DKA: Fluids, Potassium, and SQUID

George recommends balanced fluids over saline, oral potassium is effective, and SQUID subcutaneous ultra-rapid insulin for mild-moderate DKA.

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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:

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
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
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)
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:

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.
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.
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!