Provider Practice Essentials courses

Provider Certification

Information for Employers and Credentialers

About our Certification

Provider Practice Essentials, LLC is the leading authority for third-party provider skill validation.  Our certification programs provide participants with current guidelines and hands-on procedure training.

All of our programs are taught by residency-trained, board certified physicians, board-certified Nurse Practitioners, and Physician Assistants who are experts in their fields and our material.  All members of our teaching faculty are required to be actively practicing clinically and have a strong knowledge base.

Lectures are prepared and validated by all members of our clinical faculty, who are faculty at medical schools and teaching hospitals across the country.  Our material is revised annually and updated with current guidelines and recommendations.

Certification can be earned by meeting all of the following requirements:

  1. Completion of a live hands-on skills and procedure course
  2. Be directly observed by clinical faculty to demonstrate procedural proficiency in the material presented
  3. Successfully pass a 50-question multiple choice certification examination with a minimum passing score of 70%

Our certification examination is designed to be challenging, and mimics actual questions found in medical school, nurse practitioner, and physician assistant examinations.  All of our questions have been validated for accuracy, and have an overall first-time pass rate of 72%.

Certification for our programs implies that a provider has demonstrated a level of proficiency beyond that of the average participant, and overall represents the top 15% of all participants nationwide.

Independent and unsolicited feedback from employers, supervisors, and institutions further validates that providers certified in our programs are more confident, efficient, and knowledgable after they have completed our training programs.

All of our live programs are accredited by the American College of Nurse Practitioners and the American Academy of Physician Assistants.

Learning Objectives of Course

The overall objective for this course is to provide a structured supplemental skills training program that will allow the participant to broaden their basic clinical knowledge base, and also provide prospective employers, supervisors, and, when applicable, hospital credentialers documentation of their mastery of this material in the form of a certification that is earned by passing an examination at the end of the program. All participants will receive credit for completing the course, but only those who demonstrate mastery of the material will receive certification.

Certification does not coincide with any known licensing board, academic program, university or affiliate,  but provides verification of content understanding for those who achieve this distinction. Certified providers also receive a signed letter of verification from the supervising physician teaching their course that will serve to accompany their credentialing file.

The course is divided into two comprehensive days of education, each day containing a morning and an afternoon session. Morning sessions are divided into 1-hour lecture blocks that focus on specific clinical content, and allow for interactive discussion, question and answer, and clinical examples. Afternoon sessions are dedicated to procedure workshops that are scheduled in tandem with previously presented clinical content to reinforce and enhance the clinical content presented.  Upon completion, the Participants are eligible to claim CE/CEU/CME credit for their course, and may earn certification status. The objectives of each portion of the program are detailed below:

Cardiac Disorders– To enhance the provider’s understanding of basic principles of cardiac circulation, and to reinforce a systematic method of interpreting EKG’s to identify critical abnormalities that need immediate management by supervising physicians. These specific abnormalities include:

1) ST Elevation Myocardial Infarction (STEMI) in the inferior, lateral, inferolateral, anterior, anterolateral and posterior sections of the heart. (15 Minutes)

Learning Objectives: 1) To identify usual patterns of ST Elevation MI, 2) To identify pa- tients with likelihood of multi-vessel disease, 3) To understand treatment modalities, pharmacology, and current guidelines for management of STEMI. 4) To review current management theory of STEMI in relation to use of Beta Blockers, Platelet Inhibitors, and other classes of cardioselective medications.

2) Ventricular Tachycardia (15 Minutes)

Learning Objectives: 1) To understand morphology of VTACH and differentiate from mim- ics, 2) To understand safe treatment choices, 3) To consider additional cardiac diseases in patients with VTACH. (15 Min) 4) To reinforce management of ventricular tachycardia using Class 1a medications, Amiodarone, and other cardioselective medications.

3)Atrial Fibrillation (15 Minutes)
Atrial Fibrillation with Rapid Ventricular Response Atrial Flutter
Slow Atrial Fibrillation

Learning Objectives: 1) To understand causes of new onset Atrial Fibrillation, 2) To differentiate from and treat variants of atrial fibrillation, 3) To understand appropriate disposition of Atrial Fibrillation patients. 4) To review common cardioselective medications – Beta-Blockers, Calcium channel blockers, for management of Atrial fibrillation.

