received expanded guidance, with explicit clarification that these casualties are not automatically expectant. That distinction matters for triage and for the moral weight of the call. The handling guidance is specific: surface dressing to prevent contamination, hemostatic gauze with gentle pressure if there is active bleeding from the wound or wound edges. Do not pack the wound cavity. Do not attempt to close the wound with staples or sutures. Gentle low-pressure irrigation with saline or potable water is acceptable for gross contamination.

Hypertonic saline guidance for herniation is now explicit. For a casualty with asymmetric or fixed and dilated pupils or posturing, administer 250 mL of 3 percent or 5 percent hypertonic saline, or 30 mL of 23.4 percent hypertonic saline, IV/IO over at least 10 minutes followed by a saline flush. Repeat in 20 minutes if no response, with a maximum of two doses. The guidelines are explicit that hypertonic saline is not a resuscitative fluid and is not to be used prophylactically to prevent herniation.

Reassess neuro status every 5 to 10 minutes for any TBI casualty.

9. Penetrating Eye Trauma

The antibiotic recommendation for penetrating eye trauma updated to match the broader antibiotic change. Moxifloxacin in the Combat Wound Medication Pack is replaced by ceftriaxone 2g IV/IM or cefadroxil 1g PO as soon as possible. Eye shield, no pressure, no irrigation of a globe rupture, and evacuation priority remain unchanged.

11. Analgesia

The 2026 analgesia section was substantially revised. The framing emphasizes a shock-agnostic model of early pain management, with tolerable pain levels that preserve airway patency, respiratory drive, and mentation rather than complete pain elimination or total sedation.

For mission-capable casualties, the Combat Wound Medication Pack now contains:

Acetaminophen 1000 to 1300 mg PO every 8 hours (e.g., two 650 mg extended-release caplets).

Meloxicam 15 mg PO once a day.

Suzetrigine 100 mg PO once (two 50 mg tablets), then 50 mg PO every 12 hours. Suzetrigine is the new addition.

For non-mission-capable casualties, TCCC medical personnel administer ketamine. The dosing options are:

Ketamine 100 mg IM, or 50 mg IN, or 25 mg (or 0.2 to 0.3 mg/kg) IV/IO over 1 minute, or esketamine 14 mg or 28 mg IN once.

Repeat doses every 30 minutes as needed. Endpoints are reduction of pain or development of nystagmus.

OTFC and the prior fentanyl-first options are no longer listed in the primary analgesia ladder. The notes still reference opioids in the polypharmacy warnings, including that it is generally safe to give ketamine to a casualty who has previously received an opioid, but opioids are not the lead agents in the 2026 algorithm.

Procedural sedation guidance moved into the inspect and dress wounds section, where it operationally belongs. The doses for TCCC Combat Paramedics and Providers are: ketamine 1 to 2 mg/kg slow IV/IO push, or 300 mg IM (2 to 3 mg/kg IM). Endpoint is procedural dissociative anesthesia. If an emergence phenomenon occurs, midazolam 0.5 to 2 mg IV/IO is an authorized option. This is the explicit exception to the general rule against benzodiazepines with ketamine.

Other notes worth flagging:

Disarm and consider disconnecting communications equipment for any casualty given ketamine.

Document an AVPU mental status exam on the DD 1380 prior to ketamine administration.

Co-administration of benzodiazepines with ketamine or esketamine is not recommended outside the procedural-sedation emergence exception.

If a casualty appears partially dissociated, more ketamine is safer than a benzodiazepine.

Ondansetron 4 mg ODT/IV/IO/IM every 8 hours as needed for nausea or vomiting remains in the protocol.

12. Antibiotics

The 2026 antibiotic regimen replaces both 2024 options.

Out: moxifloxacin PO and ertapenem IV/IO/IM.

In: cefadroxil 1g PO as the primary option, cephalexin PO as an alternative, and ceftriaxone 2g IV/IO/IM if the casualty cannot take oral medication.

This is a logistics and stewardship change as much as a clinical one. Cefadroxil and cephalexin are stable, common, and inexpensive. Ceftriaxone has a clean dosing profile and broad coverage. The change pulls battlefield antibiotic prophylaxis closer to mainstream trauma practice and away from agents with narrower utility.

One handling note worth flagging for kit builders: ceftriaxone precipitates with calcium-containing solutions including lactated Ringer's. Reconstitute with normal saline only, and flush lines with NS before and after administration.

What stayed the same

Care Under Fire and Care Under Threat are essentially unchanged. The MARCH algorithm remains the organizing framework. The basic sequence of Tactical Field Care is the same. Tourniquets, wound packing, hemostatic dressings, chest seals, needle decompression, and airway management all remain in the same positions in the algorithm. What changed is the detail underneath.

What this means for your agency

For agency training officers and program managers, the 2026 cycle is required reading even if your authority to act on it lags. On the military side, several changes alter what responders are authorized and expected to do, particularly tourniquet reassessment and conversion at the ASM and CLS level. On the civilian side, none of these changes are in effect for your responders until they show up in your standing orders. SOP language written against the 2024 guidelines now lags the published standard, and that gap is worth a conversation with your medical director.

Practical updates worth scheduling, in coordination with medical direction:

Refresh airway training to lead with recovery position for unconscious casualties without obstruction. Confirm BVMs in your kits are 1000 mL. Confirm continuous EtCO2 capnography is paired with any cric capability.

Refresh tourniquet protocols to include the two-hour reassessment window, the reposition language (skin, 2 to 3 inches above the wound), and the conversion authority structure.

Update kit antibiotic stocking to cefadroxil and ceftriaxone. Retire ertapenem and moxifloxacin from medic packs. Confirm that any ceftriaxone in inventory is paired with normal saline diluent rather than LR.

Review TBI training to reflect the 92 percent saturation floor, the SBP greater than 100 mmHg target, the plasma-over-crystalloid recommendation for isolated TBI, and the penetrating TBI guidance. Add hypertonic saline herniation protocols if your scope of practice and standing orders authorize it.

Update TXA training to single-dose, two-gram slow push administration, with the three-hour window still in effect, and the expanded TBI indication.

If your agency operates a prehospital blood program, add calcium administration after the first transfused product to your protocols and confirm calcium gluconate or calcium chloride is in the kit.

Pull OTFC and fentanyl from primary-care training scenarios and bring suzetrigine, intranasal esketamine, and the published ketamine dosing into your analgesia modules.

Download the full 2026 TCCC Guidelines

The complete published guidelines from the Joint Trauma System are available for download below. This article is a working summary written for trainers, agency leaders, and field providers who need to know what changed and why. It does not replace the source document. For protocol revision, training development, or medical director review, work from the published guidelines directly.

Source: Tactical Combat Casualty Care (TCCC) Guidelines, 01 May 2026. Committee on Tactical Combat Casualty Care. Joint Trauma System.