EMERGENCY MEDICINE MID LEVEL PROVIDER CLINICAL OBJECTIVES Revised Feb 2010

1. Concepts a. Shock i. General approach for shock from any cause ii. Fluid and blood product resuscitation for shock iii. Know the definition, etiology and pathophysiology, clinical features, emergency treatment, and disposition for patients with the following types of shock: 1. Septic 2. Cardiogenic 3. Anaphylactic 4. Neurogenic 5. Obstructive 6. iv. Most common MedMal mistakes in shock managment

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b. Analgesia, Anesthesia, and Sedation in the Emergency Department patients i. Indications, applications, contraindication, and side effects associated with the following types of pain management: 1. Acute pain management 2. Local and regional anesthesia c. Emergency Wound Management i. Evaluation of wounds ii. Wound preparation iii. Methods of wound closure iv. Difficult lacerations 1. Eye adnexa 2. Auricular/cartilage involvement 3. Face/lip with vermillion border laceration 4. Hand 5. Nail beds 6. Joints 7. This is something which doesn t have to be a distinct bullet point however I think every procedural section needs to have a local-standard of care/ when to punt section. I.E. yeah I could close a flexor tendon lac on the dominant thumb of a violenist but I d never do that crap because it violates the local standard of care

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v. Soft tissue foreign bodies vi. Puncture wounds vii. Animal bites 1. Closure or not 2. Rabies prophylaxis viii. Post-repair wound care 1. Tetanus prophylaxis 2. Infection prophylaxis 3. Suture removal ix. Most common MedMal mistakes in Wound managment

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2. Cardiovascular Disease a. General approach to the ED patient presenting with chest pain b. Definition, epidemiology, pathophysiology, clinical features, differential diagnosis, emergency department evaluation, emergency treatment and disposition of the following entities: i. Acute coronary syndromes: Acute myocardial infarction and unstable angina ii. Syncope iii. Congestive heart failure and acute pulmonary edema iv. Heart valvular emergencies v. Cardiomyopathies vi. Myocarditis vii. Pericardial disorders viii. Pulmonary emboli ix. Hypertension- emergencies and instituting therapy in the ED x. Non- traumatic thoracic aortic artery dissection and rupture of abdominal aortic aneurysms xi. Arterial and Venous thromboembolism xii. Pace maker and AICD xiii. Noninvasive myocardial imaging 1. Sensitivity/specificity/negative predictive value for detecting coronary artery disease a. Stress test- echo, thallium, scintigraphy b. CT coronary angiography c. Cardiac catheterization c. I think they should specifically have a section on that landmark paper on characteristics and frequency of missed ACS in the ED. 3. Pulmonary Emergencies a. General approach to the patient experiencing respiratory distress

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b. Definition, epidemiology, pathophysiology, clinical features, differential diagnoses, emergency department evaluation and treatment, and disposition of the following entities: i. Community-acquired pneumonia, healthcare associated pneumonia, and hospital associated pneumonia, aspiration pneumonitis and pneumonia ii. Simple/ tension pneumothorax iii. Hemoptysis iv. Reactive airway disease 1. COPD and asthma exaserbations v. Diagnostic pulmonary imaging- select appropriate imaging modalities 1. Plain radiographs 2. CT chest with contrast 3. CT pulmonary angiogram 4. Ventilation perfusion scan 5. Pulmonary angiography 6. Magnetic resonance imaging (MRI and MRA) 7. Thoracic US 4. Gastrointestinal Emergencies a. Approach to the patient with acute abdominal pain b. Approach to abdominal pain in the elderly patient c. Definition, epidemiology, pathophysiology, clinical features, differential diagnosis, emergency department evaluation and treatment, and disposition of the following entities: i. Gastrointestinal bleeding ii. Esophageal emergencies iii. Foreign body ingestions iv. Peptic ulcer disease and gastritis v. Acute appendicitis vi. Hernia in adults and children vii. Ileitis, colitis, and diverticulitis viii. Anorectal disorders ix. Vomiting, diarrhea, and constipation x. Jaundice xi. Cholecystitis and cholelithiasis xii. Hepatic disorders and hepatic failure xiii. Acute and chronic pancreatitis xiv. Complications of general surgical procedures xv. Complications of gastrointestinal devices xvi. Liver transplant patients xvii. Gastrointestinal imaging 1. Plain radiography-acute abdominal series films 2. Ultrasonography

