Welcome to this special edition of the REBEL Cast, where we unravel key highlights and educational insights from the IncrEMentuM Conference in Spain. This event is a cornerstone for advancing emergency medicine education, drawing esteemed speakers and participants from around the globe. As emergency medicine gains traction in Spain, this conference has become an essential platform for knowledge exchange and professional growth. Today, host Dr. Mark Ramzy shines a spotlight on three distinguished speakers: Dr. Jess Mason, Dr. Tarlan Hedayati, and Dr. Simon Carley, who shared their expertise and experiences at this transformative gathering last spring.

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.

• Think about alternative diagnoses that could be driving the patient's atrial fibrillation
• Maybe the atrial fibrillation is an adaptive response and slowing them down (whether chemically or electrically) may cause more harm than good
• Get in the mental space before having to perform a High Acuity Low Occurrence (HALO) procedure and walk through each of the parts step by step
  • • EMRAP has uploaded the video of the Resuscitative Hysterotomy here (Subscription required to watch)
  • Like many things in critical care, a patient with a severe head injury requires you to do many little things very well (ie. reducing ICP increases by taking off the C-collar if able, positioning the patient appropriately, knowing when to use certain medications)

The upcoming conference aims to gather world-class educators once more and promises an enriching experience for all attendees. Drs. Tarlan Hedayati, Jess Mason and Simon Carley, along with many others, will be there at the event. For more information on the IncrEMentuM Conference and to register, visit their website! See you there!

The QT interval is a vital part of ECG interpretation, reflecting the heart's electrical recovery after each beat. When prolonged, it can set the stage for torsades de pointes. Understanding how to measure and correct the QT interval, identify high-risk medications, and act quickly when TdP occurs is essential for every clinician. This guide walks you through the physiology, interpretation, common causes, and emergency management of QTc prolongation to keep your patients safe.

📝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:

1. Severe Thyroid Storm:
   • Diagnosis Reminder: Consider thyroid storm in febrile patients with altered mental status; order TSH tests.
   • Beta Blocker Administration: Use ultrasound to assess heart function before administering propranolol to prevent low output heart failure.
   • Medication Timing: Administer iodine after antithyroid drugs.
2. Refractory Hypoglycemia:
   • Early Use of Octreotide: Beneficial in sulfonylurea-induced cases; initiate treatment promptly for better efficacy.
   • Broadened Perspective: Consider other endocrine disorders as potential causes beyond typical measures.
3. Modern Management of SCAPE:
   • Bolus Dose Nitroglycerin: A recommended practice for quick patient stabilization and improved outcomes in SCAPE scenarios.
   • We covered this topic before on REBEL EM, see Dr. Marco Propersi's post here

✈️See you in Spain!

The upcoming conference aims to gather world-class educators once more and promises an enriching experience for all attendees. George Willis, along with many others, will bring significant discourse to the event. For more information on the IncrEMentuM Conference and to register, visit their website! See you there!

🗝️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.

🛏️ 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.

• ❌ Don't chase perfect numbers: Adequate and safe is often better than "perfect but harmful."
• 💨 Oxygenation levers: Start with FiO₂ and PEEP, but remember MAP is the true driver.
• 🫁 Ventilation levers: Adjust RR and TV, tailored to underlying physiology.
• 🚫 Watch your obstructive patients: Sometimes less RR is more.

When you take the airway, you take the wheel and you now control the patient's oxygenation and ventilation. In this REBEL Crit episode, Dr. Lodeserto and Dr. Acker walk through the physiology, ventilator strategies, and clinical curveballs that separate calm control from chaos at the bedside.

• 💨 Start with Breath Types: Controlled, assisted, and supported breaths are the foundation of all modes.
• 🛌 Comfort Over "Best Mode": No mode improves mortality — focus on patient synchrony and comfort.
• ✅ Know the Big 5 Modes: AC: All controlled or assisted (volume or pressure). PS: Fully spontaneous, great for SBTs. PRVC: Pressure-delivered, volume-targeted hybrid. SIMV: Mixed mode, less favored in adults. VS: Spontaneous mode with adaptive pressure.
• ⚠️ Watch for Pitfalls: PRVC may under-ventilate in agitation. SIMV often causes dyssynchrony.
• 🎯 Bottom Line: Master mode mechanics and match the vent to the patient — not the other way around.

Mechanical ventilation can feel overwhelming, especially when faced with a sea of ventilator modes and unfamiliar terminology. In Part 2 of the series, we go beyond breath types and delivery mechanics to explore the most used modes in the ICU. We will break down each one; explaining how it works, when to use it, and why the goal isn't the "best mode" but the most comfortable one for the patient.

• 00:00 Introduction to Rebel Cast
• 00:10 Highlighting the Incrementum Conference 2026
• 00:34 Meet the Founders of Incrementum
• 01:21 The Journey to Incrementum
• 04:27 The Recognition of Emergency Medicine in Spain
• 06:04 What is Incrementum?
• 08:14 Bringing Together Top Emergency Medicine Experts
• 11:38 Exciting Sessions to Look Forward To
• 15:54 Conclusion and Invitation to Increment 2026

In this special episode of Rebel Cast, we spotlight the Incrementum Conference in Spain, a significant event in emergency medicine. Hosts welcome Dr. Francisco 'Paco' Campillo Palma and Dr. Carmen Maria Cano, founders of Incrementum, to discuss the recognition of emergency medicine as a specialty in Spain. They share their journey of creating the conference, emphasizing the importance of education, collaboration, and growth. The discussion also touches on this year's conference highlights, including sessions on mental health and evidence-based medicine, and the exceptional lineup of speakers. Listeners are encouraged to attend the conference in April 2026 for an enriching experience.

• Join us in Spain this April for the Increment Conference!
• 👉 Register now at incrementum-conference.com

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.