🧭 REBEL Rundown

🗝️ Key Points

• • ❌ 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.

Click here for Direct Download of the Podcast.

📝 Introduction

Ventilator management can feel overwhelming—there are so many knobs to turn, numbers to watch, and changes to make. But before adjusting any settings, it’s crucial to understand why the patient is in distress in the first place, because the right strategy depends on the underlying cause. In this episode, we’ll walk through three different cases to see how the approach changes depending on the problem at hand.

️ The 4 Main Ventilator Settings

Pressure maintained in the lungs at the end of exhalation to prevent alveolar collapse and improve oxygenation

🧮 Modes of Ventilation

1. AC/VC (Assist Control – Volume Control)
   • How it Works: Delivers a set tidal volume with each breath (whether patient- or machine-triggered).
   • When It’s Used / Pros: Most common initial mode; guarantees minute ventilation; good for patients with variable effort.
   • Limitations / Cons: May cause patient–ventilator dyssynchrony if set volumes don’t match patient’s demand.
2. AC/PC (Assist Control – Pressure Control)
   • How it Works: Delivers a set inspiratory pressure for each breath; tidal volume varies depending on lung compliance/resistance.
   • When It’s Used / Pros: Useful in ARDS (lung-protective strategy), limits peak airway pressures.
   • Limitations / Cons: Tidal volume not guaranteed; must closely monitor volumes and minute ventilation.
3. PRVC (Pressure-Regulated Volume Control)
   • How it Works: Hybrid: set target tidal volume, ventilator adjusts inspiratory pressure breath-to-breath to achieve it (within limits).
   • When It’s Used / Pros: Common default mode on newer vents; combines benefits of VC (guaranteed volume) + PC (pressure limitation).
   • Limitations / Cons: Can increase pressures if compliance worsens.
4. SIMV (Synchronized Intermittent Mandatory Ventilation)
   • How it Works: Delivers set breaths, but allows spontaneous patient breaths in between (without guaranteed volume).
   • When It’s Used / Pros: Used for weaning; allows patient effort.
   • Limitations / Cons: Risk of increased work of breathing if spontaneous breaths are inadequate.
5. PSV (Pressure Support Ventilation)
   • How it Works: Every breath is patient-initiated; ventilator provides preset pressure support to overcome airway resistance.
   • When It’s Used / Pros: Weaning trials; patients with intact drive who just need assistance.
   • Limitations / Cons: Not a full-support mode; not for unstable patients without spontaneous drive.

♟️ Ventilation Strategies

1. Airway Protection
   • Low GCS, seizure, stroke
   • Loss of gag/cough reflex
   • High aspiration risk (vomiting, GI bleed, poor mental status)
2. Hypoxemic Respiratory Failure
   • Severe pneumonia
   • ARDS
   • Pulmonary edema
   • Inhalation injury
3. Ventilatory (Hypercapnic) Failure / Increased Ventilation Demand
   • Severe metabolic acidosis (DKA, sepsis, renal failure) → need high minute ventilation
   • COPD, asthma (if decompensating)
   • Neuromuscular weakness (myasthenia, Guillain–Barré, spinal cord injury)
4. Airway Obstruction / Anticipated Loss of Airway
   • Tumor, anaphylaxis, angioedema
   • Facial or airway trauma
   • Pre-op / anticipated deterioration

Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO)

👤 Show Notes

Priyanka Ramesh, MD

PGY 1 Internal Medicine Resident

Cape Fear Valley Internal Medicine Residency Program

Fayetteville NC

Aspiring Pulmonary Critical Care Fellow

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The post REBEL Core Cast 146.0–Ventilators Part 4: Setting up the Ventilator appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown

📝 Introduction

Welcome to the Rebel Core Content Blog, where we delve into crucial knowledge for emergency medicine. Today, we share insightful tips from PEM specialist Dr. Elise Perelman, shedding light on respiratory challenges in infants, toddlers, and young children during the viral season. Understanding that most cases involve typical viruses, we aim to equip you with diagnostic pearls to identify more serious pathologies.

Click here for Direct Download of the Podcast.

🔍 Recognizing Respiratory Patterns

Pearl #1: Look at Your Patient

Begin exams from the doorway. Observing patterns such as accessory muscle usage can reveal a patient’s respiratory effort. Specify whether the work of breathing occurs during inspiration, expiration, or both. Inspiratory work indicates difficulty getting air in, while expiratory work suggests trouble pushing air out. Silent tachypnea may point to other issues, like acidemia or pneumothorax.

