lunes, 23 de febrero de 2026

⚕️ TACTICAL ANALGESIA 2026 — SINGLE MASTER DOCUMENT TCCC vs TECC — doctrine, operational pharmacology, and hemostatic safety Author: DrRamonReyesMD

⚕️ TACTICAL ANALGESIA 2026 — SINGLE MASTER DOCUMENT

TCCC vs TECC — doctrine, operational pharmacology, and hemostatic safety

Author: DrRamonReyesMD
Update: 2026
Use: international reference (teaching, protocols, translation-ready standardization)

1) PUBLISHED VERSION — EMS SOLUTIONS INTERNATIONAL (SEO)

SEO Title: Tactical analgesia 2026: TCCC vs TECC ladder, drugs, doses, and why “classic NSAIDs” are avoided
Slug: tactical-analgesia-2026-tccc-vs-tecc-meloxicam-celecoxib-ketamine
Meta description: Master document 2026 (TCCC vs TECC) with current algorithms, dosing, pros/cons, contraindications, and hemostatic/renal rationale. Includes Israel/IDF experience, Ukraine training materials, and an international note on Penthrox® and nitrous oxide.
Keywords: TCCC analgesia 2026, TECC pain management, meloxicam CWMP, celecoxib COX-2, ketamine shock analgesia, OTFC fentanyl, tactical medicine analgesia, austere trauma pain control, IDF battlefield pain management

Editorial introduction (for publication)

Tactical analgesia is not “ED pain control in military clothing.” It is a doctrinal subfield where the analgesic is selected for its net effect on survival, operational function, and population risk under uncertainty: potential hemorrhage (visible or occult), hypovolemia, sympathetic surge, uncertain evacuation, and limited monitoring. That is why TCCC standardizes a simple oral pack (CWMP) and TECC explicitly reinforces avoidance of traditional NSAIDs on hemostatic grounds.

INTEGRATED CORE TEXT (ENGLISH MASTER VERSION)

⚔️ TACTICAL ANALGESIA 2026

Comparative Master Document: TCCC vs TECC

Doctrinal, pharmacologic, and operational integration

Author: DrRamonReyesMD Update: 2026 Scope: Tactical Combat Casualty Care (TCCC) · Tactical Emergency Casualty Care (TECC) Level: International professional reference

0️⃣ OPERATIONAL DEFINITIONS AND ABBREVIATIONS (EXPANDED)

TCCC (Tactical Combat Casualty Care): doctrine for combat casualty care developed by the Committee on Tactical Combat Casualty Care (CoTCCC).
TECC (Tactical Emergency Casualty Care): high-threat civilian adaptation developed by the Committee for Tactical Emergency Casualty Care (C-TECC).
CoTCCC: Committee on Tactical Combat Casualty Care.
C-TECC: Committee for Tactical Emergency Casualty Care.
DoD (Department of Defense): U.S. Department of Defense.
JTS (Joint Trauma System): DoD Joint Trauma System.
MARCH: Massive Hemorrhage, Airway, Respiration, Circulation, Head injury/Hypothermia.
DTC / ITC / EC (TECC): Direct Threat Care / Indirect Threat Care / Evacuation Care.
AVPU: Alert, Voice, Pain, Unresponsive.
CWMP: Combat Wound Medication Pack.
PO: Per Os (oral route).
IV: Intravenous.
IO: Intraosseous.
IM: Intramuscular.
IN: Intranasal.
OTFC: Oral Transmucosal Fentanyl Citrate.
NSAID: Non-steroidal anti-inflammatory drug.
COX-2: Cyclooxygenase-2.
TBI (Traumatic Brain Injury): traumatic brain injury.
CKD (Chronic Kidney Disease): chronic kidney disease.

1️⃣ CORE DOCTRINAL PRINCIPLE

Tactical analgesia does not aim for maximal isolated pharmacodynamic effect.
It aims for:

✔ population survival ✔ operational functionality ✔ hemodynamic safety ✔ logistical simplicity ✔ adherence under extreme stress

In combat or high-threat civilian scenarios:

potential hypovolemia is common,
massive sympathetic activation is common,
diagnostic uncertainty is common,
continuous advanced monitoring is not available.

