2026 NYC REMAC Protocols: A Section-by-Section Study Overview

The 2026 NYC REMAC Prehospital Treatment Protocols (version 2026-01) took effect on August 1, 2026, and they are what the NYC REMAC Basic exam is built on. The book has three parts: the General Operating Procedures (26 pages), the Prehospital Treatment Protocols (91 pages) and the Appendices (42 pages). This overview walks through each part, says what it covers, and points to the high-yield facts worth drilling, with page numbers so you can check every one.

A note on what this article is not: it is not a list of changes from the previous edition. The 2026 protocol text does not include a summary of changes, revision notes or "new" markers, and we are not going to guess at a diff. If you trained on an older book, the safe approach is to study the 2026-01 edition as if it were new.

Key facts

• Edition: 2026-01, effective August 1, 2026
• Three parts, three page sequences: GOP pp. 1-26, Treatment Protocols pp. 1-91, Appendices pp. 1-42. Page numbers restart in each part, so always note which part you are in
• Same layout in every treatment protocol: CFR and all provider levels, EMT, Paramedic, Medical Control Options, Key Points / Considerations
• Exam weighting (Administrative Manual, approximate): GOP 12%, Treatment Protocols 60%, Appendices 12%, scenario-based questions 16%
• Always follow the current official protocols and medical control in the field. This article is a study aid

How the 2026 protocols map to the REMAC exam

The NYC REMAC Certification & Credentialing Administrative Manual (revised June 2025) describes the exam as 120 regional protocol questions with four choices each, roughly:

The question counts are simple arithmetic on 120, so treat them as rough. The big picture is clear, though: the treatment protocols carry the most weight, and the GOP and appendices together are about a quarter of the exam. Scenario questions usually blend the two, for example a clinical picture plus a transport or OLMC decision.

For exam logistics (eligibility, fee, registration, retakes), see the complete NYC REMAC exam guide.

How every treatment protocol is organized

Before you study a single protocol, read the Introduction on page 1 of the Treatment Protocols. It explains the layout that the exam constantly tests:

• CFR and All Provider Levels: standing orders that apply to everyone, ending at "CFR STOP"
• EMT: EMT and paramedic standing orders that continue after the CFR section, ending at "EMT STOP"
• Paramedic: paramedic standing orders, ending at "Paramedic STOP"
• Medical Control Options: treatments that may only be given after contacting online medical control (OLMC). Aside from a few listed exceptions, these are paramedic-only
• Key Points / Considerations: extra guidance for all levels

Each level starts at the beginning of the protocol and completes the treatments in order, using clinical judgment (2026 NYC REMAC Protocols, Introduction, p. 1).

Why this matters for the exam: many questions are really asking "which section is this in?" The same drug can be a standing order in one protocol and a Medical Control Option in another. Magnesium sulfate 4 g IV is a paramedic standing order for eclampsia but a Medical Control Option for pre-eclampsia with severe features (2026 NYC REMAC Protocols, Obstetric Emergencies, p. 30). Study with that question in mind every time.

Part 1: General Operating Procedures (GOP pp. 1-26)

The GOP sets the rules every protocol inherits: definitions, medical control, transport, airway, medications and special situations. About 12% of the exam targets it directly, and scenario questions lean on it heavily.

What it covers

• Purpose, scope, responsibilities and definitions (pp. 1-3)
• On-scene medical control by operations and by physicians (pp. 4-6)
• Scene safety and the universal approach to patient care (p. 6)
• Requesting help, initiating transport and transport decisions, including specialty centers (pp. 7-9)
• Helmet removal, spinal motion restriction and CPR (pp. 9-11)
• Oxygen, airway management and airway monitoring (pp. 11-13)
• Blood drawing and medication administration (pp. 13-15)
• Pediatric size estimation, shock, stable and unstable dysrhythmia (pp. 15-16)
• IVs by EMTs, central lines, pediatric age definitions, minors, abuse and the Abandoned Infant Protection Act (pp. 16-18)
• Coordination of prehospital resources and MCIs (pp. 19-21)
• Alternative treatment and alternative destinations (pp. 22-23)
• Mutual aid and weapons of mass destruction (pp. 25-26)