🩺 Localizing Sounds for Accurate Diagnosis

Pearl #2: Localize the Sound

Breathing noises signal varied respiratory issues. Stridor, often heard on inspiration, results from obstructions above the thoracic inlet. Conversely, wheezing, generally linked to exhalation, indicates obstructions in the lower airways. Watch for signs like ‘silent chest’—a dangerous, severe obstruction, and distinguish grunting as a bodily mechanism to prevent alveolar collapse. Correctly identifying the sound assists in determining the appropriate intervention.

💉 Tailoring Treatment for Effective Results

Once a sound is localized, treatments vary. We explore Soder from nasal congestion, typically needing supportive care and suctioning. Stridor from conditions like croup is eased with interventions to reduce airway swelling, such as steroids or inhaled epinephrine. Conversely, wheezing in infants is often due to bronchiolitis—not bronchospasms—and over-treatment is to be avoided. Supportive measures including suction, hydration, and oxygen are preferred unless improvement warrants bronchodilators.

🌬️ Intervening with Severe Asthma

In severe cases of asthma or bronchiolitis, where standard at-home treatments fail, immediate adjunct therapies like intramuscular epinephrine become essential. Administering this quickly can alleviate obstruction when inhalants aren’t effective due to low air movement.

🦓 Navigating the Zebras of Respiratory Cases

When recognizing Zebras—uncommon cases overshadowed by routine diagnoses—remain vigilant for histories or presentations that don’t conform. Conditions like pneumonia, bacterial tracheitis, and even myocarditis may mimic more common issues.

📌 Conclusion

As attending physicians, our role extends beyond conventional treatment—it’s about discerning the atypical from the typical. Dr. Perelman urges continual reassessment, emphasizing reliance on observational skills as much as technological aid. Keeping keen on respiratory nuances ensures we catch those outlier cases, paving the way for adept medical care despite the overwhelming prevalence of viral infections.

Stay tuned for more pearls and insights in our future posts, as Dr. Perelman shares further strategies for effective pediatric emergency care. For more resources, continue exploring our faculty’s valuable contributions on our site. Until then, stay safe and perceptive in your practice.

Post Peer Reviewed By: Mark Ramzy, DO (X: @MRamzyDO), and Marco Propersi, DO (X: @Marco_Propersi)

👤 Guest

Elise Perlman MD

Pediatric Emergency Medicine​

Assistant Professor, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell

Meet The Team

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The post REBEL Core Cast – Pediatric Respiratory Emergencies: Beyond Viral Season appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown

📝Introduction

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.

Click here for Direct Download of the Podcast.

🤔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 Their IncrEMentuM 2025 Lectures

• 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)

See you in Spain!

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!

Tarlan Hedayati, MD

Vice Chair of Education and Associate Program Director

Cook County, Chicago, IL

Jess Mason, MD

Associate Professor of Emergency Medicine

Vanderbilt University, Nashville, TN

Simon Carley, MD, PhD

Professor of Emergency and Dean of the Royal College of Emergency Medicine

Manchester, England

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The post REBEL CAST – IncrEMentuM26 Speaker Spotlight : Drs. Tarlan Hedayati, Jess Mason and Simon Carley appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown

📌 Key Points

• • 🫀 Prolonged QTc raises risk of torsades de pointes
  • ⏱️ Correct for heart rate: QTc > 440 ms (men) or > 460 ms (women); > 500 ms = high TdP risk.
  • 💊 Common culprits: Methadone, ondansetron, macrolides, fluoroquinolones, antipsychotics.
  • 🧪 Prevention: Check & replete K, Mg, Ca and avoid QT-prolonging meds when possible.
  • 🚑 If TdP develops: Defibrillate + IV magnesium and stop offending agents.

Click here for Direct Download of the Podcast.

📝 Introduction

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.

🤔 Definition and Physiology

• QT evaluation is a fundamental component of EKG analysis. The QT interval reflects the time from ventricular depolarization and contraction through ventricular repolarization and relaxation.
• Clinically, QT prolongation increases the risk of torsades de pointes (TdP) – a form of polymorphic ventricular tachycardia (a non-perfusing rhythm) that is classically described as a pattern of “twisting points” or alternating amplitudes. This occurs when a premature ventricular contraction leads to an R on T phenomenon during the repolarization period.
• The differential for QT prolongation is long and varied: congenital long QT, electrolyte disturbances (hypoK, hypoMg, hypoCa), hypothermia, myocardial ischemia, and increased intracranial pressure. Moreover, a whole host of xenobiotics can prolong the QT interval: methadone, anti-microbials, anti-emetics, anti-psychotics, and anti-dysrhythmics.