4)Torsades des Pointes (15 Minutes)

Learning Objectives: 1) To differentiate TDP from VTACH, 2) understand how to appropriately treat TDP, 3) Learn to predict patient populations like to have TDP, 4) To under-

stand electrolyte replacement strategies for potassium and magnesium in the setting of renal failure and other clinical conditions known to cause torsades de pointes.

5)1st, 2nd, and 3rd degree AV Blocks (15 Minutes)
Learning Objectives: 1) To understand and identify differences between each type of AV block, 2) To understand treatment needs of each type of Block, 3) To understand modalities of treatment and specialist role of management.

6)Multifocal Atrial Tachycardia (15 Minutes) Sinus Tachycardia

Learning Objectives: 1) to understand the various types of tachycardia, 2) To place tachycardia into a broad clinical differential, 3) Understand what treatment options are specific to each type of tachycardia. 4) To consider the relative effect of Beta-Blockers, sympathomimetic agents and bronchodilators on heart rate when managing COPD.

7)Bundle Branch Blocks (15 Min)
Learning Objectives: 1) To understand the types of cardiac blocks, 2)To clinically correlate cardiac blocks with relative underlying diseases, 3)To interpret STEMI through a bundle branch block using Sgarbossa Criteria.

Program Participants will gain confidence and learn how to differentiate these rhythms and morphologies from each other. Additional objectives of this portion of the program will be to comfort- ably identify EKG abnormalities in a random fashion and in combination with the patient’s clinical picture. Finally, any relevant Core measures and PQRS standards will be reviewed and their applicability applied to the appropriate clinical environment.

Pulmonary (1 hour)

The objectives of this program portion will be for each participant to perform the following parts of basic patient examination:

8) Basic Airway and Breathing Assessment (15 Minutes)

Learning Objectives: 1) Identification of suspected airway obstruction, 2)
Identification of Stridor and likely causes, 3) Understand when to suspect non-traumatic of Pneumothorax and patient populations involved.

9) Additional Objectives will be to reinforce current decision-making rules for ordering of appropriate tests, and anticipating procedural intervention (15 Min). These include:

Application of Wells Criteria for Pulmonary Embolism
Application of the PERC rule
Identification of populations who are at high risk for Pulmonary Embolism
Appropriate use of the D-Dimer
Prediction of severity of Asthma using Peak Flow Meter
Understand the mechanisms of common bronchodilators for management of Asthma and COPD.
Understand selection strategies for anticoagulants (Heparin, LMWH, Xa Inhibitors in the setting of PE/DVT.

Procedural Objectives will be to intervene with appropriate management when clinical conditions arise. These procedures will include:

10) Tracheostomy replacement (for patients with routine established tracheostomy) (15 Minutes)

Learning Objectives: 1) To understand the different types of tracheostomy tubes, 2) To understand how they are placed and maintained, 3) To become comfortable with tracheostomy exchange in patients with mature stoma.

11) Needle Decompression (15 Minutes)

Learning Objectives: 1) To understand the indication for Needle Decompression, 2) To understand the principle behind the procedure of needle decompression, 3) To demonstrate clinical ability of placement of needle thoracostomy.

12) Chest Tube Insertion (using percutaneous kit) (30 Minutes)
Learning Objectives: 1) To understand the indication for chest tube insertion, 2) To differentiate between different types of chest tubes and their indications, 3) To demonstrate clinical ability to insert a chest tube. 4) Understand the procedural analgesia approach of regional nerve block, chest wall nerve block, and intrathoracic nerve block prior to procedure.

Practice-related objectives will include education and adherence to appropriate quality-based treatment decisions and documentation related to asthma, bronchitis, upper respiratory infection, and other common pulmonary complaints.

Additional focus will be placed on provider quality reporting measures, complete documentation, and other tools designed to maximize medical communication through improved documentation while increasing charting compliance and reducing reviews and payment denials to supervising physicians.

Radiology

This portion of the program is intended to be an enhanced review of the various types of radiology studies, appropriate utilization and technique of the studies being ordered, and quality-based decision-making related to studies that are part of the PQRS program. This will be a system-focused portion of the program, with the primary objective being to educate the participant that a broad differential diagnosis should be considered when examining each patient, and to reinforce the need to apply this broad differential when ordering studies and treatment. Each section of the human body will be presented to the participant, who will be given a comparison course book with normal anatomy to compare to a sequence of pathologic radiographs for review, comparison, and diagnosis. The intent of these modules is not to expect the participant to memorize and learn the details and nuances of a variety of fractures, but to learn mechanisms and patterns of disease and fractures that should be considered and identified in routine practice.

