The Committee on Tactical Combat Casualty Care published its 2026 guideline update on 1 May 2026. The committee flags the headline changes this year as airway management and traumatic brain injury management in tactical field care. For anyone carrying medical responsibility on a CP detail, the TBI section is the one to absorb.
The guidelines split mild from serious. Suspected mild TBI/concussion can be deferred to later phases of care. The hard case is moderate or severe TBI: a casualty who cannot follow simple instructions (thumbs up, two fingers, blink) beyond 10 minutes post-injury, with a suspected head injury and no other cause. For that casualty the document sets clear physiological targets:
- **Oxygenation.** Prevent hypoxaemia. Target oxygen saturation at or above 92% and give supplemental oxygen where available. - **Blood pressure.** Prevent hypotension. Target a systolic BP above 100 mmHg, or — with no monitoring — a normal radial pulse. If hemorrhagic shock is also present, treating the shock takes precedence. - **Evacuation.** Get the casualty to neurosurgical capability as fast as possible; the guideline notes outcomes improve with surgical intervention within five hours of injury.
The update also hardens the herniation drill (asymmetric or fixed/dilated pupils, or posturing): hypertonic saline IV/IO over at least 10 minutes, repeatable once after 20 minutes, with an explicit warning not to use it prophylactically and that it is not a resuscitation fluid. It elevates the head and torso above 30 degrees where the casualty is not in shock and it is tactically feasible, loosens any cervical collar, and reassesses neuro status every 5–10 minutes. Penetrating TBI and open skull fractures are no longer treated as automatically expectant: dress the surface, do not pack the wound cavity, do not attempt to close it. For significant TBI with altered mental status, 2g of tranexamic acid is given by slow IV/IO push as soon as possible and no later than three hours after injury.
**What it means for operators.** A CP medic's job on a head injury is now a set of numbers and a clock: 92% oxygen, 100 mmHg systolic, neuro check every five to ten minutes, and a hard five-hour push to surgery. Hypertonic saline is a herniation tool, not a fluid you hang to be safe. And cervical-spine stabilisation is not required for casualties with penetrating trauma only — useful to know when a collar would cost you time you don't have. None of this replaces a TCCC course; it tells you what the current standard says so your kit, your training refresh and your medical brief line up with it.
