TCCC DROPPED THE I-GEL… BUT SHOULD CIVILIAN EMS DROP IT TOO?

Critical doctrinal review of supraglottic airways in TCCC, TECC, civilian EMS, ATLS, NATO and modern tactical medicine

Scientific and operational update 2026

By DrRamonReyesMD ⚕️

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INTRODUCTION

During 2024 and 2025, a statement rapidly spread across tactical medicine and EMS social media:

“TCCC removed the i-gel and supraglottic airways.”

Soon afterward, that statement evolved into a far more extreme interpretation:

“If TCCC removed them, civilian EMS should remove them too.”

That conclusion is doctrinally incorrect.

The reality is far more nuanced and requires understanding a fundamental principle:

TCCC is NOT ATLS.

TCCC is NOT civilian EMS.

TCCC is NOT TECC.

And the combat casualty is NOT the average civilian prehospital patient.

The 2024–2025 CoTCCC airway update does NOT represent a universal condemnation of supraglottic airway devices (SGAs) such as:

• i-gel,
• King LT,
• LMA (Laryngeal Mask Airway),
• LT-D,
• or equivalent devices.

What actually occurred was a doctrinal restructuring of the military airway algorithm for Tactical Field Care (TFC), adapted to:

• modern combat trauma,
• prolonged evacuation realities,
• devastating facial injuries,
• massive blood contamination,
• severe shock states,
• delayed CASEVAC,
• and operational limitations observed in contemporary warfare.

The simplistic interpretation that:

“the i-gel no longer works”

is scientifically inaccurate and operationally superficial.

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HISTORICAL CONTEXT

THE RISE OF SUPRAGLOTTIC AIRWAYS

For decades, supraglottic airway devices transformed prehospital airway management because they allowed:

• relatively rapid airway access,
• reduced interruption of CPR,
• lower technical complexity compared with endotracheal intubation,
• fewer failed airway attempts,
• and rescue management of difficult airways.

The i-gel in particular gained enormous popularity due to:

• rapid insertion,
• noninflatable cuff design,
• favorable seal pressures,
• relative ease of training,
• and strong utility during out-of-hospital cardiac arrest.

In many modern civilian EMS systems, the i-gel became an operational standard.

However:

the modern battlefield is not equivalent to a suburban medical cardiac arrest.

And that is where the doctrinal divergence truly begins.

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WHAT ACTUALLY CHANGED IN TCCC?

The 2024 CoTCCC airway update substantially modified the Tactical Field Care airway approach.

The revised algorithm shifted emphasis toward:

• patient positioning,
• aggressive suction,
• manual airway maneuvers,
• effective basic ventilation,
• continuous reassessment,
• and surgical cricothyrotomy when indicated.

Supraglottic airway devices were removed from the primary TFC airway flowchart.

That does NOT mean:

• they are useless,
• prohibited,
• or completely abandoned operationally.

It means something much more specific:

CoTCCC determined that SGAs should no longer occupy a primary standard role within the Tactical Field Care airway algorithm.

That distinction is critically important.

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WHY DID TCCC CHANGE ITS POSITION?

1. MODERN COMBAT TRAUMA HAS CHANGED

Recent conflicts including:

• Ukraine,
• Syria,
• Iraq,
• Afghanistan,
• Nagorno-Karabakh,
• and modern hybrid warfare environments

demonstrated dramatic increases in:

• catastrophic maxillofacial trauma,
• blast injuries,
• burns,
• massive airway blood contamination,
• vomiting,
• airway edema,
• inhalational injury,
• and profound hemorrhagic shock.

A supraglottic airway performs reasonably well in:

• medical cardiac arrest,
• relatively clean airways,
• overdose patients,
• intoxications,
• or controlled prehospital environments.

Its performance becomes less reliable when confronted with:

• severe anatomical disruption,
• continuous hemorrhage,
• heavy secretions,
• persistent vomiting,
• facial destruction,
• or prolonged definitive airway requirements.

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2. REAL OPERATIONAL LIMITATIONS

TCCC does not operate in:

• controlled ambulance systems,
• operating rooms,
• emergency departments,
• or anesthetic environments.

It operates in:

• hostile fire,
• darkness,
• mud,
• hypothermia,
• noise,
• delayed evacuation,
• resource-limited settings,
• and extreme physiologic stress.

In those conditions:

• simplicity,
• speed,
• durability,
• and definitive procedures

carry much greater doctrinal weight.

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3. SURGICAL CRICOTHYROTOMY REGAINED PROMINENCE

CoTCCC reinforced the principle that:

if the airway is truly compromised, a definitive surgical airway may be required.

Especially in cases involving:

• catastrophic facial trauma,
• progressive edema,
• inhalational injury,
• or failed ventilation.

This doctrinal shift partially explains the reduced role of SGAs within Tactical Field Care.

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THE MOST COMMON MISINTERPRETATION ONLINE

A major current problem is that many online discussions reduce the issue to:

“TCCC removed the i-gel because it fails.”

That is NOT what the official doctrine actually states.

There is no official universal declaration saying:

“the i-gel has a universally high combat failure rate.”

What does exist is:

• doctrinal reevaluation,
• operational reprioritization,
• battlefield data analysis,
• and adaptation to modern combat realities.

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TECC: WHY IT DID NOT FOLLOW TCCC

This is one of the most important aspects of the discussion.

In 2024, the Committee for Tactical Emergency Casualty Care (C-TECC) released a formal position statement supporting continued supraglottic airway use within civilian TECC practice.

Why?