In addition to plain film ordering and fracture diagnosis, learning about the appropriate immobilization/splinting and referral for routine fractures will also be taught with the objective that each participant have a working understanding of which fractures types require emergent management, urgent follow-up, routine follow-up, or expectant management. Paramount to practicing in the role of an Advanced Practice Provider will be the ability to communicate fracture findings to the receiving consultant, and the appropriate nomenclature will be reinforced. It will be an objective to present and briefly discuss the origin of each of the following radiographic findings:

13) Chest/Abdomen (1 Hour)

Learning Objectives: 1) To differentiate between the different types of abdominal imaging. 2) To understand the indications for oral and IV contrast for CT imaging, 3) To understand different studies indicated for different patient populations (i.e. pregnancy), 4) To demonstrate ability to interpret plain radiographs of the chest and abdomen:

• Pneumonia
• Pneumothorax
• Hemothorax
• Hiatal hernia
• Perforated viscous
• Pneumopericardium
• Pneumomediastinum
• Pericardial effusion
• Pleural effusion
• Empyema
• Rib fractures
• Shoulder/humerus fractures • Scapula fractures
• Clavicle fractures
• Signs of high impact injury

• Constipation
• Bowel Obstruction
• Porcelain Gallbladder • Gallstones
• Foreign Bodies

14) Spine (45 Minutes)

Learning Objectives: 1) To associate mechanism of injury with type of fracture, 2) To understand stable versus unstable fractures of the cervical spine, 3) To learn appropriate clearance of the cervical spine, 4) to demonstrate inline mobilization and placement of a cervical collar. 4) To understand the role of specialty consultation and referral with cervical spine fractures:

• X-ray interpretations
• Long board and collar removal
• Unstable Fractures
• Mechanisms for common fractures • Immobilization
• Correct studies
• Correct consult and referral

15) Nexus Criteria (15 Minutes)

Learning Objectives: 1) Understand appropriate use and application of the clinical decision rule for cervical spine clearance. 2) Understand limitations to NEXUS application, 3) Understand appropriate documentation of clinical decision rule and outcome.

16) Other spinal fractures and considerations (30 Minutes)

Learning Objectives: 1) Understand additional spinal fractures and their management, 2) Under- stand resource utilization and clinical utility of imaging in low back pain. 3) Understand and identify life-threatening and disabling disorders of the back, and their appropriate diagnosis and referral, 4) Correlate clinical findings to radiographic findings for back pain and other disorders of the spine:

• Plain film reading
• Lumbar spine imaging
• Cauda Equina syndrome
• Epidural abscess
• When to order an MRI
• Neurological exam findings

17) Upper Extremity images (1 Hour)

Learning Objectives: 1) To understand mechanism and expected fracture associations, 2) To identify common fracture patterns on plain radiographs, 3) To understand appropriate disposition of various fracture types, 4) To understand the appropriate immobilization needed for upper ex- tremity injuries.

• Shoulder dislocations and reduction techniques without sedation • Hill-sacs deformity
• AC separation
• Humeral head fracture

• Humeral neck fracture
• Surgical neck fracture
• Supracondylar fracture (pediatrics) • Elbow dislocation and reduction
• Radial head fracture

• Galeazzi fracture
• Monteggia fracture
• Distal radius fracture
• Ulnar fracture
• Nightstick fracture
• Greenstick fracture
• Hand Fractures
• Carpal fractures and dislocations • Metacarpal fractures
• Boxers fracture
• Finger fractures
• Fingertip amputations
• When to consult ortho

18) Pelvis and lower extremity images (1 Hour)

Learning Objectives: 1) To correlate injury type and mechanism with expected fracture patterns on plain films. 2) To understand which fractures need emergent reduction and consultation. 3) To understand method of routine disposition, 4) To understand which types of immobilization are required for management of lower extremity injuries:

