Analgesia in Tactical Combat Casualty Care (TCCC): TCCC Guideline Change 25-03.

Abstract

Battlefield pain management (BPM) is a critical and ethical component of TCCC. In 2025, the loss of access to oral trans-mucosal fentanyl citrate (OTFC) and a strategic focus on large-scale combat operations prompted the Committee on Tactical Combat Casualty Care (CoTCCC) to update its analgesia guidelines. The CoTCCC performed an extensive literature review to address key questions regarding OTFC alternatives, ketamine dosing, ethical challenges, and scalability. The review identified buprenorphine and intranasal esketamine as viable alternatives to OTFC, based on their pharmacology, efficacy, and safety. The updated TCCC guidelines propose a simpli-fied, two-step model: Step 1 recommends a non-opioid pill pack for mission-capable casualties, including a novel sodium channel inhibitor, suzetrigine; and Step 2 advises a fixed dose of ketamine (or esketamine) via intramuscular, intranasal, or slow intravenous/intraosseous push alongside the pill pack for non-mission-capable casualties. This framework reduces provider cognitive burden, simplifies logistics, and enhances battlefield analgesia. Recommendations are rated from level of evidence A to C-EO and Class I to IIa, highlighting future research needs.

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