🧮 ECG Interpretation

• The QT interval must be interpreted in conjunction with the patient’s heart rate. The QT interval with shorten in the context tachycardia and length in the context of bradycardia. In other words, tachycardia is protective when evaluating the patient with prolonged QT.
• With that in mind, many EKG machines will calculate a corrected QT interval or QTc. The QTc is a standardized way to account for variations in heart rate so clinicians are able to compared QT intervals at different heart rates over time and thus calculate risk.
• Generally, a QTc is considered prolonged if greater than 440ms in males or 460ms in females. Once the QTc > 500msec, the risk of TdP increases 2-3 fold.1
• A variety of different correction formulas exist: Bazett, Fridericia, Hodges, Framingham, Rautaharju.
• Manually, the QT interval should be measured from the beginning of the QRS complex to the end of the T wave – and thus should be measured in leads where all portions can be visualized, most frequently lead II or V5/V6. Ideally, the QT interval should be average over 3 or more beats.2 To determine the end of the T wave, a tangent line should be drawn through the maximum slope of the T wave – the point at which this line crosses the isoelectric line is the end of the T wave.3

💊 Commonly Used QTc Prolonging Medications

• Methadone: particularly concerning because not only does it inherently prolong QT but also induces a bradycardia
• Antiemetics: Ondansetron
• Macrolides: azithromycin, erythromycin, clarithromycin
• Fluroquinolones: ciprofloxacin, levofloxacin
• Antipsychotics: Haloperidol, Olanzapine

️ Management

• Prevention is key!
  • Assess electrolytes (Mg, Ca, K) and replete as needed
  • Telemetry Monitoring
• If patient happens to fall into TdP, initiate ACLS with immediate defibrillation and magnesium.
• Withdrawal of offending agents.

📚 References

1. Drew BJ, Ackerman MJ, Funk M, Gibler WB, Kligfield P, Menon V, Philippides GJ, Roden DM, Zareba W. Prevention of torsade de pointes in hospital settings: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. Circulation. 2010 Mar;121(8):1047-1060.
2. Postema PG and Wilde AAM. The measurement of the QT interval. Curr Cardiol Rev. 2014 Aug;10(3): 287-294.
3. https://litfl.com/qt-interval-ecg-library/

Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO)

👤 Associate Editor

Anand Swaminathan MD, MPH

All Things REBEL EM

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🧭 REBEL Rundown

📌 Key Points

• 🩸 Tourniquets save lives and limbs: Apply immediately when you’ve got arterial bleeding.
• 📍 Placement matters: Position the tourniquet 5–6 cm proximal to the arterial bleed, or if you can’t identify the exact source, place it as high up on the limb as possible.
• 🔧 Windlass technique: The windlass provides only a small amount of extra pressure. Tighten the velcro first, then twist the windlass 1–2 turns to complete compression.

Click here for Direct Download of the Podcast.

⏰ Highlights

• 00:00 Introduction to Tourniquets
• 00:40 Optimal Placement of Tourniquets
• 01:21 Proper Tightening Techniques
• 01:57 Importance of Timing and Application
• 02:36 Summary and Conclusion

📝 Introduction

In this episode of the Rebel Core Content podcast, Swami provides crucial tips on using tourniquets. Highlighting the significance of these life and limb-saving devices, the discussion focuses on the optimal placement of tourniquets, emphasizing placing them 2-3 inches (5-6 cm) above the bleeding source and avoiding joints. Swami also advises on the correct way to tighten the tourniquet using the Velcro strap first, followed by minimal use of the windless. The importance of noting the application time to avoid prolonged arterial flow interruption is also discussed. The episode concludes with a reminder to visit the podcast’s website for more valuable content.

Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO)

👤 Associate Editor

Anand Swaminathan MD, MPH

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🧭 REBEL Rundown

📝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.

Click here for Direct Download of the Podcast.

🤔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:

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 the Algorithm George mentioned in the episode
   • 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!

Mark Ramzy, DO

Co-Editor-in-Chief

RWJBH / Rutgers Health, Newark NJ

George Willis, MD

Vice Chair and Assistant Program Director

UT Health, San Antonio, TX

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The post REBEL CAST – IncrEMentuM26 Speaker Spotlight : George Willis and Mark Ramzy appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown

🔑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.