High-yield GOP targets

• No OLMC contact means standing orders only (GOP: Definitions, p. 2).
• Appropriate oxygen therapy: NRB at 10-15 L/min or NC at 2-6 L/min, required for SpO2 under 92%, SpO2 unavailable, or other signs of respiratory distress (GOP: Oxygen Administration, p. 11).
• Intubation rules: an attempt is the blade past the teeth; after two total unsuccessful attempts, use a supraglottic airway or effective BVM; nasal intubation is not approved in NYC (GOP: Airway Management and Airway Monitoring, p. 13).
• Waveform capnography is mandatory with any advanced airway, except a supraglottic device when resources are insufficient, such as an MCI (GOP: Airway Monitoring, p. 12).
• IO access: in shock, after two failed IV attempts, attempt IO (maximum 2 attempts); for a conscious patient, preservative-free 2% lidocaine 0.5 mg/kg IO (maximum 50 mg) before any IO medication or fluid (GOP: Intravascular Access and Medication Administration, p. 15).
• Intranasal list: glucagon, fentanyl, lorazepam, midazolam, naloxone, ketamine and diazepam, when there is no intravascular access; IN is contraindicated with epistaxis (GOP: Medication Administration, pp. 14-15).
• Length-based tapes estimate weight and equipment size only. Dose from the protocols, not the tape (GOP: Pediatric Size Estimation, p. 15).
• Adult shock definition: MAP under 65 or SBP under 90, plus signs of hypoperfusion such as heart rate over 110, respiratory rate over 20 or ETCO2 under 30 (GOP: Shock, p. 15).
• Pediatric hypotension: SBP under 70 + (2 x age in years) (GOP: Shock, p. 16).
• Ages: 15 or older is an adult for protocol purposes; under 18 is a minor for consent (GOP: Age Definitions and Minors, p. 17).
• Specialty transport: STEMI Center for at least 1 mm ST elevation in two or more contiguous leads after OLMC consultation; if the patient arrests en route, continue to the STEMI Center (GOP: Transportation to Specialty Care Facilities, p. 9). Stroke Center for symptoms under 24 hours, with exceptions for arrest, unmanageable airway and trauma criteria (p. 8).
• ALS to BLS handoff: allowed only if the patient meets all listed conditions, including no ALS medications or treatments and no acute coronary syndrome in the past 24 hours (GOP: Coordination of Prehospital Resources Procedure, p. 20).
• MCIs: generally five or more patients with potential need for extraordinary resources; FDNY determines transport decisions during an MCI (GOP: Coordination of Prehospital Resources Procedure, p. 21).

Part 2: Prehospital Treatment Protocols (pp. 1-91)

This is about 60% of the exam. The table of contents groups the protocols into four blocks.

Critical / cardiac arrest protocols (pp. 2-12)

Adult and pediatric non-traumatic cardiac arrest, pediatric severe bradycardia, obstructed airway, and adult and pediatric respiratory distress / respiratory failure.

High-yield targets:

• Adult arrest: epinephrine 1 mg IV every 3-5 minutes; for VF/pVT, amiodarone 300 mg or lidocaine 100 mg IV; consider OLMC after 20 minutes of ALS treatment on scene (Non-Traumatic Cardiac Arrest (Adult), p. 2).
• Adult arrest OLMC options: sodium bicarbonate, calcium chloride, fluids, and repeat antiarrhythmics including magnesium (p. 3).
• Pediatric arrest: epinephrine 0.01 mg/kg IV (max 1 mg); defibrillation 2 J/kg, then 4 J/kg, then 10 J/kg (Non-Traumatic Cardiac Arrest (Pediatric), p. 4).
• Pediatric severe bradycardia: heart rate under 60 with signs of shock or altered mental status. Ventilate first for one minute (Severe Bradycardia (Pediatric), p. 6).
• Adult respiratory distress: CPAP at the EMT level for persistent distress; nitroglycerin 0.4 mg SL/IV for suspected cardiogenic pulmonary edema with SBP over 120 (Respiratory Distress / Respiratory Failure (Adult), p. 9).

General adult and pediatric medical protocols (pp. 13-68)

The largest block. It runs from altered mental status through vaccine administration and includes the cardiac rhythm protocols, OB, neonatal, respiratory, environmental, toxicology, sepsis, shock, stroke, pain and sedation.

High-yield targets:

• Hypoglycemia: for BGL under 60, adult dextrose up to 25 g IV, pediatric 0.5 g/kg (max 25 g), or glucagon 1 mg IM/IN without IV access (Altered Mental Status, p. 13).
• Anaphylaxis epinephrine: auto-injector by age and weight (0.15 mg under 9 years and under 30 kg; 0.3 mg at 9 years or older or 30 kg or more); paramedic 0.01 mg/kg IM (max 0.5 mg); dose limits by level (Anaphylaxis / Severe Allergic Reaction, pp. 15-17).
• Behavioral: standing-order midazolam only for adults with hyperactive delirium who keep violently struggling despite physical restraint; never transport prone (Behavioral Emergencies, pp. 18-20).
• ACS: aspirin 324 mg chewable; nitroglycerin only if SBP over 120; no nitroglycerin within 72 hours of erectile dysfunction medication unless OLMC directs (Acute Coronary Syndrome, p. 21).
• Rhythms: unstable A-fib/flutter starts at 200 J; unstable SVT and unstable VT with a pulse start at 100 J; stable SVT gets a vagal maneuver, then adenosine 6 mg, then 12 mg (Atrial Fibrillation, p. 24; SVT, p. 26; Ventricular Tachycardia, p. 27). Adult brady-dysrhythmia: rate under 50 with signs of shock gets atropine 1 mg and pacing (p. 25).
• Pediatric rhythms: synchronized cardioversion is a Medical Control Option at 0.5-1 J/kg, then 1-2 J/kg (Dysrhythmia (Pediatric), p. 28).
• OB: magnesium sulfate 4 g IV over 10 minutes for eclampsia; pre-eclampsia with severe features defined by blood pressure plus symptoms (Obstetric Emergencies, p. 30).
• Childbirth and neonate: cord clamp positions, breech, prolapsed cord, shoulder dystocia (Emergency Childbirth, pp. 32-34); ventilate at 40-60/min, compressions at 3:1 if heart rate stays under 60 (Neonatal Care / Resuscitation, pp. 35-37).
• Asthma/COPD: albuterol-ipratropium at the EMT level; magnesium 2 g IV for adults with persistent symptoms; under 2 with first-time wheezing is likely bronchiolitis (Asthma / COPD / Wheezing, pp. 38-40).
• Croup and epiglottitis: nebulized epinephrine for stridor at rest; no advanced airway if epiglottitis is suspected (Stridor / Croup / Epiglottitis, pp. 41-42).
• Overdose: paramedics titrate naloxone 0.5 mg at a time (adult max 4 mg) instead of the CFR/EMT dose (Overdose, pp. 48-49).
• Seizures: midazolam preferred, then lorazepam, then diazepam, with dose and cumulative limits (Seizures, pp. 51-52).
• Sepsis and shock: 20 ml/kg fluid, then a choice of more fluid, a norepinephrine infusion or epinephrine 10 mcg IV for adults still in shock (Severe Sepsis and Septic Shock, p. 54; Shock (Adult), p. 55).
• Stroke: S-LAMS 3 or less to a Primary Stroke Center; 4 or more, contact OLMC about a Thrombectomy Stroke Center (Stroke, p. 58).
• Pain and sedation: acetaminophen, ketorolac (with contraindications including age 65 or older and pregnancy), morphine and fentanyl options (General Pain Management, pp. 62-63); standing-order sedation for intubation is only for adults who meet every listed criterion, including a respiratory rate under 10 and SpO2 under 90% (Procedural Sedation, pp. 64-65).

Trauma protocols (pp. 69-82)

General trauma care, traumatic cardiac arrest, amputation, avulsed tooth, bleeding control, burns, eye injuries, bone and joint injuries, and head, neck and spine injuries.

High-yield targets:

• Trauma fluids: 20 ml/kg IV (max 2 L) to keep SBP over 90 or MAP over 65; don't delay transport for IV access or fluids (General Trauma Care, pp. 69-70).
• Traumatic arrest: needle decompression is the only ALS intervention that should not wait for the ride; everything else happens en route (Traumatic Cardiac Arrest, p. 71).
• Tourniquets: 2-3 inches proximal to the wound, a second one proximal to the first if needed, never remove one placed for life-threatening bleeding (Bleeding / Hemorrhage Control, pp. 75-76).
• Burns: moist dressings only for burns of 10% TBSA or less; 20 ml/kg (max 1 L) for 2nd degree or deeper over 20% TBSA (Burns, p. 77).
• Eyes: flush chemical injuries with Normal Saline for at least 20 minutes; proparacaine or tetracaine may assist irrigation (Eye Injuries, p. 79).
• Spinal motion restriction criteria and the examples of high-risk mechanisms, including falls over 10 feet (Head, Neck, and Spine Injuries, p. 82).

Hazardous materials protocols (pp. 83-91)

Carbon monoxide poisoning, smoke inhalation, cyanide poisoning, and WMD nerve agent exposure.

High-yield targets:

• Carbon monoxide: hyperbaric center criteria include an asymptomatic patient with SpCO over 25% and a pregnant patient over 15%; pulse oximetry may read falsely high (Carbon Monoxide Poisoning, p. 83).
• Cyanide: hydroxocobalamin 5 g IV over 15 minutes for adults, given before sodium thiosulfate if you only have one line; draw blood samples first (Cyanide Poisoning, pp. 86-87).
• Nerve agents: a class order from FDNY OMA is required; NAAK and atropine by tag color and weight; no more than 3 NAAK units per patient; diazepam is the drug of choice for nerve-agent seizures (Weapons of Mass Destruction: Nerve Agent Exposure, pp. 88-91).