Because:

the civilian tactical environment is not identical to military combat medicine.

Civilian TECC systems manage:

• law enforcement,
• SWAT operations,
• active shooter incidents,
• terrorism,
• tactical rescue,
• EMS integration,
• and mass casualty incidents,

while still encountering large volumes of:

• medical cardiac arrests,
• overdoses,
• seizures,
• intoxications,
• altered mental status,
• and noncatastrophic trauma.

In these environments:

• the i-gel remains fast,
• operationally practical,
• effective as a rescue airway,
• and doctrinally defensible.

C-TECC explicitly stated that automatically removing SGAs from civilian tactical medicine solely because of CoTCCC’s military decision would represent an inappropriate extrapolation.

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JTS 2026: THE NUANCE MANY PEOPLE MISS

The Joint Trauma System (JTS) also does not adopt a simplistic “anti-SGA” position.

In:

“Airway Management in Trauma CPG”

Joint Trauma System – January 2026

the JTS still includes supraglottic airway devices as operational options in selected trauma contexts.

The guideline specifically references:

• i-gel,
• King LT,
• and other SGAs

within suggested airway equipment and operational airway strategies.

This point is extremely important because it demonstrates that:

even within the broader U.S. military trauma ecosystem, there is no universal prohibition of the i-gel.

What exists instead is:

• contextualization,
• reprioritization,
• and redefinition of its operational role.

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WHY THE I-GEL STILL MAKES SENSE IN CIVILIAN EMS

Modern civilian EMS systems continue to use SGAs because they solve real operational problems:

• rapid airway access,
• reduced CPR interruption,
• lower procedural complexity,
• rescue airway capability,
• fewer failed airway attempts,
• and applicability across varied provider skill levels.

The landmark:

AIRWAYS-2 Trial

(Benger et al., JAMA 2018)

compared:

• i-gel supraglottic airways versus
• endotracheal intubation

during out-of-hospital cardiac arrest.

The result:

There was no clear superiority of i-gel regarding favorable neurologic outcomes.

However, the study also did NOT demonstrate that SGAs were ineffective.

DOI:

The correct interpretation is NOT:

“the i-gel is superior.”

Nor is it:

“the i-gel is useless.”

The correct interpretation is:

SGAs function reasonably well within trained systems using appropriate indications and quality control.

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ATLS: A COMPLETELY DIFFERENT PHILOSOPHY

ATLS operates under an entirely different framework.

The ATLS environment assumes:

• hospital resources,
• anesthesia support,
• surgery,
• advanced monitoring,
• organized difficult airway systems,
• and definitive airway capability.

In severe trauma:

the definitive airway remains:

endotracheal intubation.

However, ATLS still recognizes SGAs as:

• rescue devices,
• bridging tools,
• or transitional airway adjuncts

when:

• intubation fails,
• ventilation becomes difficult,
• or a definitive airway is being prepared.

Using ATLS doctrine to justify removing i-gels from civilian EMS would therefore represent a doctrinal misuse of ATLS principles.

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NATO / MULTINATIONAL REALITY

Within NATO/OTAN systems, substantial variability still exists.

Many allied nations continue to:

• use supraglottic airways,
• deploy i-gels in ambulances,
• and integrate SGAs into tactical police medicine and civilian EMS.

There is no universal NATO-wide abandonment of SGAs.

Operational doctrine depends on:

• national systems,
• epidemiology,
• logistics,
• provider training,
• and evacuation realities.

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CRITICAL ANALYSIS OF THE CLAIMS IN THE IMAGE

“HIGH FAILURE RATE IN COMBAT”

This statement requires nuance.

Yes, there are legitimate concerns regarding:

• performance in severe facial trauma,
• blood contamination,
• vomiting,
• and secretion-heavy airways.

However, universally stating:

“high failure rate”

without operational context or specific supporting data is scientifically weak.

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“HEAT/HUMIDITY DEGRADATION”

This statement also requires precision.

Any medical device may be affected by:

• prolonged storage,
• humidity,
• extreme temperatures,
• packaging limitations,
• and harsh operational logistics.

However, presenting this as a primary official reason for doctrinal change oversimplifies the issue considerably.

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FINAL DOCTRINAL POSITION — DRRAMONREYESMD

The i-gel has NOT been “condemned.”

What actually occurred is far more sophisticated:

CoTCCC redefined airway priorities for modern combat medicine.

That does NOT automatically require:

• civilian EMS,
• TECC systems,
• tactical police medicine,
• urban ambulance services,
• or international civilian systems

to eliminate supraglottic airways.

The mistake is not carrying an i-gel.

The mistake is:

• using it without training,
• using it without capnography,
• using it outside appropriate indications,
• using it as a universal substitute for definitive airway management,
• or blindly copying military doctrine without epidemiologic analysis.

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FINAL CONCLUSION

TCCC did not ban the i-gel.

TCCC modified a specific military airway algorithm.

Civilian TECC is NOT obligated to follow that decision.

Civilian EMS still has valid indications for SGAs.

Operational context defines doctrine.

There is no perfect airway.

There is only the right airway, for the right patient, in the right environment, performed by the right operator.

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PRIMARY REFERENCES AND SOURCES

C-TECC Position Statement 2024

Joint Trauma System – Airway Management in Trauma CPG 2026

AIRWAYS-2 Trial – JAMA

NAEMT / JSOM

Otten EJ, Montgomery HR, Butler FK.
Extraglottic Airways in Tactical Combat Casualty Care.
Journal of Special Operations Medicine. 2017.

DoD TCCC Handbook