📝Introduction:

In this exciting episode of REBEL Cast, host Dr. Mark Ramzy joins forces with renowned educator and speaker, Dr. George Willis. Broadcasting straight from the ACEP 25 in Salt Lake City, the duo talk about bringing together the international emergency medicine community, as they reflect on their experiences at the Increment Conference in Murcia, Spain, and preview the upcoming event this spring.

🤔What's IncrEMentuM?

A new conference and a pivotal gathering for emergency medicine professionals worldwide, has become an essential platform for education, collaboration, and advocacy, especially in light of emergency medicine's recent recognition as a specialty in Spain. The conference is praised for its outstanding production quality, engaging speakers, and its capacity to foster a global community of emergency care professionals.

🦪Pearls from George's IncrEMentuM 2025 Lectures:Pearls from George's IncrEMentuM 2025 Lectures:

1. Sodium Bicarbonate Use:
   • Appropriate Use: Focus on specific instances like metabolic acidosis with renal failure or severe metabolic cases with tox patients (e.g., salicylate or TCA overdose).
   • Emphasis on Patient-Centric Care: Treat the patient, not the number; avoid harmful overreliance on bicarb based solely on lab results
2. Diabetic Ketoacidosis (DKA):
   • Balanced Solutions: Preferenced over normal saline to prevent hyperchloremic acidosis.
   • Potassium Management: Oral potassium is effective and should be utilized, challenging the myth of impaired gastric absorption in DKA.
   • Squid Protocol: Usage of ultra-rapid insulin subcutaneously as an alternative to insulin drips in mild to moderate DKA cases.
   • We covered this topic before on REBEL EM. Check out the post here and the podcast here
3. Crashing Aortic Dissection:
   • Hypotension Insights: Do not attribute sudden hypotension solely to medication; prioritize ruling out tamponade or cardiogenic shock.
   • Ultrasound Utilization: Essential tool for detecting complications like tamponade or low EF due to myocardial infarction or aortic valve regurgitation.
   • Controlled Pericardial Drainage: Crucial technique to stabilize hemodynamics without increasing mortality, avoiding extensive fluid removal

     Here's a helpful algorithmic infographic to reference for aortic dissection patients

     
     Image Courtesy of Dr. Mark Ramzy, DO (@MRamzyDO)

4. Hyperkalemia
   
   • Not every patient needs calcium. Dont just give it prophylatically, only those with EKG changes should get it and get enough of it.
   • Give an appropriate dose of your other medications. That includes giving 10 units of insulin and 2 amps of dextrose 50. One when they get the 10 units of insulin and the other 30 minutes later
   • Patients may be dehydrated, dont give them furosemide or diuretics. Those patients need fluid to help perfuse their kidneys and eliminate potassium
   • Here's George Willis' Hyperkalemia Removal Algorith:
     
   • Here's a REBEL REVIEW breaking down the different electrolytes in each of the types of fluids:

🫣Teasers from George's IncrEMentuM 2026 Lectures:

🗝️Key Points

• 💧 Fluid Choice Matters: Plasma-Lyte, a balanced crystalloid, corrected acidosis faster than normal saline in severe DKA patients, with no increase in adverse events.
• 🧪 Chloride Load Concerns: Normal saline’s high chloride content can worsen acidosis, potentially slowing bicarb recovery even after the anion gap closes.
• 🔬 Study Design Strengths: The SCOPE-DKA trial was a cluster crossover, open-label RCT, protocolizing all variables except fluid type, enhancing the reliability of its findings.
• 🧮 Base Excess & Strong Ion Difference: Base excess/deficit and strong ion difference are valuable but underutilized tools for assessing acid-base status—don’t rely solely on pH or bicarb.
• ⚠️ Limitations & Next Steps: The study did not include lactated Ringer’s, and fluid rates were left to clinical discretion. More research, including three-arm trials, is needed for definitive guidance.

📝 Introduction

Managing diabetic ketoacidosis (DKA) requires careful consideration of fluid therapy, especially in severe cases. In part two of our REBEL Cast DKA series, we shifted from insulin strategies to fluid choice in severe DKA, diving into the SCOPE-DKA trial—a cluster, crossover, open-label RCT from Australia. While normal saline (NS) is commonly used, concerns about its high chloride content and impact on acidosis have sparked growing interest in balanced solutions like Plasma-Lyte.

🚨  Clinical Bottom Line

Plasma-Lyte showed a modest but meaningful benefit over normal saline in resolving metabolic acidosis in patients with severe DKA. Though safety profiles were similar, the more balanced electrolyte composition of Plasma-Lyte helped normalize acid-base status slightly faster—without worsening ketosis. While this won’t revolutionize care overnight, it’s one more step toward physiologic resuscitation in DKA. Understanding fluid composition and its impact on acid-base balance is crucial for optimal patient care.

🔑 Key Points

🛏️ Fewer ICU Admissions
Only 5 patients in the SQuID group required ICU care vs 99 in the traditional insulin drip group.

⏱️ Shorter ED Stays
ED length of stay dropped by ~3 hours in the SQuID group—an operational win in crowded departments.

💉 No Drop in Nursing Workload
Despite using subQ insulin, nurses still performed hourly glucose checks and frequent injections.

🧪 Focus on the Anion Gap
DKA resolution = closing the anion gap, not just normalizing blood sugar—critical concept for trainees and nurses alike.

👶 Peds Has the Edge
Pediatric ICUs routinely use a 2-bag system (D10 + electrolytes vs electrolytes alone) to safely continue insulin while managing glucose—adult medicine should take note.

📝Introduction

In this episode of REBEL Cast, we dive into part one of our Diabetic Ketoacidosis (DKA) series with a twist—subcutaneous insulin instead of the traditional IV drip. We explore the SQuID Protocol (Subcutaneous Insulin in DKA), which could potentially shift how we manage mild to moderate DKA—from the ICU to the general floor.

With ICU bed shortages, ED boarding, and nursing resource challenges, it's time to ask: Do all DKA patients really need a drip and an ICU bed?

We reviewed a quasi-experimental study comparing traditional insulin drips versus subcutaneous insulin (lispro q4h + glargine at time zero) in a busy urban ED. The results? Promising—but not without caveats.