  • –  Pelvic Fracture

  • –  Acetabular Fracture

  • –  Hip Fractures

  • –  Femur Fractures

  • –  Knee hyperextension and vascular injury

  • –  Patellar Fracture

  • –  Tibial Plateau Fracture

  • –  Maissoneuve Fracture

  • –  Tib/Fib Fractures

  • –  Bimalleolar Fracture

  • –  Trimalleolar Fracture

  • –  Tarsal Fracture

  • –  Tarsal Dislocation

  • –  Lisfranc Fractures

  • –  Metatarsal Fractures

  • –  Dancer’s Fracture

  • –  Toe Fractures

  • –  Distal Toe Amputations

Skin and Soft Tissue Conditions (60 Minutes)

This portion of the program is designed to provide participants with a structured, systematic process to evaluate all skin lesions as they present frequently in the primary care, urgent care, and emergency department setting. The objective will be for all participants to gain a level of comfort excluding life-threatening skin conditions prior to treating them, and also have the confidence to better communicate their findings to higher levels of care. These conditions will include the following:

  • –  Emergent Rash Identification (meningitis, Stevens-Johnson Syndrome, Erythema Multi- forme, Toxic Epidermal Necrolysis, Necrotizing Fasciitis)

  • –  Cellulitis

  • –  Abscess

  • –  DVT identification and decision rules with D-Dimer

  • –  Burn Care

  • –  Burn Referral Criteria

  • –  What not to send home.

  • –  Understand anticoagulation options for DVT (Heparin, LMWH, Factor Xa Inhibitors) and their utility in the clinical setting.

  • –  Understand regional injection for analgesia prior to abscess incision and drainage.

  • –  Understand medication choices for routine management of mild to moderate allergic re- actions (Epinephrine, Diphenhydramine, H2 Blockers, and Steroids).

Procedures

This portion of the program will allow the participant to practice a variety of common procedures performed in the primary care office, urgent care, or emergency department setting, and is timed and organized to complement the clinical didactic section presented on the same days. Participants will be given the latest mannequin and simulation products to practice and improve their techniques. The Objective of this portion is to educate and demonstrate proper technique to per- form these procedures, and to reinforce the confidence level of the practitioner to perform these procedures in the clinical setting. In addition, relevant pharmacologic interventions will be pre- sented as clinically appropriate to procedure being performed. Skill will be assessed and scored by the teaching faculty, and performance review will be included along with the written didactic test for those wishing to be certified. The complete procedure list will consist of many physical stations during the program, but due to supply availability, discontinued stock, or other logistical reasons, not every skill session may be available on the date(s) of the training program. The Corporation will make every effort to ensure that the following procedure stations are available at each course:

Needle Decompression Chest Tube insertion Tracheostomy replacement

20)Upper Extremity Fracture reductions (30 Minutes)

Learning Objectives: 1) To understand when emergent reduction of the upper extremity is indicated. 2) To understand the role of sedation with upper extremity reduction, 3) To demonstrate proper reduction techniques.

21)Upper extremity splinting (Long Arm, Short Arm, Sugar Tong, Ulnar Gutter) (30 Minutes)

Learning Objectives: 1) To understand the different types of splints used for upper extremity immobilization. 2) To demonstrate appropriate clinical skill for placement of splints on the upper extremities. 3) To demonstrate technique for post-splint examination.

22)Upper extremity joint aspiration (30 Minutes)

Learning Objectives: 1) To identify the indications for upper extremity joint aspiration. 2) To demonstrate landmarks used for identification of aspiration site, 3) To demonstrate clinical skill to perform joint aspiration.

23)Trigger Point Injection (15 Minutes)

Learning Objectives 1) To understand clinical diagnosis of trigger point. 2) To under- stand indications for trigger point injection. 3) To demonstrate clinical skill of joint aspiration.

24)Nail Trephination and Nail Removal (15 Minutes)

Learning Objectives: 1) to identify clinical indications for trephination versus removal of the nails. 2) To identify high risk populations related to this procedures (diabetics, smokers), 3) To understand clinical outcomes of this procedure

25)Punch Biopsy (15 Minutes)

Learning Objectives: 1) To identify lesions that require biopsy in the primary care set- ting, 2) To describe the procedure and risks of benefits to the patients, 3) To demonstrate skill of performing the procedure.

26)Foreign body/fish hook removal (15 Minutes)

Learning Objectives: 1) Understanding of various types of soft tissue foreign bodies and their appropriate management. 2) Understanding of fishhook injuries in general and different techniques for removal. 3) Demonstration of understanding of safe ways to perform foreign body removal fro soft tissues.