Therefore, pharmacologic design is pragmatic and population-based.

2️⃣ CURRENT ANALGESIA ALGORITHM (2026)

🔴 TCCC (CoTCCC 2024 + JTS FY26)

Mild–moderate pain (functional casualty)

CWMP:

Acetaminophen / Paracetamol 1,000 mg PO every 8 h
Meloxicam 15 mg PO every 24 h

Doctrinal justification:

multimodal approach,
1 NSAID dose per day → higher adherence,
no sedation.

Moderate–severe pain WITHOUT shock or respiratory distress

OTFC 800 micrograms, repeatable at 15 min.

Medical alternatives:

Fentanyl 50 mcg IV/IO (≈0.5–1 mcg/kg).
Fentanyl 100 mcg IN.

Naloxone 0.4 mg available.

Severe pain WITH shock or respiratory risk

Analgesic ketamine:

20–30 mg IV/IO (0.2–0.3 mg/kg).
50–100 mg IM/IN (0.5–1 mg/kg).

Preferred in hypovolemia due to lower respiratory depression.

Procedural sedation

Ketamine 1–2 mg/kg IV/IO.
300 mg IM.

If emergence phenomenon occurs:

Midazolam 0.5–2 mg IV/IO.

Doctrinal prohibition: no prophylactic benzodiazepines. Avoid opioid + benzodiazepine combination.

Antiemetic

Ondansetron 4 mg ODT/IV/IO/IM every 8 h PRN.

🟠 TECC (C-TECC 2025)

Mild–moderate pain

Avoid traditional NSAIDs:

Aspirin
Ibuprofen
Naproxen
Ketorolac

Reason: platelet interference.

Consider:

Acetaminophen
Celecoxib (COX-2 selective)

Moderate–severe pain

Titrated opioids (per local protocol).
Ketamine:
- 0.1–0.2 mg/kg IV/IO
- 0.3–0.4 mg/kg IN/IM

Ketamine is no longer contraindicated in TBI.

3️⃣ KEY DOCTRINAL DIFFERENCE

Variable
TCCC
TECC

NSAID baseline
Meloxicam
Celecoxib suggested

Logistics
Closed military standard
Civilian adaptation

Dosing
Highly protocolized
Flexible framework

Interpretation: TCCC prioritizes global uniformity. TECC prioritizes contextual adaptation.

4️⃣ OPERATIONAL PHARMACOLOGIC MONOGRAPHS

(Executive summary with tactical focus)

Acetaminophen / Paracetamol

Central mechanism. No clinically significant anti-platelet effect. Primary risk: hepatotoxicity.

Meloxicam

COX-2–preferential NSAID. Advantage: 1 dose/24 h. Renal risk in hypoperfusion. GI and CV class risk.

Celecoxib

COX-2 selective. No platelet effect. Dose-dependent CV risk.
PRECISION trial: DOI: 10.1056/NEJMoa1611593

Fentanyl

Potent. Risk: respiratory depression. Naloxone mandatory.

Ketamine

Robust analgesia. Less ventilatory impact. Useful in shock. Caution: neurologic reassessment.

5️⃣ INTERNATIONAL COMPLEMENTARY NOTE

🟢 Methoxyflurane (Penthrox®)

Used in:

Australia
New Zealand
United Kingdom

Self-administered inhalational delivery.

Advantages:

rapid onset,
self-titration,
no IV required.

Limitations:

historical nephrotoxicity concern (older high-dose exposure),
not widely adopted in TCCC doctrine,
not standardized in TECC 2026.

Regulatory reference: TGA Australia https://www.tga.gov.au

🟡 Nitrous Oxide (N₂O)

Historically used in European and UK EMS.

Advantages:

rapid inhalational analgesia,
easy administration.

Operational concerns:

bulky equipment,
risk in occult pneumothorax,
risk in cranial trauma with intracranial air,
limitations in tactical environment.

In Spain: progressively removed from many EMS systems due to:

logistics
safety
clinical limitations

Not part of TCCC or TECC.

6️⃣ MASTER CONCLUSION 2026

TCCC and TECC do not select the newest drug.
They select the most robust drug under uncertainty.