Click here for Direct Download of the Podcast.

📝 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 Question

Does the fluid you choose affect how quickly acidosis resolves in DKA? 

IV Fluid Composition

🚨 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.

Post Peer Reviewed By: Marco Propersi (Twitter/X: @Marco_propersi), and Kim Bambach, MD

Show Notes By: Mark Ramzy, DO

Authors

Mark Ramzy, DO

Co-Editor-in-Chief

RWJBH / Rutgers Health, Newark, NJ

Frank Lodeserto

Associate Editor

Cape Fear Valley Medical Center,

Fayetteville NC

🔎 Your Deep-Dive Starts Here

It seems we can't find what you're looking for.

REBEL Cast

is the blogs audio version. The podcast typically starts by setting a clinical stage with a pertinent clinical question, followed by a discussion of the paper with pertinent results, strengths, limitations, and further discussion. Finally, we end every podcast with clinical take home points from the papers being reviewed. If there are papers you think we should evaluate, email them to [email protected].

REBEL EM stands for Rational Evidence Based Evaluation of Literature in Emergency Medicine.  We cover a myriad of topics, primarily focusing on evidence-based clinical topics.

At its core, evidence-based medicine (EBM) incorporates clinical judgment, relevant scientific evidence, and patient values/preferences. Research and scientific evidence help inform care but should not dictate care of patients.

With the constant influx of new published research, it makes it difficult to stay current with the latest and greatest. REBEL EM was created October 2013 in an effort to cut down knowledge translation of research to clinical application (Bench to Bedside), using a structured critical appraisal method of evaluation.

REBEL Core Cast – DKA: Beyond the Basics Part 2 – SCOPE DKA-Trial

Mark Ramzy

October 21, 2025

No Comments

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.

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The post REBEL Core Cast – DKA: Beyond the Basics Part 2 – SCOPE DKA-Trial appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown

🗝️ 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.

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📝 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.

🦑 SQuID Protocol

🚨 Clinical Bottom Line

The SQuID Protocol appears safe and effective for carefully selected patients with mild to moderate DKA. It may reduce ICU admissions and shorten ED stays. But implementation requires thoughtful coordination, nursing comfort, and institutional buy-in. This isn’t ready for prime time everywhere—but it’s worth knowing and considering when ICU resources are tight.

Post Peer Reviewed By: Marco Propersi (Twitter/X: @Marco_propersi), and Kim Bambach, MD

Show Notes By: Mark Ramzy, DO

Authors

Mark Ramzy, DO

Co-Editor-in-Chief

RWJBH / Rutgers Health, Newark, NJ

Frank Lodeserto

Associate Editor

Cape Fear Valley Medical Center,

Fayetteville NC

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The post REBEL Core Cast – DKA: Beyond the Basics Part 1 – The SQuID Protocol appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown

🗝️ Key Points

• • ❌ 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.

Click here for Direct Download of the Podcast.

📝 Introduction

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.

️ The Two Pillars of Vent Management

1. Oxygenation — Getting O₂ In

• Primary levers: FiO₂ (fraction of inspired oxygen) and PEEP (positive end-expiratory pressure).
• Real driver: Mean Airway Pressure (MAP) :  the average pressure applied to the lungs across the entire respiratory cycle.
• Key physiology:
  • Oxygen enters blood by diffusion down a concentration gradient.
  • Adequate alveolar surface area is critical → PEEP keeps alveoli open, prevents collapse/reopen injury, and ensures FiO₂ delivery actually translates into effective oxygenation.
• MAP analogy: Just as mean arterial pressure drives perfusion, mean airway pressure drives oxygenation. Prolonged inspiratory time or sustained pressure (e.g., APRV, inverse I:E) can raise MAP.
• Risks: Excessive pressure/volume can cause barotrauma or volutrauma. 

2. Ventilation — Getting CO₂ Out

• Primary levers: Tidal Volume (TV) and Respiratory Rate (RR).
• Minute Ventilation = RR × TV.
• Mechanism: Ventilation removes CO₂ through bulk convection (movement of air in and out).

