The current Tactical Combat Casualty Care guideline is dated 1 May 2026. Its own summary calls this a focused update from the 2024 version, with the largest changes in traumatic brain injury, analgesia, antibiotics, penetrating eye trauma, and selected tourniquet refinements; Care Under Fire/Threat is essentially unchanged (TCCC Guidelines, 1 May 2026; TCCC Guidelines: 1 May 2026 Updates). This matters for a unit brief. The task is not to announce a new TCCC system. It is to replace specific outdated actions, doses, and source documents before the next training event.
The changes below are adopted in the published 1 May 2026 edition unless identified otherwise. “Proposed Change 25-2” is discussed separately because its title still says proposed, even though related language appears in the adopted guideline.
The 2026 guideline removes both oral transmucosal fentanyl citrate and the other fentanyl options that appeared in the 2024 guideline. OTFC is not an exception; it is one of the options removed (TCCC Guidelines, 1 May 2026). The change summary attributes the removal to initial-management and logistical-availability concerns, rather than claiming that every use of fentanyl is clinically unsafe (TCCC Guidelines, 1 May 2026).
The adopted structure now has two categories based on mission capability, not three tiers based on pain severity or risk of shock and respiratory depression. The guideline describes the new initial approach as shock-agnostic (TCCC Guidelines, 1 May 2026).
For a casualty who can remain in the fight, the Combat Wound Medication Pack contains acetaminophen 1,000 to 1,300 mg by mouth every eight hours, meloxicam 15 mg by mouth daily, and suzetrigine 100 mg once followed by 50 mg every 12 hours (TCCC Guidelines, 1 May 2026). For a casualty who cannot remain in the fight, TCCC medical personnel add ketamine 100 mg IM, 50 mg IN, or 25 mg IV/IO over one minute, with 0.2 to 0.3 mg/kg as the weight-based IV/IO alternative; intranasal esketamine 14 or 28 mg is another adopted option, and repeat dosing is every 30 minutes as needed (TCCC Guidelines, 1 May 2026). The two-step model in TCCC Guideline Change 25-03, a non-opioid pill pack followed by fixed-dose ketamine or esketamine, is reflected in the adopted edition (Analgesia in TCCC: Change 25-03).
At the next training event, remove OTFC and fentanyl lanes from 2026 TCCC stations. Rebuild the medication lane around mission-capable versus non-mission-capable casualties. Require the learner to choose a route that matches available access, document AVPU on DD Form 1380 before ketamine, disarm the casualty and consider disconnecting communications equipment, and avoid benzodiazepine co-administration with ketamine or esketamine (TCCC Guidelines, 1 May 2026).
The 2026 regimen replaces the 2024 moxifloxacin and ertapenem options. The adopted choices are cefadroxil 1 g by mouth daily as preferred oral therapy, cephalexin 500 mg by mouth every six hours as an oral alternative, or ceftriaxone 2 g IV, IO, or IM daily when the casualty cannot take oral medication (TCCC Guidelines, 1 May 2026). The underlying change document is TCCC Change 25-1, which recommends cefadroxil or cephalexin orally and ceftriaxone parenterally (Antibiotics in TCCC: Change 25-1).
Penetrating eye trauma also receives the revised antibiotic choices: ceftriaxone 2 g IV or IM, or cefadroxil 1 g by mouth, as soon as possible (TCCC Guidelines, 1 May 2026).
At the next training event, replace medication cards, aid-bag labels, scenario answer keys, and evaluator sheets that still list moxifloxacin or ertapenem. Include one casualty who can take oral medication and one who cannot, because the route decision is now part of the tested action.
The guideline identifies traumatic brain injury as a major area of change. Suspected moderate or severe TBI includes inability to follow simple instructions for more than 10 minutes after injury, and the guideline calls for evacuation to neurosurgical capability ideally within five hours (TCCC Guidelines, 1 May 2026).
The recognition and transport decisions underneath this are covered in Moderate-to-Severe TBI: Immediate Management & Transport.
For moderate or severe TBI, the adopted targets include systolic blood pressure above 100 mmHg, oxygen saturation at least 92%, and end-tidal carbon dioxide from 35 to 45 mmHg when measured (TCCC Guidelines, 1 May 2026). When there is no evidence of hemorrhage, the guideline replaces crystalloid bolus guidance with one to two units of plasma (TCCC Guidelines, 1 May 2026). For signs of cerebral herniation, such as asymmetric or fixed and dilated pupils or posturing, hypertonic saline may be given IV/IO over at least 10 minutes followed by a saline flush: 250 mL of 3% or 5%, or 30 mL of 23.4%. If there is no response, it may be repeated after 20 minutes, to a maximum of two doses; it must not be used prophylactically, and the guideline states that it is not a resuscitation fluid (TCCC Guidelines, 1 May 2026). Penetrating TBI is not automatically categorized as expectant (TCCC Guidelines, 1 May 2026).