Part 3: Appendices (Appendix pp. 1-42)

About 12% of the exam, and the GOP and protocols point to the appendices constantly. Some appendices are reference lists; others are pure exam material.

The priority column is our study suggestion, not an official weighting.

High-yield appendix targets

• Trauma Center criteria: physical findings, vital signs (for example motor GCS under 6, room-air SpO2 under 90%), mechanisms such as falls over 10 feet, and the pediatric trauma center rule with its 30-minute limit (Appendix E: Trauma Center Transport Criteria, pp. 8-9).
• Burn Center criteria: 15% TBSA or more partial or full thickness, 5% or more full thickness, 9% or more in patients under 5 or over 60, plus respiratory, electrical and special-area burns (Appendix F: Burn Center Transport Criteria, p. 10).
• NYC S-LAMS: facial droop, arm drift, speech and grip, scored 0-6, and the OLMC exclusion criteria for thrombectomy transport (Appendix G, pp. 11-12).
• APGAR: scored at 1 and 5 minutes; 7 or less requires immediate intervention (Appendix K, p. 23).
• Modified START: the five tag colors, including Orange (Urgent) for bleeding controlled with a tourniquet or hemostatic dressing and for infants who don't meet Red or Black criteria (Appendix L, pp. 24-26).
• Needle decompression: second intercostal space mid-clavicular or fifth intercostal space anterior axillary; adult 14 gauge 3.25 inch catheter (Appendix M, p. 28).
• CPAP: age 15 or older, alert and in respiratory distress; exclusions include SBP under 100, trauma and suspected pneumothorax (Appendix N, p. 29).
• Treat-in-place / alternative destination: inclusion and exclusion criteria, including adult vital-sign exclusions and age under 5 (Appendix P, pp. 32-33).

A study order that follows the book

1. Read the Treatment Protocols Introduction (p. 1) so the structure is clear.
2. Work through the GOP in two or three sittings. It frames everything else.
3. Treatment Protocols by block: critical and arrest, then medical, then trauma, then HAZMAT. As each protocol sends you to an appendix (Appendix M from the arrest protocol, Appendix G from stroke), read that appendix the same day.
4. Finish the appendices you haven't touched, prioritizing the High rows above.
5. Mix it up. Once you've read everything, switch to mixed practice so you have to recognize which protocol a question is about.

For a day-by-day version of this order, see How to Study for the NYC REMAC Exam in 30 Days.

Frequently asked questions

When do the 2026 NYC REMAC protocols take effect?

August 1, 2026. The edition number is 2026-01, printed on the cover of each part.

Is there an official list of what changed in the 2026 protocols?

The 2026 protocol text itself does not include a summary of changes or revision markers. If REMAC publishes advisories or update materials, they are posted through REMSCO; check nycremsco.org and the NYC REMSCO LMS. Until then, study the 2026-01 book as written.

Which part of the protocols is on the REMAC Basic exam most?

The Treatment Protocols, at about 60% of the questions according to the Administrative Manual. The GOP and the Appendices are about 12% each, and scenario-based questions are about 16%.

Why do the page numbers start over?

Each part of the book, the GOP, the Treatment Protocols and the Appendices, numbers its own pages from 1. When you cite or look up a page, include the part.

What is the difference between a standing order and a Medical Control Option?

Standing orders are medications and treatments you may give without contacting OLMC. Medical Control Options may only be given after contacting OLMC, and aside from a few listed exceptions they are paramedic-only (2026 NYC REMAC Protocols, GOP: Definitions, pp. 2-3; Introduction, p. 1).

Where can I read the official protocols?

REMSCO posts the NYC REMAC protocols at nycremsco.org/protocols. RemacReady also includes a Protocol Reader for signed-in users, with search, highlights, notes and links from each practice question to its cited page.

Study the 2026 protocols with questions

Reading the book is the foundation. Answering questions is how you find out what stuck. RemacReady has 1,000 NYC REMAC practice questions written to the 2026 protocols, each citing its page, plus a full 120-question mock exam. Start free with a daily Quick 10 (opens in a new tab), browse the study modes on the exam prep page, or read the FAQ.

Keep reading:

• NYC REMAC Exam: The Complete 2026 Guide
• Free NYC REMAC Practice Questions (2026 Protocols) with Answers
• How to Study for the NYC REMAC Exam in 30 Days