The CoTCCC issued two major guideline changes in 2024-2025 that affect how every combat medic, corpsman, and CLS manages airways and administers antibiotics. If you're still teaching jaw thrust, supraglottic airways in TFC, or carrying moxifloxacin in your CWMP, your training is outdated. Here's what changed and why.
Change 24-1: Airway Management Overhaul
Published in the Journal of Special Operations Medicine (Shaw et al., Spring 2025), Change 24-1 is the most significant revision to TCCC airway management since the guidelines were formalized. The CoTCCC spent years reviewing every assumption about prehospital airway management and concluded that several longstanding practices lacked evidence in the combat trauma setting.
### What was removed from TFC
Jaw thrust is out. It was previously recommended for unconscious casualties with suspected C-spine injury. The CoTCCC found insufficient evidence that it provides meaningful benefit over simpler positioning in the tactical environment.
Supraglottic airways (SGAs) are out of TFC. The i-gel, KingLT-D, and LMA have been removed from the Tactical Field Care airway algorithm entirely. The evidence showed no survival benefit over BVM ventilation in battlefield conditions. Placement without RSI sedation in trauma patients demonstrated very high mortality. Environmental factors like extreme temperatures and altitude changes during TACEVAC made them unreliable.
NPA is out of the Airway section. The nasopharyngeal airway has been moved to the Respiration/Breathing section. It is no longer a routine airway adjunct. NPA is now only indicated when the casualty has impaired ventilation with SpO2 dropping below 90% and positioning alone is insufficient.
Control-Cric is out as the preferred device. The CoTCCC found it performed second or third in every evaluation category. Providers should train with whatever surgical airway kit is available to them.
### What the new TFC airway algorithm looks like
The sequence is now dramatically simplified:
- Positioning and suction. For conscious casualties with maxillofacial trauma: Sit-Up and Lean-Forward. For unconscious casualties without traumatic airway obstruction: recovery position with head tilted back and chin away from the chest.
- Surgical cricothyrotomy if positioning fails or for massive facial/airway trauma. This is now the only advanced airway intervention in TFC. No intermediate devices.
- Mandatory continuous capnography after any cricothyrotomy to confirm and monitor tube position.
That's it. Position, suction, cric. The cognitive load on the provider just dropped significantly.
### Why this matters
The old algorithm had multiple decision points: try jaw thrust, consider NPA, consider SGA, then cric as last resort. Each step added complexity, consumed time, and required equipment that might not work in the field. The new algorithm acknowledges that if basic positioning doesn't fix the airway, you need a definitive surgical airway. Intermediate devices were consuming time and resources without improving survival.
Change 25-1: Antibiotic Replacement
Published in JSOM (Wisniewski et al., December 2025), Change 25-1 replaces both the oral and parenteral TCCC antibiotics based on new data from the Russo-Ukrainian War.
### What was replaced
Moxifloxacin is out. The fluoroquinolone that's been the TCCC oral antibiotic since 2002 has been replaced. Moxifloxacin is no longer recommended.
Ertapenem is out. The carbapenem that served as the parenteral antibiotic since 2017 has been removed. The reason is serious: data from the Global War on Terror showed that 86% of hospital-acquired multidrug-resistant organisms were Acinetobacter baumannii, with 91% being carbapenem-resistant. Field use of ertapenem was contributing to the resistance problem that killed patients downstream at the hospital.
### What replaced them
Oral: Cefadroxil 1g PO daily (preferred) or Cephalexin 500mg PO (alternative). First-generation cephalosporins that cover the point-of-wounding organisms identified in Ukrainian casualty wound cultures taken a median of 7 hours post-wounding.
Parenteral: Ceftriaxone 2g IV/IO/IM once daily. Third-generation cephalosporin with good tissue penetration. Narrower spectrum than ertapenem, which is the point. Important: reconstitute in normal saline only. Do NOT mix with lactated Ringer's or any calcium-containing solution (causes precipitation).
Metronidazole 500mg IV q8hr remains for penetrating abdominal/pelvic wounds (anaerobic coverage).
### What you need to do
Update your CWMP contents. Replace moxifloxacin with cefadroxil. Replace ertapenem with ceftriaxone 2g in your aid bag. Screen your unit for cephalosporin/penicillin allergies during pre-deployment medical screening, the same way you screened for fluoroquinolone allergies before.
TXA Update
The TXA dosing protocol was previously updated to a single 2g IV/IO slow push (replacing the old 1g + 1g infusion protocol). The 3-hour administration window has also been removed. Current guidance is to administer TXA as soon as possible after wounding. Earlier administration provides the greatest survival benefit. TXA is also now indicated for significant traumatic brain injury.
Train on current guidelines
If your unit is still teaching the old airway algorithm or carrying moxifloxacin, you're training to an outdated standard. The free training modules at medeor.app have been updated to reflect Change 24-1 and 25-1 across all content, quizzes, and flashcards.