27)Introduction to Suturing (30 min)

Learning Objectives: 1) To understand and differentiate the different types of suturing techniques that are commonly used. 2) To understand which types of repair are need- ed for different tissue injuries and lacerations 3) to demonstrate appropriate selection of closure technique. 4) To demonstrate clinical skill and mastery of each type of su- ture technique and knot tying. 5) To understand multiple-layer injuries and the appro- priate technique for closure of each tissue layer. 6) To understand the appropriate documentation for all laceration repairs. Techniques, knots, and topics will include the following:

a.Simple interrupted b.Simple running c.Mattress d.Subcutaneous/multi layer e.Staple

f.Skin adhesive
g.Surgeons knot
h.Buried knot
i.Documentation for complexity

28)Local injection, digital blocks, Hematoma Blocks (30 Minutes)

Learning Objectives: 1) To understand different techniques for local anesthesia, including topical applications, 2) To understand the anatomical landmarks, risks, and benefits of, and procedure for digital block, regional joint block, and hematoma block, 3)To demonstrate skill and performance of digital block.

29)Lumbar Puncture (30 Minutes)

Learning Objectives: 1) To understand the indications, contraindications, and purpose for performing a lumbar puncture. 2) To understand the lumbar puncture as a procedure and the core studies that should be ordered with a CSF sample. 3) To demonstrate procedural skill by performing a Lumbar Puncture.

30)Incision and Drainage of Abscess (15 Minutes)

Learning Objectives: 1) To differentiate clinically between an abscess, sebaceous cyst, infected sebaceous cyst, and soft tissue mass. 2) To understand the common approach to incision and drainage of an abscess. 3) To demonstrate clinical procedural ability to perform incision and drainage.

31)Joint Reduction (30 Minutes)

Learning Objectives: 1) To anticipate the type of joint dislocation based on mechanism, anatomic position of extremity, and patient presentation. 2) To understand the correlation of radiograph findings and reduction approach. 3) To differentiate between the different types of reduction approaches, 4) To know when operative management is warranted, 5) to understand referral and post-reduction management. Joints edu- cated will include:

a.Patella Reduction

b.Ankle Reduction c.Hip Reduction

32)Lower Extremity Splinting (30 Minutes)

Learning Objectives: 1) Understand appropriate splint application for lower extremity injuries. 2) Identify radiographic correlation to splint placement, 3) Demonstrate clinical procedural skill and placement of lower extremity splints.

33)Lower Extremity Joint Aspiration (30 Minutes)

Learning Objectives: 1) Understand indications for joint aspiration. 2) Understand diagnosis of condition based on fluid sample. 3) Understand procedural approach to joint aspiration and proper technique. 4) Understand contraindications of joint aspiration. 5) Demonstrate clinical procedural skill of joint aspiration.

34)IO Access (15 Minutes)

Learning Objectives: 1) Understand indications, contraindications, complications, and utility of Intraosseous lines as alternative types of venous access. 2) Identify and understand common sites of Intraosseous line placement and techniques for insertion. 3) Demonstrate clinical procedural skill of Intraosseous insertion

35)Central Venous Catheter Insertion (45 Minutes)

Learning Objectives: 1) Understand indications, contraindications, complications, utility, and site preference of central venous catheter insertion. 2) Understand procedural technique, approaches to common difficulties with the procedure, and correct placement confirmation. 3) Demonstrate clinical procedural skill of Intraosseous line insertion.

Learning Objectives of Course

The overall objective for the course is to provide a structured supplemental skills training program that will allow the participant to broaden their basic clinical knowledge base, and also provide prospective employers, supervisors, and, when applicable, hospital credentialers documentation of their mastery of this material in the form of a certification that is earned by passing an examination at the end of the program. All participants will receive credit for completing the course, but only those who demonstrate mastery of the material will receive certification.

Certification does not coincide with any known licensing board, academic program, university or affiliate,  but provides verification of content understanding for those who achieve this distinction. Certified providers also receive a certificate that will serve to accompany their credentialing file.