3. CT scan of the abdomen and pelvis 4. MRI of the abdomen and pelvis 5. Radionucleotide imaging a. Meckel scan b. Tagged RBC scan 5. Renal and genitourinary disorders a. Definition, epidemiology, pathophysiology, clinical features, differential diagnoses, emergency department evaluation and treatment, and disposition of the following entities: i. Acute renal failure ii. Emergencies in chronic peritoneal and hemodialysis iii. Urinary tract infections iv. Male genital problems 1. Common disorders a. Scrotal edema b. Scrotal abscess c. Fournier gangrene d. Balanoposthitis e. Phimosis f. Paraphimosis g. Fractured penis! h. Peyronie disease i. Priapism j. Penile carcinoma! k. Testicular torsion l. Torsion of the testicular appendages m. Edidymitis and orchitis n. Testicular cancer o. Acute prostatitis p. Urethritis q. Urethral stricture r. Urethral foreign bodies s. Urinary retention v. Urologic stone disease vi. Hematuria vii. Renal transplant patient viii. Renal imaging 1. Plain radiography- abdominal x-rays (KUB) 2. Ultrasonography 3. CT scans 4. Intravenous pyelogram (IVP) 5. MRI

6. Gynecology and Obstetrics a. Definition, epidemiology, pathophysiology, clinical features, differential diagnosis, emergency department evaluation and treatment, disposition of the following entities: i. Abnormal vaginal bleeding in the nonpregnant patient 1. Exogenous hormone usage 2. Pregnancy 3. Cervical and endometrial polyps and cancer 4. Uterine leiomyoma 5. Atrophic Vaginitis 6. Metabolic- thyroid disorders, coagulopathy ii. Abdominal and pelvic pain in the nonpregnant patient 1. Adnexal (ovarian) torsion 2. PID 3. Endometriosis 4. Tubo ovarian abscess 5. Bartholin gland cyst or abscess iii. Ectopic pregnancy iv. Emergencies during pregnancy and the postpartum period 1. Less than 20 weeks gestation a. Vaginal bleeding i. Abortion/miscarriage ii. Ectopic pregnancy iii. Gestational trophoblastic disease (molar disease) b. Hyperemesis gravidarum 2. Greater than 20 weeks gestation a. Pre-eclampsia b. Eclampsia c. HELLP syndrome d. Vaginal bleeding i. Abruptio placenta ii. Placenta previa e. Preterm labor and premature rupture of membranes 3. Post-partum a. Thromboembolic disease b. Postpartum hemorrhage c. Postpartum infections d. Amniotic fluid embolus e. Peripartum cardiomyopathy v. Emergency delivery vi. Breast disorders 1. Mastitis/breast abscesses 2. Breast mass

3. Galactorrhea vii. Gynecologic radiology 1. Ultrasonography 2. CT scan 3. Magnetic resonance imaging 7. Infectious diseases a. Definition, epidemiology, pathophysiology, clinical features, differential diagnoses, emergency department evaluation and treatment, and disposition of the following entities: i. Sexually transmitted diseases 1. General recommendations for STI testing, treatment , and follow-up 2. Chlamydia infections 3. Gonorrhea 4. Trichomoniasis 5. Syphilis 6. HSV 1 and 2 7. Sexual assault prophylaxis ii. Toxic shock syndrome and streptococcal toxic shock syndrome iii. Common viral infections 1. Influenza type A and B 2. Varicella 3. Herpes Zoster 4. Mononucleosis 5. Cytomegalovirus infections iv. HIV infection and AIDS v. Infective endocarditis vi. Rabies vii. Food-borne and water-borne infections 1. Norwalk and noroviruses 2. Hepatitis A 3. Ciguatoxin 4. Scombroid 5. Tetrodotoxin- Puffer fish 6. Clostridium perfringens 7. Vibro parahaemolyticus 8. Mushroom toxins 9. Clostridium botulinum viii. Zoonotic infections 1. Tick- borne disease a. Tick removal b. Rocky mountain spotted fever c. Lyme disease