TCCC maintains: Acetaminophen + Meloxicam
TECC allows: Acetaminophen + Celecoxib
Both share: Ketamine as the cornerstone in the unstable patient.

7️⃣ DrRamonReyesMD VERDICT

Tactical analgesia is a survival discipline, not pharmacologic elegance.
The key question is not which drug is “more potent.” It is which drug reduces mortality without creating new mortality.

ISRAEL (IDF) EXPANSION — 2026 (meticulous, operational, publishable)

Why Israel matters in tactical analgesia

Israel provides one of the longest real-world published windows on point-of-injury analgesia within a modern military system using a formal registry approach (IDF Trauma Registry / ITR). This is doctrinally valuable because it tests pain-control decisions under sustained operational pressure, where logistics, training, and airway/ventilation constraints shape what survives over time.

Key IDF paper (17-year view)

Benov A, et al. Battlefield pain management: A view of 17 years in Israel Defense Forces. J Trauma Acute Care Surg. 2017.
DOI: 10.1097/TA.0000000000001481.
Editorial access: https://journals.lww.com/10.1097/TA.0000000000001481

What this adds doctrinally (without over-claiming)

It anchors analgesia decisions to registries and operational reality, not only theory.
It supports the principle that battlefield analgesia converges toward agents and dosing strategies that can be delivered safely at the point of injury with limited monitoring and uncertain evacuation timelines.
It is consistent with the TCCC/TECC doctrine principle: operational robustness (airway safety, hemodynamic stability, training repeatability, and logistical availability) drives standardization.

Post-publication related item (bibliography utility)

A related publication/comment exists in 2019 with its own DOI:
Battlefield pain management: A view of 17 years in Israel Defense Forces. J Trauma Acute Care Surg. 2019;86(2):376-377.
DOI: 10.1097/TA.0000000000002111.

How to teach it internationally (doctrinal sentence)

Israel did not “invent a new ladder.” It validated that in prolonged real conflict, protocols that survive are those that are repeatable, safe at point of injury, and operationally compatible with the constraints of evacuation and monitoring.

“MOTHER-LAYER” PRIMARY SOURCES (2026)

TCCC Guidelines 2024 (CoTCCC/Allogy, PDF):
https://learning-media.allogy.com/api/v1/pdf/f4cf1d4e-3191-443a-befc-415838fb04f2/contents

TECC Guidelines BLS/ALS 2025 (C-TECC, PDF):
https://www.c-tecc.org/images/F_TECC_ALS_BLS_Guidelines_2025_FINAL.pdf

DoD/JTS En Route Care Guidelines FY26 (PDF):
https://jts.health.mil/assets/docs/cpgs/CoERCCC%20Guidelines%20FY26.pdf

2) EXPANDED ACADEMIC VERSION (VANCOUVER) — 2026

Structured abstract

Introduction: TCCC and TECC are convergent doctrines with logistical and formulary differences.
Objective: to synthesize current analgesia algorithms and their hemostatic/renal rationale, with operational monographs and comparative safety evidence.
Method: primary doctrinal review (CoTCCC/Allogy; C-TECC; JTS FY26) and key literature (NSAID risk mapping, celecoxib CV safety; IDF operational evidence).
Results: TCCC standardizes CWMP (non-opioid + once-daily NSAID) and escalates to OTFC/opioids or ketamine depending on shock/respiratory risk; TECC avoids traditional NSAIDs due to platelet effect and suggests COX-2 selective options with dosing flexibility; ketamine consolidates as the strategic analgesic in instability.
Conclusion: tactical analgesia = population survival. TCCC/TECC differences reflect civil-military governance and logistics, not “drug potency.”