The course is taught over a single comprehensive day, using live human models with known pathology to enhance learning and reinforce clinical findings. There are several learning sessions throughout the day, each with focused ultrasound training, in small group format.  Large screen televisions are used to display ultrasounds being performed by other students, and allowing members of each small group to learn from the student practicing the study.  This allows for repetition and reinforces concepts of probe movement and use. Upon completion, the Participants are eligible to claim CE/CEU/CME credit for their course, and may earn certification status. The objectives of each portion of the program are detailed below:

Ultrasound Course Schedule and Objectives

Introduction to Ultrasound

Understand Ultrasound Physics

Understand Probe Functions and Types, and when to use them

Learn and Master Methods and Techniques of Scanning

“Knobology” – Understanding the various settings and adjustment options

available on common devices.

Abdominal Ultrasound

Aorta – identification, imaging, measurement, and diagnosis of aortic

aneurysm

 

Biliary Quadrant – Identification, imaging, measurement, and diagnosis of

Liver and Gallbladder pathology, gallstones, and management

 

Kidney – Identification, imaging, measurement, and diagnosis of kidney

pathology including reflux, hydronephrosis, and signs of obstruction.

 

Transabdominal Pelvis – Identification, imaging, measurement,

and diagnosis of bladder pathology.  Female organs are taught but not

strongly emphasized in this program.  Basic identification of ruptured

ectopic pregnancy is discussed and demonstrated.

Trauma Ultrasound

eFAST exam

Right Upper Quadrant Imaging

Left Upper Quadrant Imaging

Bladder Imaging

Cardiac Imaging

Lung Imaging

Identification of pneumothorax

Identification of intrabdominal trauma and bleeding

Clinical Management of postive FAST patients

Specialty Ultrasound

Ocular Ultrasound

Foreign Body Imaging

Ultrasound-Guided IV Access

Lower Extremity Vascular Ultrasound

Students have successfully demonstrated peripheral IV and Central venous

catheter access using ultrasound

Learning Objectives of Course

The overall objective for the Advanced and Difficult Airway course is to provide a structured supplemental skills training program that will allow the participant to broaden their basic clinical knowledge base, and also provide prospective employers, supervisors, and, when applicable, hospital credentialers documentation of their mastery of this material in the form of a certification that is earned by passing an examination at the end of the program. All participants will receive credit for completing the course, but only those who demonstrate mastery of the material will receive certification.

Certification does not coincide with any known licensing board, academic program, university or affiliate,  but provides verification of content understanding for those who achieve this distinction. Certified providers also receive a certificate that will serve to accompany their credentialing file.

The course is taught over a single comprehensive day, using standard equipment found in most hospitals and acute care centers.  Skills mastery is taught by applying airway management techniques using simulators, which are built using correct human anatomy, and customizable to individual participants. There are several learning sessions throughout the day, each with focused airway training, in a small group format.  Upon completion, the Participants are eligible to claim CE/CEU/CME credit for their course, and may earn certification status by completing a multiple choice examination, and scoring in the to 80% of all participants. Certification and the award of CME credits for this program is granted automatically to all participants to successfully pass the examination. The objectives of each portion of the program are detailed below:

Ultrasound Course Schedule and Objectives

Airway Anatomy and Assessment

How to assess an airway

Identification of landmarks

Predicting a difficult airway

Special scenarios

Airway classification and grading

Indications for Airway Management

Clinical conditions

Respiratory status

Anatomy

Predictors of airway need

Common approaches

Invasive and Non-Invasive Airway Management

Escalation of intervention

BIPAP

CPAP

Endotracheal Intubation

Airway Adjuncts

Airway Options and Medications

Types of airway devices

Airway equipment

Laryngoscopes

Fiberoptic and Video Scopes

Induction Agents and Dosing

Induction and Intubation

Procedure organization and setup

Stepwise airway protocols

Anatomy

Endotracheal Intubation

Hands-on Procedure Practice

Tube Confirmation and Difficult Airway Management

Confirmatory tests

Defining an intact airway

How to manage a failed airway

Difficult airway algorithm and management

Fiberoptic laryngoscopy

Laryngeal mask airway

Video laryngoscopy

Difficult Airway Algorithm and Simulation

Application of the difficult airway algorithm

Simulated patient scenarios

Intubation with video laryngoscopy

Hands-on airway procedure lab

Individual review with instructor

The Advanced and Difficult Airway Course

The Ultrasound Course

The Clinical Skills & Procedure Workshop

The Clinical Skills & Procedure Workshop + The Airway Course

The Clinical Skills & Procedure Workshop + The Ultrasound Course

Dermatology Overview

Dermatology Essentials

Definition

Cellulitis: infection of dermis and subcutaneous fat

Impetigo: superficial purulent lesions, esp. on face and extremities. Commonly with bullae and/or golden crust

Erysipelas: raised erythematous lesion with clear borders

Folliculitis: hair follicle inflammation. Superficial and limited to the epidermis.

