📝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.

Key Points:

• 💨 Master the 3 Types of Breaths
  Control, Assist, and Spontaneous — know the difference before tackling ventilator modes.
• 📦 Breath Delivery: Volume vs. Pressure
  Volume-Targeted = fixed volume → monitor pressure
  📈 Pressure-Targeted = fixed pressure → monitor volume
• 🫁 Lung Compliance = Pressure-Volume Relationship
  Volume mode: ↑ pressure = ↓ compliance (stiff lungs)
  Pressure mode: ↓ tidal volume = ↓ compliance
• 🏋️‍♂️ Use Analogies to Simplify
  The pull-up analogy makes complex concepts easier to grasp and remember.
• 🧱 Build the Foundation First
  Before diving into complex ventilator modes, get solid on breath types, delivery methods, and lung mechanics.

Introduction:
For many medical residents, the ICU can feel like stepping into a pressure cooker. At the heart of that stress often lies one intimidating machine: the ventilator. Rather than diving headfirst into complex ventilator modes, this episode lays a critical foundation by breaking down the basic building blocks of mechanical ventilation, something every clinician should master before moving on to more advanced concepts. Once you know the 3 types of breaths and how those breaths are delivered, you can more easily understand most of the mechanical ventilator modes. 

• Placing an IO in a bone with a proximal fracture, a previous IO placement attempt or any circulatory compromise proximal to the site is contraindicated
• Blood work drawn from an IO are generally not accurate, so once the patient has been resuscitated with the IO, intravenous blood draws are recommended
• Dislodgement is common; it is best to use the stabilizer that comes with the IO kit; if the kit does not have a stabilizer, stack lots of gauze on both sides of the IO needle and tape it down

• While proximal humerus site portents faster infusion rates than proximal tibia site, the main limitation of the proximal humerus site is that the arm must be held in internal rotation to avoid dislodgement of the IO
• Proximal tibia may be easier to landmark than proximal humerus
• Other sites include distal tibia, distal femur and sternum but are uncommonly employed in EDs

 In this episode, we will dive into a simple yet effective bedside approach to a patient in shock. By using quick physical exam findings and bedside vitals (particularly pulse pressure), you can form a quick assessment of the likely underlying etiology of a critically ill patient. 

Sinus tachycardia is the most prevalent cardiac dysrhythmia in critically ill patients, yet it often receives less attention than it warrants. While the rhythm itself is not inherently dangerous, it serves as a crucial indicator of underlying physiological disturbances that require prompt evaluation and management.

In this episode, we focus on the bedside evaluation of the tachypneic patient. Tachypnea (increased respiratory rate) can be an early indicator of serious illness, but not every tachypneic patient is on the verge of arrest. The key is honing your bedside assessment to recognize who is at risk for rapid deterioration and why. We break down a practical approach you can use immediately at the bedside.

In this episode, we break down a practical bedside approach to hypoxemia. We clarify the difference between hypoxemia (low oxygen in the blood) and hypoxia (low oxygen at the tissue level), and walk through the major causes of hypoxemia that you need to recognize quickly at the bedside.

Acetaminophen (APAP) overdose remains one of the most common causes of acute liver failure in the United States. While its therapeutic use is widespread and generally safe, unintentional overdoses and delayed presentations can lead to devastating outcomes. In this episode of REBEL Cast, Swami breaks down the pathophysiology, clinical course, diagnostic approach, and evidence-based management of APAP toxicity—including when to initiate NAC, how to apply the Rumack-Matthew nomogram, and the evolving role of adjunctive therapies like fomepizole. Whether you're in the ED or elsewhere , this is core content every clinician should know.

In this episode of Rebelcast, hosts Dr. Marco Propersi and Dr. Joe Bove discuss the Queen of Hearts, a groundbreaking AI tool changing the game in EKG interpretation for detecting occlusive myocardial infarctions. Joined by experts Dr. Pendell Meyers and Dr. Steve Smith, they delve into the nuances of OMI classification and highlight the advanced capabilities of this AI model. The conversation covers the development, validation, and implementation of the Queen of Hearts AI model, its potential impact on emergency medicine, and its future implications for medical education and practice.

We're back with our in house toxicologist Dr. Sanjay Mohan chatting about toxic alcohol ingestin.

This week we're featuring a cross post from the Only in Staten podcast on peds hem onc emergencies.

This week we dive into hyperkalemia management.

This week we sit down with our in house toxicologist Dr. Sanjay Mohan to chat about HIET.

The REVERT Randomized Controlled Trial demonstrated the superiority of the modified valsalva maneuver (MVM) over the standard valsalva maneuver in re-establishing normal sinus rhythm in patients with Paroxysmal SVT. MVM exaggerates venous return to the heart and increases vagal outflow by elevating the patient's legs. However, the success rate of the MVM is still significantly lower than that of intravenous adenosine, the first-line pharmacological therapy for treating PSVT, which establishes NSR by transiently slowing electrical conduction through the AV node. 

Given that these two treatment options operate via different physiologic mechanisms, could MVM and IV adenosine be combined synergistically to convert PSVT with better success rates than either treatment individually and with better safety profiles?

This week we discuss the management of posterior epistaxis.

This week we dive into neutropenic fever

This week, we discuss acute sinusitis and identifying patients who will benefit from antibiotics.