d. Ehrlichiosis e. Tularemia f. Babesiosis 2. Meningoencephalogel Sxs a. Viruses i.West Nile virus ii.Eastern and western equine viruses iii.i. St. Louis virusesI d lump all the marqui viruses into one (west nile etc ii. Herpes, iii. HIV b. Bacterial infections- many i. Brucellosis ii. Tularemia iii. Leptospirosis iv. Ehrlichiosis v. Psittacosis c. Crypto/HIV 3. Respiratory Sxs a. Inhalation anthrax b. Psittacosis c. Pneumonic plague d. Hantaviruses e. Influenza A 4. GI Sxs a. Campylobacter b. Giardia lamblia c. Salmonella d. Yesinia enterolcolitica e. Vibrio cholera 5. Skin Sxs a. Dermatophytoses b. Cat-scratch disease c. Anthrax d. Aeromonas e. Vibrio vulnificans f. Mycobacteria marinum g. Plague- bubonic 8. Toxicology and pharmacology a. General management of poison patients b. Principles of drug interactions

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c. Definition, epidemiology, pathophysiology, clinical features, differential diagnoses, emergency department evaluation and treatment, and disposition of patients with the following toxicologic emergencies: i. Tricyclic antidepressants ii. Newer antidepressants and serotonin syndrome iii. Monoamine oxidase inhibitors iv. Antipsychotics/neuroleptics v. Lithium vi. Barbiturates vii. Benzodiazepines viii. None benzodiazepine sedatives ix. Alcohols- ethylene glycol, methanol, isopropyl alcohol, ethanol x. Opioids xi. Stimulants-cocaine, amphetamines, caffeine and nicotine xii. Hallucinogenic xiii. Salicylates xiv. Acetaminophen xv. Nonsteroidal anti-inflammatory drugs xvi. Theophylline xvii. Digitalis xviii. Beta blocker toxicity xix. Calcium channel blockers xx. Antihypertensive agent toxicity xxi. Phenytoin and fosphenytoin toxicity xxii. Iron xxiii. Hydrocarbons and volatile substances xxiv. Caustics xxv. Insecticides, herbicides, and rodenticides xxvi. Anti-cholinergic toxicity xxvii. Metals and metalloid toxicity xxviii. Toxicology of hazardous chemicals xxix. Vitamins and herbal preparations xxx. Cyanide xxxi. Dyshemoglobinemias- Methemoglobinemia and sulfhemoglobinemia xxxii. Hypoglycemic agents 9. Environmental injuries a. Definition, epidemiology, pathophysiology, clinical features, differential diagnoses, emergency department evaluation and treatment, and disposition of the following environmental injuries: i. Frost bite and other cold weather related injuries ii. Hypothermia iii. Heat related injuries- heat stroke, heat exhaustion, heat cramps

iv. Arthropod bites and stings v. Trauma and envenomations from marina fauna vi. Dysbarism and complications from diving vii. Near drowning viii. Thermal burns ix. Chemical burns x. Electrical injuries xi. Lightning injuries xii. Carbon monoxide poisoning xiii. Mushroom poisoning xiv. Poisonous plants 10. Endocrine emergencies a. Definition, epidemiology, pathophysiology, clinical features, differential diagnoses, emergency department evaluation and treatment, and disposition of the following endocrine emergencies: i. Hypoglycemia ii. Diabetic ketoacidosis iii. Diabetes mellitus iv. Alcoholic ketoacidosis v. Hyperosmolar hyperglycemic state (Hyperosmolar nonketotic coma) vi. Hyperthyroidism and thyroid storm vii. Hypothyroidism and myxedema coma viii. Adrenal insufficiency and adrenal crisis 11. Hematologic and oncologic emergencies a. Definition, epidemiology, pathophysiology, medical features, differential diagnoses, emergency department evaluation and treatment, and disposition of the following hematologic and oncologic emergencies: i. Acquired bleeding disorders ii. Hemophilias and von Willebrand Disease iii. Hereditary hemolytic anemia iv. Acquired hemolytic anemia v. Transfusion therapy vi. Anticoagulants antiplatelets and fibrinolytics vii. Emergency complications of malignancies 12. Neurology a. Neurologic examination in the emergency department b. Definition, epidemiology, pathophysiology, clinical features, emergency department evaluation and treatment, and disposition of the following neurologic abnormalities: i. Headache and face pain ii. Stroke, TIA, and other central local conditions iii. Altered mental status and coma iv. Ataxia and gait disturbances