Disease-specific strategies:

• Obstructive Disease (COPD / Asthma)
  • RR ↓ to allow more time for exhalation.
  • Ensure expiratory flow = inspiratory flow → prevents air trapping.
  • If not equal → auto-PEEP → increased intrathoracic pressure → ↓ preload, risk of hypotension, cardiac arrest, or pneumothorax.
• Metabolic Acidosis
  • RR ↑ to blow off CO₂ and buffer acidosis.
• ARDS
  • Tidal volume limited to 4–6 mL/kg IBW to minimize ventilator-induced lung injury.
  • RR becomes the main adjustment knob.
  • Exception: in obstructive lung disease, patients need extra time to exhale (I:E may be 1:4–1:6).

💡 Why This Matters

Ventilator management is part science, part art. Understanding the physiology and knowing when to bend or break the rules  helps protect patients from ventilator-induced injury and improves outcomes.

Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO)

Show Notes By: Rubén Tapia-Bucheli, M.D.

👤 Guest Contributors

Rubén Tapia-Bucheli, M.D.

3rd Year Internal Medicine Resident

Cape Fear Valley Internal Medicine Residency Program

Fayetteville NC

Aspiring Pulmonary Critical Care Fellow

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The post REBEL Core Cast 143.0–Ventilators Part 3: Oxygenation & Ventilation — Mastering the Balance on the Ventilator appeared first on REBEL EM - Emergency Medicine Blog.

🧭 REBEL Rundown

🗝️ Key Points

• 💨 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.

Click here for Direct Download of the Podcast.

📝 Introduction

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.

️ Ventilator Modes Explained

Assist Control (AC)

• Commonly mislabeled as “volume control” or “pressure control.”
• Two main types:
  • AC Volume: Delivers a preset tidal volume with each breath, whether machine-initiated (controlled) or patient-initiated (assisted).
  • AC Pressure: Delivers a preset pressure; tidal volume varies based on compliance.
• All breaths are either controlled or assisted.

Pressure Support (PS)

• All breaths are spontaneous initiated by the patient.
• The ventilator provides a preset level of pressure support, like a resistance band during a pull-up.
• No set rate, but a backup mode (often AC) activates during apnea.
• Commonly used for spontaneous breathing trials (SBTs) to assess extubation readiness.
  • Typical goal: Patient breathing comfortably with PS ~5 cmH₂O and reasonable rate.

Pressure Regulated Volume Control (PRVC)

• Also called autoflow or adaptive pressure ventilation.
• A hybrid mode: Pressure-delivered, volume-targeted.
• Delivers breaths with a decelerating flow waveform, mimicking physiologic breathing.
• Adjusts pressure breath-to-breath to meet a target tidal volume with minimal required pressure.
• Safety feature: Pressure limit (e.g., 30–35 cm H₂O). If exceeded, volume delivery stops early.
• Pitfall: In agitated patients, rapid breathing may trick the ventilator into reducing pressure, causing under-ventilation.

Synchronized Intermittent Mandatory Ventilation (SIMV)

• Less common in adult ICU but still commonly used in pediatrics.
• Delivers a set number of mandatory (controlled or assisted) breaths.
• Allows spontaneous, pressure-supported breaths between mandatory ones.
• Example: SIMV 10 = 10 guaranteed AC breaths; additional breaths are spontaneous + supported.
• Why it’s less popular: Found to be less effective than daily SBTs for weaning and frequent dyssynchrony from not giving enough PS (PS should target at least  2/3 of the AC breath volumes) .

Volume Support (VS)

• A newer, fully spontaneous mode (like PS + PRVC).
• Patient initiates all breaths.
• The ventilator automatically adjusts pressure support to achieve a target tidal volume.
• Think of it as the spontaneous cousin of PRVC—adaptive and volume-driven.

🚨 Clinical Bottom Line

Understanding ventilator modes starts with knowing breath types, delivery mechanics, and clinical goals. When it comes to choosing the right mode:

• Focus less on the “best” mode and more on patient comfort and synchrony.
• Recognize the strengths, limitations, and pitfalls of each mode.
• Stay tuned for future episodes that dive into ventilator troubleshooting and advanced respiratory strategies.

Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO)

Show Notes By: Nicole Ebalo, DO

👤 Guest Contributors

Eric Acker, MD

Internal Medicine, Chief Resident,

Cape Fear Valley Medical Center,

Fayetteville NC

Nicole Ebalo, DO

Internal Medicine, Chief Resident,

Cape Fear Valley Medical Center,

Fayetteville NC

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The post REBEL Core Cast 142.0–Ventilators Part 2: Simplifying Mechanical Ventilation – Most Common Ventilator Modes appeared first on REBEL EM - Emergency Medicine Blog.