Resuscitationists have debated the choice of induction agents in rapid sequence intubation (RSI) for decades. Critics of etomidate will highlight its link to adrenal suppression in critically ill patients (Albert 2011), while critics of ketamine will highlight the higher incidence of post-intubation hypotension (Mohr 2020). Amidst the debate, the Ketased Trial (Jabre 2009), a large multicenter prospective, single-blind randomized clinical trial (RCT), reported no significant difference in SOFA scores or 28-day mortality between the two induction agents. However, the EvK trial (Matchett 2022) identified a statistically significant difference in 7-day mortality but not 28-day mortality in favor of ketamine. However, methodological concerns from the EvK Trial warrant a cautious interpretation of the data. In light of these and several other recent high-quality clinical trials comparing ketamine and etomidate, this meta-analysis aims to provide a point estimate of the mortality rate.

https://rebelem.com/from-debate-to-data-emerging-insights-into-rsi-induction-with-ketamine-vs-etomidate/

Swami sits down with Emergency Physicians and the authors of the soon to be released book MicroSkills Drs. Adaira Landy and Resa Lewiss.

Swami sits down with Drs. Dara Kass and Monica Saxena to discuss the EMTALA law and current challenges in the area of reproductive health.

Swami chats with Brendan Freeman, Emergency doc and medical education fellow at Staten Island University Hospital about improving our sleep hygiene.

There is a shifting paradigm towards shorter durations of antibiotics in pediatric infections. Conflicting international guidelines recommend treatment of urinary tract infection (UTI) with antibiotic courses ranging from just 3 days to 7–14 days. Antimicrobial resistance is a global health crisis, underscoring the importance of antibiotic stewardship. Investigators in the SCOUT Trial examine the impact of short-course (5 day) antibiotic therapy in UTI, with potentially far reaching implications.

https://rebelem.com/pediatric-utis-short-course-vs-standard-course-antibiotics-is-it-time-for-a-change/

Community-acquired pneumonia (CAP) can lead to pulmonary and systemic inflammation, resulting in impaired gas exchange, sepsis, organ failure, and an increased risk of death. Corticosteroids have excellent anti-inflammatory and immunomodulatory effects that could mitigate some of the inflammation caused by pneumonia. There have been several randomized trials that have shown glucocorticoids have positive effects in patients with CAP. However, except for one trial, none showed a between-group difference regarding mortality.  We now have the Community-Acquired Pneumonia: Evaluation of Corticosteroids (CAPE COD) Trial.

https://rebelem.com/corticosteroids-in-severe-community-acquired-pneumonia-could-cape-cod-catalyze-a-change-in-critical-care-management/

Should we give oral ibuprofen or intramuscular ketorolac in the ED in patients who can take PO?

This week we discuss some of the serious infectious processes of pregnancy.

This week we discuss the diagnosis and management of Achilles tendon ruptures.

This week we once again borrow audio from the Only in Staten Podcast and feature a discussion on cardiogenic shock with the director of the CCU at SIUH, Dr. Martin Amor.

We've got toxicologist Dr. Sanjay Mohan back on to chat about carbon monoxide toxicity in the ED.

This week, Swami sits down with director of the Staten Island University Hospital cardiac catheterization lab, Dr. Ruben Kandov, to discuss ACS management.

This week we chat with Dr. Danielle Langan, MedEd Fellow and Attending at Staten Island University Hospital, about awareness during paralysis post-RSI.

Simply put, flow is the peak of human performance, maximum focus with maximum responsiveness, an optimal state of consciousness. This state of mind is accessible to anyone under the right circumstances and has huge implications to how we live, work and train. 

In this podcast episode, three Emergency Medicine Physicians, Drs. Marco Propersi, Dan Wolf and Will Smith, discuss flow in relation to working in the ED, how it intersects with medical training, on shift performance and even in daily life outside the hospital. 

• Does the high stakes life or death environment in the ED allow us to access a flow state, even though our own lives are not at risk? 
• How can you set yourself up to achieve flow?
• While on shift how does being ‘in flow’ facilitate mastery of our profession?

We will discuss these topics and many more on this episode of REBEL Reflections!

The Rise of Superman on Amazon.com

From the Only in Staten Podcast - Swami sits down with cardiologist Dr. Samantha Lee to chat about cardiac testing.

This week, Swami shares some pearls from a recent critical care shift.

Toxicologist Sanjay Mohan is back to discuss sodium channel blocker poisoning management.

This week, we discuss angioedema focusing on treatment.

This week we chat about an uncommon, but potentially lethal, cause of back pain.

This week we sit down with Dr. Billy Caputo, Associate Professor of EM and residency director at SIUH to chat about nerve blocks.

Toxicologist and ED doc Sanjay Mohan is back talking methylxanthines.

This week, we chat with toxicologist Sanjay Mohan about caustic ingestions.

This week, Swami sits down with Dr. Mike Cooper, Director of the Staten Island University Hospital Burn Center, to talk emergency burn management.

This week, we discuss the indications for imaging in renal colic.

This week, Swami sits down with EM doc and toxicologist Sanjay Mohan to chat about alcoholic ketoacidosis.

This week we discuss RBBB, LBBB as well as LPFB and LAFB.

This week we chat about AVNRT - diagnosis, management and why we shouldn't be getting troponins on the vast majority of cases.

Swami explores some common causes of non-traumatic, acute, monocular vision loss including retinal detachment and CRAO.

Swami explores some common causes of non-traumatic, acute, monocular vision loss including glaucoma and giant cell arteritis.

This week, Swami sits down with Dr. Danielle Langan to chat about lithium toxicity.

This week we discuss testicular torsion focusing on some pearls and pitfalls.

This week we discuss the diagnosis and management of Methemoglobinemia.

This week we discuss the diagnosis and management of SBP.

This week we dive into diagnosis and management of hypocalcemia.

This week, we review the median, ulnar and radial nerve blocks and how they can be useful in clinical practice.

This week we discuss the diagnosis and management of superficial venous thrombosis.

This week, we discuss the ins and outs of management of AVNRT.

This week we discuss the diagnosis and management of post-LP headache.

This week we discuss AAA presentations and diagnosis.