Vertigo and dizziness Seizures and Status Epilepsy Acute peripheral neurologic lesions Chronic neurologic disorders CNS infections Complications of CNS devices- VP shunts Neuroimaging in the ED 1. Cat scans of the head and spinal cord with and without contrast 2. MRI of the head and spinal cord with and without contrast 3. MRA of the head and neck vessels (carotid and vertebral arteries) 13. Eye, Ear, Nose, Throat, and Oral Surgery a. Definition, epidemiology, pathophysiology, clinical features, differential diagnosis, emergency management and treatment, and disposition of patients with the following entities: i. Ocular emergencies 1. Trauma a. Corneal abrasion b. Conjunctival foreign bodies c. Lid lacerations d. Hyphema e. Blunt trauma f. Orbital fractures g. Penetrating trauma/Globe rupture h. Chemical injury i. Ultraviolet keratitis 2. Acute vision loss- painful a. Acute angle-closure glaucoma b. Optic neuritis c. Giant cell (Temporal) arteritis 3. Acute vision loss- non-painful a. Central retinal artery occlusion b. Central retinal vein occlusion Retinal detachment c. Vitreous hemorrhage d. Retinal detachment e. Vitreous hemorrhage 4. Infections a. Preseptal and septal cellulitis b. Corneal ulcers/ Contact lens wearer c. HSV infections d. Herpes zoster ophthalmicus e. Hypopyon f. Iritis

v. vi. vii. viii. ix. x. xi.

5. Neuro-ophthalmogic a. Bell palsy b. CN 3 or 4 palsies i. Diabetic/hypertensive ii. Posterior communicating artery aneurysm c. Internuclear ophthalmoplegia d. Horner syndrome e. Papilledema f. Pseudotumor cerebri (Idiopathic intracranial hypertension) ii. Disorders of the external, middle, and inner ear 1. Malignant Otitis externa 2. Mastoidisitis iii. Non-traumatic maxillo-facial emergencies 1. Facial infections a. Erysipelas b. Cellulitis 2. Soft-tissue space infections a. Masseter space b. Temporal space c. Pterygomandibular space 3. TMJ dysfunction and fracture iv. Nasal emergencies and sinusitis 1. Epistaxis 2. Septal hematoma 3. Acute sinusitis v. Oral and dental emergencies 14. Disorders of the skin- acute life-threatening a. General approach to ED evaluation of dermatologic conditions b. Definition, epidemiology, pathophysiology, clinical features, differential diagnosis, emergency department evaluation and treatment of the following dermatologic conditions: i. Toxic epidermal Necrolysis ii. Pemphigus 15. Trauma a. Initial approach to the trauma patient b. Clinical features, differential diagnosis, emergency department evaluation and treatment, and disposition of the following: i. Pediatric trauma ii. Geriatric trauma iii. Trauma in pregnancy iv. Head injury v. Spinal cord injuries

vi. Maxillofacial trauma vii. Neck trauma viii. Thoracic trauma ix. Abdominal trauma x. Penetrating injuries to the flank and buttocks xi. Genitourinary trauma xii. Extremity trauma xiii. Forensics xiv. Injury control 16. Orthopedic injuries a. Initial ED evaluation of orthopedic injuries b. Clinical features, ED evaluation and treatment of the following orthopedic injuries: i. Injuries to the 1. Hand/fingers 2. Wrist 3. Elbow and forearm 4. Shoulder/arm 5. Spine 6. Pelvis, hip, femur 7. Knee, leg, ankle, foot ii. Compartment syndromes iii. Rhabomyolysis 17. Nontraumatic musculoskeletal disorders a. Definition, epidemiology, pathophysiology, clinical features, differential diagnosis, emergency evaluation and treatment, and disposition of the following disorders: i. Neck pain ii. Back pain syndromes iii. Systemic rheumatologic diseases iv. Disorders of the joints/bursa 18. Psychiatric Disorders a. General evaluation/assessment of psychiatric disorders in the ED b. Psychotropic medication use in the ED c. Criteria for commitment Assessing suicidality, homicidality, and acute mania c.Other psychiatric disorders that may come to the ED i. Definition, epidemiology, pathophysiology, clinical features, emergency department evaluation and treatment, and disposition of the following psychiatric disorders: 1. Eating disorders- anorexia nervosa and bulimia 2. Panic disorders 3. Conversion disorders 4. Substance/alcohol abuse ii. Death in the ED