Furunculosis: hair follicle infection that extend to dermis. Multiple = carbuncle

Necrotizing Infection: Deeper SSTI that involve fascial and/or muscle compartments

Etiology

Microbiology

  • Cellulitis: primarily Staph and Strep, incl. MRSA. In immunocomp./diabetics, GNRs also
    • Other etiologies: cat/dog bite P. moltocida; gardening Sporothrix; salt water Vibrio vulnificus; puncture wound → Pseudomonas
  • Impetigo: Strep or Staph
  • Erysipelas: group A Strep usu.
  • Folliculitis/furunculosis: S. aureus, Pseudomonas
  • Necrotizing Infections: Polymicrobial (eg strep and GNRs in Type I, Fournier’s), Group A Strep, S. aureus, Aeromonas hydrophila, Vibrio vulnificus

At risk: athletic teams, military, prison, MSM, communities with MRSA infxn, Diabetic

High risk for more aggressive infection: splenectomy, immunocompromised

Differential Diagnosis

  • Cellulitis
  • Impetigo
  • Erysipelas
  • Folliculitis
  • Furunculosis
  • Necrotizing fasciitis
  • Myonecrosis
  • Calciphylaxis
  • Cutaneous metastasis from neoplasms (especially adenocarcinoma)
  • Graft-versus-host disease (in appropriate population)
  • Sweet syndrome

Patient History

  • Recent trauma to the affected area?
  • Any recent surgeries (hip replacement is risk factor)?
  • Ask about the presence of HIV, diabetes, liver disease, or kidney disease.
  • History of IV drug abuse or subcutaneous injection.
  • Recurrent Cellulitis: Assess for predisposing conditions such as edema, obesity, eczema, venous stasis, and toe web abnormalities.
  • Recurrent Abscesses: Search for local causes such as pilonidal cyst, HS, or foreign body. Consider 5-day decolonization (intranasal mupirosin, daily chlorhexidine). Consider neutrophil disorder if abscesses began in childhood.

Physical Exam

  • Evaluate affected area for erythema, edema, warmth, and pain on palpation.
  • Look for lymphangiitis (erythematous tracks under the skin marking an inflamed lymphatic system), palpate for lymphadenopathy.
  • Assess for evidence of necrotizing infection: systemic toxicity with high temperature, hypotension, disorientation, lethargy, skin discoloration or bullous lesions, anesthesia, firm skin with wooden-hard induration, pain extending beyond cutaneous erythema, pain out of proportion to exam

Work Up

Note: Diagnosis is largely clinical

Laboratory:

  • CBC with diff, ESR/CRP if concern for osteo, CK if concern for necrotizing infection or pyomyositis.
  • Furuncle/pustule can be aspirated for gram stain and culture.
  • For cellulitis, blood cultures are generally low yield, but should be obtained in patients undergoing chemo, neutropenic patients, and those who suffered animal bites.

Imaging:

  • If concern for osteo, xray; consider MRI
  • If concern for necrotizing infection can look for gas in fascial planes on x-ray or CT, but this is highly insensitive

Triage

More serious presentations of skin and soft tissue infections:

  • Toxic shock syndrome: fever, HA, vomiting, myalgias, pharyngitis, diarrhea, diffuse rash with desquamation. Hypotension and shock.
  • Osteomyelitis: infection of bone due to hematogenous seeding or direct spread from overlying focus.
  • Necrotizing fasciitis: infection and necrosis of superficial fascia, subq fat, and deep fascia. Clues: rapidly spreading cellulitis, systemic toxicity (inc TSS), pain out of proportion to exam, bullae formation, gangrene, crepitus. Surgical and medical emergency.
  • Gas gangrene: Clostridial myonecrosis, a fulminant skeletal muscle infection. C. perfringins usually in the setting of trauma; C. septicum in setting of cancer. Surgical and medical emergency.

