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There were a number of changes to the grammar and formatting of the protocols.

Those are important, I suggest you read through those and discover them for yourself.

LINK TO THE NEW PROTOCOLS

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The changes to the cardiac protocols come from the American Heart Association changes made to the 2025 guidelines. If you want to read more: https://doi.org/10.1161/CIR.0000000000001376

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Epinephrine infusion is now standing order for the following:

Cardiac – Adult: Bradycardia / Heart Blocks – Symptomatic

• Paramedic
  • Epinephrine infusion starting at 5 mcg/min titrated to MAP >65 mmHg or SBP >100 mmHg

Epinephrine infusion is preferred over norepinephrine for symptomatic bradycardia because its potent β1-adrenergic activity increases heart rate and myocardial contractility while also providing vasopressor support. (Source 1, Source 2, Source 3)

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Anaphylaxis and Allergic Reaction – Adult

Epinephrine infusion is preferred over norepinephrine for anaphylaxis because it provides α1-mediated vasoconstriction, β1-mediated cardiac support, and β2-mediated bronchodilation and inhibition of further mast cell and basophil mediator release.

• Paramedic
  • Epinephrine infusion starting at 5 mcg/min titrated to MAP >65 mmHg or SBP >100 mmHg

*** It’s not listed but 0.5 mcg/kg/min is max infusion dose ***

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Epinephrine infusion recipe:

1 mg/1000 mL or 0.5 mg/500 mL = 1 mcg/mL

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Cardiac – Adult: Tachycardia – Narrow Complex

• Increased cardioversion to 200 Joules across all indications.

Per the AHA: Higher first-shock energy settings (≥200 J) are preferable to lower settings for cardioversion of atrial fibrillation and atrial flutter.

(source 1, source 2, source 3)

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Antipsychotics

I tried to find a meme for this, but they’re all pretty dark.

Antipsychotic medications are primarily utilized to manage severe psychiatric emergencies, typically in patients suffering from underlying conditions like Schizophrenia or Bipolar I disorder. In the field, these interventions are usually required when a patient is experiencing:

• Schizophrenia: A chronic, severe mental health disorder that fundamentally alters how a person thinks, feels, and behaves. Its features are generally broken down into positive symptoms (additions to normal behavior, like hallucinations, delusions, and severely disorganized thought or speech) and negative symptoms (reductions in normal behavior, such as a “flat” emotional affect, lack of motivation, or severe social withdrawal).
• Psychosis: Often the hallmark of an acute schizophrenic episode characterized by a complete disconnection from reality. A person experiencing psychosis cannot easily distinguish what is real from what is not, driven largely by intense hallucinations (hearing voices or seeing things) and delusions (strongly held, irrational false beliefs, such as extreme paranoia).
• Mania: A psychological state defining Bipolar I disorder, characterized by an abnormally elevated, expansive, or extremely irritable mood accompanied by a massive surge in energy. A manic episode often involves racing thoughts, rapid or pressured speech, a severely decreased need for sleep, and highly impulsive, agitated, or reckless behavior.

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First-Generation (Typical) Antipsychotics

Older drugs like Haloperidol work by aggressively blocking dopamine receptors (D2 antagonism) to reduce hallucinations and delusions. However, because they block dopamine so strongly, they disrupt the brain’s motor pathways.

This creates a high risk of Extrapyramidal Symptoms (EPS), which are severe, involuntary movement disorders. In an acute setting, this often presents as acute dystonia (sudden, painful muscle spasms, like a locked neck or clenched jaw) or akathisia (an agonizing internal restlessness and inability to sit still).

Second-Generation (Atypical) Antipsychotics

Newer drugs were developed to avoid these severe movement disorders. Second-generation antipsychotics work by blocking both dopamine (D2 antagonism) and specific serotonin receptors (5-HT2A). This dual-action “softens” the dopamine block, drastically reducing the risk of EPS. Many atypical antipsychotics also strongly block histamine receptors (H1 antagonism), which produces a heavy sedative effect.

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Olanzapine has been moved to standing order.

Haloperidol was the in the protocols, but was removed due to slow onset of action and high risk of severe neurological side effects. In its place, Olanzapine (Zyprexa), a second-generation antipsychotic has been added to the protocols. Olanzapine is preferred of because its strong sedative properties provide a much more rapid onset, without the dangerous movement disorders associated with older medications.

The protocol(s):

Behavioral: Agitated Patient – Adult

Behavioral: Agitated Patient – Pediatric

Olanzapine can act as a strong sedative when administered, when feasible cardiac monitor along with waveform capnography is required.

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Pre-Eclampsia and Eclampsia are a separate protocol now.

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Heat Emergencies

There is now a helpful description of active cooling, this is considered a time critical intervention;

• Begin active, whole-body cooling immediately until their mental status returns, at which time stop cooling efforts. Transport may be delayed if means of active cooling is available. Use any of the following in decreasing order of preference:
  • Ice water immersion, cold water immersion,
  • Tarp-Assisted Cold water with Oscillation (TACO),
  • cold water dousing, or
  • cold water-soaked towels with ice packs.

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Another New Protocol:

NYS has finally warmed up to the idea of Oxytocin (brand name Pitocin), a synthetic hormone used to induce or strengthen uterine contractions to control bleeding after childbirth.

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Oxymetazoline

Oxymetazoline (brand name Afrin) is a topical alpha-adrenergic agonist that works by causing vasoconstriction in the nasal mucosa. During an anterior nosebleed, spraying into the affected nostril constricts small blood vessels reducing blood flow and promoting clot formation.

Protocol:

We will be adding Oxymetazoline (brand name Afrin) to the drug bags in the near future. THEY ARE SINGLE USE PER PATIENT.

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Tourniquet Conversion

Tourniquet conversion is the process of removing a tourniquet and replacing it with a hemostatic dressing or pressure bandage. The goal is to restore blood flow to the rest of the limb, preventing ischemic tissue damage.

• Tourniquet Conversion may be performed on a non-amputated extremity as follows:
  • Apply a pressure dressing to the wound
  • Slowly release the windlass and monitor for re-bleeding:
    • If re-bleeding occurs, re-tighten the tourniquet
      If no bleeding occurs, release the tourniquet completely but leave in place
    • and monitor the dressing for re-bleeding until facility arrival

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Post Intubation Management – Adult

The state update guide states that they “Added supraglottic airway under indications for use of protocol.”

This means if the patient has an iGel in place you can provide the following:

• Administer continual analgesia and, if necessary, sedation:
  • Fentanyl 100 mcg IV once, and then 50 mcg IV every 5 minutes, as needed
  • Midazolam (Versed) up to 5 mg IV every 10 minutes, as needed
    • May substitute Ketamine up to 100 mg every 15 minutes, as needed

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TL;DR

https://www.health.ny.gov/professionals/ems/pdf/26-03.pdf

LINK TO TEST