At the next training event, add a TBI lane that forces serial mental-status documentation, prevention of hypoxemia and hypotension, ventilation to the new target, a fluid-choice decision, and an evacuation request tied to neurosurgical capability. A station that ends after an initial AVPU score will not test the new material.
The long-standing goal to convert an appropriate tourniquet in less than two hours is not new in 2026. Conversion requires all three conditions: the casualty is not in shock, the wound can be monitored closely for bleeding, and the tourniquet is not controlling bleeding from an amputated extremity. The guideline still says not to remove a tourniquet that has been in place for more than six hours unless close monitoring and laboratory capability are available (TCCC Guidelines, 1 May 2026).
The decision framework behind those conditions is unchanged and is covered in depth in Tourniquet Tactics: TCCC Decision-Making for Medics.
The adopted 2026 changes are narrower. “Reposition” replaces “replace”: apply a second tourniquet directly to the skin two to three inches above the wound, confirm hemorrhage control, and then loosen the first tourniquet (TCCC Guidelines, 1 May 2026). The guideline also adds that All Service Member and Combat Lifesaver personnel should not attempt conversion after two hours unless directed by Combat Medic/Corpsman, Combat Paramedic/Provider, or other advanced medical personnel; without oversight, they maintain the tourniquet and continue monitoring (TCCC Guidelines, 1 May 2026).
The rationale paper is titled “TCCC Guidelines Proposed Change 25-2,” so it must remain labeled proposed when cited (Proposed Change 25-2). For doctrine, use the adopted section 6g in the 1 May 2026 guideline, not the proposed paper.
At the next training event, score three separate actions: reassessment, repositioning, and conversion. Give learners a timestamp and provider tier. The evaluator should require the learner to state whether conversion is authorized, not merely whether it is anatomically possible.
Cold-stored low-titer group O whole blood remains first in the TCCC fluid preference order, followed by pre-screened low-titer group O fresh whole blood, but this is not a 2026 change. That order and the removal of crystalloids and Hextend as hemorrhagic-shock resuscitation options came from TCCC Change 21-01 in November 2021 and appeared in the 15 December 2021 guideline edition (Fluid Resuscitation in TCCC: Change 21-01; TCCC Guidelines, 15 December 2021). Hextend still appears in the 2026 burn section, so the accurate statement is that it was removed for hemorrhagic shock, not erased from every TCCC use (TCCC Guidelines, 1 May 2026).
The i-gel is not the preferred 2026 airway. CoTCCC removed i-gel as the preferred extraglottic airway in 2021, and extraglottic airways were eliminated from the guideline in January 2024 (TCCC Guidelines change summaries). The current airway sequence uses positioning, recovery position, suction if available, and surgical cricothyroidotomy as indicated. A nasopharyngeal airway appears under respiration/ventilation when uncorrectable hypoxia and impaired ventilation require BVM support, not as a step in the airway ladder (TCCC Guidelines, 1 May 2026). The PDF’s Principles of Tactical Evacuation Care section says trained providers may consider endotracheal intubation instead of cricothyroidotomy (TCCC Guidelines, 1 May 2026).
Simple finger thoracostomy is not an all-medic replacement for needle decompression. The responder-level skill list assigns simple finger thoracostomy and tube thoracostomy to the Combat Paramedic/Provider tier, while needle chest decompression is listed for Combat Lifesaver, Combat Medic/Corpsman, and Combat Paramedic/Provider tiers (TCCC Skill Sets by Responder Level). Train the procedure only inside the unit’s authorized scope and credentialing structure.
REBOA does not appear in the 1 May 2026 TCCC guideline. It is addressed in a separate Joint Trauma System clinical practice guideline for trained providers and fully trained, equipped resuscitation teams with surgical support and blood-product capability (JTS REBOA CPG, 3 December 2025). No “hemostatic polymer” is named in the 2026 TCCC guideline. The named hemostatic options are Combat Gauze as the dressing of choice, with Celox Gauze, ChitoGauze, XStat, and iTClamp as alternatives (TCCC Guidelines, 1 May 2026).
The TCCC guideline and change papers used here are CoTCCC products, not CoSCCC products. REBOA, whole-blood storage, and prolonged casualty care are addressed in separate Joint Trauma System clinical practice guidelines rather than the May 2026 CoTCCC guideline (TCCC Guidelines, 1 May 2026; JTS REBOA CPG; JTS Whole Blood Transfusion CPG; JTS PCC CPG).