References (Vancouver)

Committee on Tactical Combat Casualty Care (CoTCCC). TCCC Guidelines. 25 Jan 2024 (PDF). Available at: https://learning-media.allogy.com/api/v1/pdf/f4cf1d4e-3191-443a-befc-415838fb04f2/contents
Committee for Tactical Emergency Casualty Care (C-TECC). TECC Guidelines for BLS/ALS Clinicians. 2 Jan 2025 (PDF). Available at: https://www.c-tecc.org/images/F_TECC_ALS_BLS_Guidelines_2025_FINAL.pdf
Joint Trauma System (DoD). Committee on En Route Combat Casualty Care Guidelines FY 2026 (PDF). Available at: https://jts.health.mil/assets/docs/cpgs/CoERCCC%20Guidelines%20FY26.pdf
Bhala N, et al. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet. 2013. doi: 10.1016/S0140-6736(13)60900-9. Available at: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60900-9/fulltext
Nissen SE, et al. Cardiovascular Safety of Celecoxib, Naproxen, or Ibuprofen for Arthritis. N Engl J Med. 2016. doi: 10.1056/NEJMoa1611593. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa1611593
Benov A, et al. Battlefield pain management: A view of 17 years in Israel Defense Forces. J Trauma Acute Care Surg. 2017. doi: 10.1097/TA.0000000000001481. Editorial access: https://journals.lww.com/10.1097/TA.0000000000001481
Margaux SM, et al. Battlefield pain management: A view of 17 years in Israel Defense Forces. J Trauma Acute Care Surg. 2019;86(2):376-377. doi: 10.1097/TA.0000000000002111.

3) OPERATIONAL CLINICAL PROTOCOL (CPG) + POCKET REFERENCE (1 PAGE)

3.1 CPG (IF/THEN) — Tactical Analgesia TCCC/TECC 2026

Operational objective: adequate analgesia + do not worsen bleeding/renal function/ventilation.

IF mild–moderate pain and casualty is functional (no clear shock)
THEN baseline analgesia (multimodal, non-sedating) per doctrine:

TCCC: acetaminophen/paracetamol + meloxicam 15 mg PO every 24 h (CWMP).
TECC: acetaminophen/paracetamol and consider COX-2 selective (celecoxib) per local protocol; avoid traditional NSAIDs for hemostatic reasons.

IF moderate–severe pain WITHOUT shock or respiratory distress (and not high risk)
THEN titrated opioid per role/protocol:

TCCC: OTFC as doctrinal option (and medic alternatives IV/IO/IN per guideline).
Always: airway/respiratory vigilance and naloxone available.

IF moderate–severe pain WITH hemorrhagic shock or respiratory risk
THEN analgesic ketamine (IV/IO/IM/IN per guideline/protocol), due to more robust respiratory/hemodynamic profile.

IF dissociative ketamine/procedure and emergence phenomenon occurs (agitation/dysphoria)
THEN benzodiazepine at minimum effective dose (e.g., midazolam), avoiding polypharmacy, especially benzo + opioid, unless necessary with airway rescue capability.

IF nausea/vomiting associated with analgesia (opioid/ketamine)
THEN antiemetic (e.g., ondansetron) per guideline/protocol.

TACTICAL “NO NSAID” CHECKLIST (if any present): shock/hypovolemia, severe dehydration, oliguria, known/suspected CKD, active bleeding, active ulcer or recent GI bleed, significant anticoagulation/antiplatelet therapy, NSAID-induced asthma.

TERMINOLOGY NOTE: acetaminophen = paracetamol.

ISRAEL LAYER (doctrinal lesson): sustained point-of-injury analgesia under registry-based operational conditions supports convergence toward repeatable, safety-compatible protocols (IDF record-based experience). DOI 10.1097/TA.0000000000001481.

3.2 POCKET REFERENCE (1 page — compact text)

TACTICAL ANALGESIA 2026 (TCCC/TECC) — DrRamonReyesMD

Baseline non-sedating: acetaminophen/paracetamol ± NSAID/COX-2 per doctrine.
Avoid “classic NSAIDs” when bleeding/renal risk exists (TECC states this explicitly).
Opioid only if NO shock / NO respiratory distress; monitor; naloxone available.
Ketamine = strategic analgesic in shock/respiratory risk.
No polypharmacy: avoid benzo + opioid unless necessary with rescue capability.
Israel/IDF: 17-year point-of-injury record supports operationally repeatable selection. DOI 10.1097/TA.0000000000001481.
Mother sources: TCCC 2024 (Allogy), TECC 2025 (C-TECC), JTS FY26.

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