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1. Family notification in the ED 2. Coroner cases 3. Death certificate/primary care physician notification 19. Abuse and assault a. Definition, clinical features, emergency evaluation and treatment, and disposition of the following abuse/assault situations: i. Child, mental/physically impaired, and elder abuse ii. Sexual assault iii. Violent patient in the ED 20. Pediatric patients a. Medical consent and treatment of minors b. Definition, epidemiology, pathophysiology, clinical features, differential diagnosis, and disposition of the following pediatric entities: i. Fever 1. Neonate- 0-4 weeks 2. Infant- 4-8 weeks 3. Infant > 8 weeks ii. NICU graduate- premature and congenital abnormalities 1. Complications of bronchopulmonary dysplasia 2. Apnea and home monitoring 3. Posthemorrhagic hydrocephalus- VP shunts iii. Bacterial sepsis and meningitis iv. SIDS/ALTE v. Pediatric heart disease- congenital and acquired vi. Otitis media and pharyngitis vii. Skin and soft tissue infections 1. Impetigo 2. Cellulitis 3. Periorbital and orbital cellulitis viii. Pneumonia- viral and bacterial ix. Asthma and bronchiolitis x. Seizures and status epilepticus xi. Vomiting and diarrhea xii. Abdominal disorders 1. Intestinal obstruction a. Malrotation/Volvulus 2. Hernias- incarcerated 3. Pyloric stenosis 4. Intussusception 5. Appendicitis 6. Meckel s diverticulum 7. Henoch-Schonlein purpura

xiii. xiv. xv. xvi. xvii. xviii.

xix. xx.

8. Rectal bleeding a. Anal fissures b. Colon polyps Pediatric DKA Hypoglycemia Altered mental status and headache Syncope/sudden death Fluid and electrolyte therapy Upper respiratory emergencies 1. Causes of stridor a. Foreign body aspiration b. Croup c. Larynomalacia d. Tracheomalcia 2. Epiglottitis 3. Viral croup 4. Bacterial tracheitis 5. Foreign body aspiration 6. Peritonsillar abscess 7. Retropharyngeal abscess Acute pain management and procedural sedation Pediatric exanthema 1. Bacterial a. Bullous impetigo b. Impetigo contagiosum c. Erysipelas d. Scarlet fever e. Anthrax 2. Rickettsial a. Rocky mountain spotted fever 3. Viruses a. Enterovirus b. Herpes virus- HSV 1 and 2 c. Erythema Infectiosum (Fifth Disease) d. Measles i. Rubeola ii. Rubella e. Varicella f. Variola g. Roseola infantum 4. Idiopathic a. Erythema nodosum

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xxii. xxiii.

xxiv.

b. Kawasaki disease (Mucocutaneous lymph node syndrome) c. Pityriasis rosea Musculoskeletal disorders 1. Types of fractures a. Physis (Salter-Harris) b. Torus c. Greenstick d. Plastic (bowing) e. Metaphyseal (corner) 2. Common fractures and dislocations a. Supracondylar b. Elbow fracture and dislocation c. Nursemaid s elbow d. Slipped capital femoral epiphysis 3. Common nontraumatic musculoskeletal disorders a. Acute septic arthritis b. Transient synovitis of the hip c. Henoch-Schonlein Purpura d. Juvenile rheumatoid arthritis e. Legg-Calve-Perthes disease f. Osgood-Schlatter disease g. Post-infection reactive arthritis (streptococcal and viral infection sequelae) Sickle cell disease Evaluating the child with special healthcare needs 1. General management 2. Congenital/developmental disorders and associated medical problems a. Cerebral palsy b. Meningomyelocele and neural tube defects c. Hydrocephalus d. Arnold-Chiari malformations e. Autism f. Mental retardation/Developmental delays g. Down syndrome h. Spinal cord injury 3. Technical device complications a. Tracheostomy failure b. Mechanical ventilation c. Feeding tubes d. Cerebral fluid shunts e. Urinary diversions Urogenital problems in children

Labial adhesions Precocious puberty/menarche Ovarian torsion Vaginal obstruction i. Imperforate hymen ii. Transverse vagina e. Vaginal foreign bodies f. Vaginitis g. Vaginal bleeding xxv. Urinary tract infections 1. Febrile UTIs and referral for further anatomic evaluation in males and females < 5 years of age

1. Males a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. 2. Females a. b. c. d.

Balanitis Balanoposthitis Phimosis Paraphimosis Priapism Hair tourniquet Zipper injury Meatal stenosis Epididymitis Testicular torsion Torsion of testicular appendix Hernia Hydrocele Varicocele Testicular trauma