The 2026 module moves Role 1 triage detail to Supplement A and says the Tactical Evacuation Care guidelines are now a separate document managed by the Committee on En Route Combat Casualty Care, although the downloadable 1 May PDF still includes a Principles of Tactical Evacuation Care section (TCCC Guidelines, 1 May 2026; Supplement A, Triage in TCCC). Units should update lesson references rather than continue teaching those subjects from an old all-in-one slide deck.
For Army formations, ATP 4-02.11, released 23 March 2026, supersedes TC 4-02.1 and is the current doctrinal guide for casualty response, TCCC, and first aid for nonmedical Soldiers (U.S. Army; ATP 4-02.11 PDF).
Scenario repetition is what moves a guideline change from a slide into a medic's hands. If you want a worked example of the format, the free scenario runs a full casualty decision sequence.
The practical brief for next week is short: rebuild the drug lanes, make TBI the major clinical rehearsal, score tourniquet decisions by time and tier, remove the i-gel and REBOA claims from TCCC instruction, and verify that every instructor is teaching from the 1 May 2026 guideline rather than a 2024 slide set.
I sign training plans for a state's medical formations, and I have watched the gap this article describes open in real time. A unit briefs TCCC from a slide deck built three editions ago. The medic in the back row learns a drug that is no longer on the card. Nobody in that room is negligent. The deck simply outlived the doctrine. This article gets the framing right, and the framing is the useful part: the 1 May 2026 edition is not a new system, and treating it as one wastes the training hour. It is a list of specific replacements. The analgesia lane changed. The antibiotic card changed. TBI moved to the center of the clinical rehearsal. Almost everything else is the guideline you already teach.
That being said, awareness is not the bottleneck, and I would push back on any brief that treats it as one. Most medical officers I talk to already know the drugs changed. What stops them is the distance between a published guideline and a stocked aid bag. Suzetrigine has to reach a formulary before a medic can carry it. Ceftriaxone has to survive a supply request. An evaluator sheet has to be rewritten by somebody who has the time to rewrite it. I have signed a training plan that was doctrinally current and logistically fictional, and the medics in that formation knew it before I did. The honest answer is that a guideline change arrives in a unit at the speed of its property book, not the speed of its slide deck.
If you are a medical officer building the next training cycle, do three things in this order. Pull the 1 May 2026 guideline itself, not a summary of it. Walk your aid bags and medication cards against the analgesia and antibiotic sections, and write every mismatch as a supply action with a name attached to it. Then fix your evaluator sheets, because a scenario scored against retired doctrine teaches retired doctrine no matter what the instructor says out loud. The tier language in the tourniquet section deserves particular attention: your junior personnel now have a stated limit on when they may convert without direction, and that limit only works if the people supervising them know it too. Train the delta, not the whole course.
Fentanyl is out of the analgesia lane entirely, including oral transmucosal fentanyl citrate, and the structure is now two mission-capability categories rather than tiers by pain severity. Moxifloxacin and ertapenem are replaced by cefadroxil, cephalexin, and ceftriaxone, so medication cards and aid-bag labels need reprinting. TBI carries the largest clinical change and deserves the main rehearsal lane, including serial mental-status documentation and a fluid-choice decision. The tourniquet change is narrower than it appears: repositioning language and a tier limit on conversion, not a new time standard. Several claims circulating about this edition are wrong, including the i-gel as preferred airway, REBOA as a TCCC addition, and whole blood at the point of injury as new in 2026.
Yes, and that includes oral transmucosal fentanyl citrate. Some summaries claim OTFC was retained as an exception. The 1 May 2026 guideline removes both. The change summary attributes the removal to initial-management and logistical-availability concerns rather than a finding that fentanyl is unsafe in every use.
Cefadroxil 1 g by mouth daily is the preferred oral option, cephalexin 500 mg by mouth every six hours is the oral alternative, and ceftriaxone 2 g IV, IO, or IM daily covers the casualty who cannot take oral medication. These replace the moxifloxacin and ertapenem options from the 2024 edition.
No. CoTCCC removed the i-gel as the preferred extraglottic airway in 2021, and extraglottic airways left the guideline in January 2024. Claims that the 2026 edition made the i-gel preferred are incorrect and are worth correcting in any lesson plan that still carries them.
No. The goal of conversion inside two hours and the restriction on removing a tourniquet after six hours are older, unchanged text. What changed in 2026 is the word "reposition" replacing "replace", and a stated limit on All Service Member and Combat Lifesaver personnel converting after two hours without direction from advanced medical personnel.
No. REBOA does not appear in the 1 May 2026 TCCC guideline. It is governed by a separate Joint Trauma System clinical practice guideline written for trained, equipped resuscitation teams with surgical support and blood-product capability.