Treatment

Purulent (furuncle/carbuncle/abscess):

  • Mild: I & D
  • Moderate: I & D, send for culture and sensitives
    • Empiric treatment: Bactrim 1-2 DS tab BID or Doxycycline 100mg BID
    • Defined treatment: MRSA: Bactrim 1-2 DS tab BID, MSSA: Dicloxacillin 250 Q6H or Cephalexin 500 Q6H or Cefadroxil 500mg po q12.
  • Severe: I & D, send for culture and sensitiivies
    • Empiric treatment: Vancomycin or Daptomycin or Linezolid or Ceftaroline
    • Defined treatment: MRSA: similar to empiric, MSSA: Nafcillin or Cefazolin or Clindamycin (if Susceptible)

Nonpurulent (necrotizing infection/cellulitis/erysipelas):

  • Mild: impetigo: topical mupirocin; oral treatment: Penicillin VK or Cephalosporin (eg Cephalexin 500mg PO Q6H) or Dicloxacillin 500mg PO Q6H or Clindamycin 300mg PO Q8H
  • Moderate: IV therapy: penicillin or Cefriaxone or Cefazolin or Clindamycin 300mg PO Q8H or 600mg IV Q8H
  • Severe: emergency surgical evaluation/debridement to rule out necrotizing process
    • Empiric treatment: Vancomycin PLUS Piperacillin/Tazobactam
    • Defined treatment for necrotizing infections:
      • Strep. pyogenes:Penicillin PLUS Clindamycin
      • Vibrio vulnificus:Doxycycline PLUS Ceftazidime
      • Aeromonas hydrophila:Doxycycline PLUS Ciprofloxacin
      • Polymicrobial: Vancomycin PLUS Piperacillin/Tazobactam

Duration of Therapy: 5-7 Days

Treatment Notes:

Erythema may initially worsen with antibiotics 2/2 local bacterial killing.

– For cellulitis, elevation of the affected extremity is essential to treatment.

– For Staph aureus infections (eg suppurative cellulitis) in 2014 at Hopkins susceptibilities were: TMP-SMX 87-88%, Tetracycline 89-91%, and Clindamycin 46-60%.

– For Beta-hemolytic Strep infections (eg non-suppurative cellulitis) all strains are susceptible to penicillin. At Hopkins there are high rates of resistance to TMP-SMX and tetracyclines and variable rates of resistance to Clindamycin.

– If you are concerned for a necrotizing infection, CONSULT SURGERY. Empiric antibiotic treatment with vancomycin (or linezolid) PLUS zosyn (or carbapenem) should be initiated. Clindamycin can be added to inhibit toxin production.

References

  1. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-52. [PMID:24973422]
  2. Swartz MN. Clinical practice. Cellulitis. N Engl J Med. 2004;350(9):904-12. [PMID:14985488]

Resources

Heart Failure

Cardiology Essentials

Definition

Syndrome characterized by impaired myocardial performance and progressive maladaptive neurohormonal activation of the cardiovascular system leading to circulatory insufficiency to meet the body’s demands.

Systolic heart failure or heart failure with reduced ejection fraction (HFrEF): Clinical diagnosis of heart failure and an EF of less than 50%.

Diastolic heart failure or heart failure with preserved ejection fraction (HFpEF): Clinical signs and symptoms of heart failure with evidence of normal or preserved EF and evidence of abnormal LV diastolic function by Doppler echocardiography or cardiac catheterization

Right heart failure: Majority of cases are a result of left heart failure, although isolated pulmonary diseases can also cause this syndrome.

Etiology

  • Non-ischemic dilated cardiomyopathy (familial or idiopathic)
  • Hypertrophic cardiomyopathy
  • Restrictive cardiomyopathy
  • Cardiomyopathy as a result of fibroelastosis
  • Mitochondrial disease
  • Left ventricular non-compaction
  • Ischemic cardiomyopathy
  • Stress induced cardiomyopathy
  • Valvular obstruction or insufficiency
  • Hypertensive cardiomyopathy
  • Inflammatory (lymphocytic, eosinophilic, giant cell myocarditis)
  • Infectious (Chagas, Lyme disease, HIV, viral, bacterial, or fungal infections)
  • Endocrine disorders (thyroid disease, adrenal insufficiency, pheochromocytoma, acromegaly)
  • Familial storage disease (hemochromatosis, glycogen storage disease, Hurler syndrome, Anderson-Fabry disease)
  • Amyloidosis
  • Connective tissue disease (SLE, polyarteritis nodosa, scleroderma, myositis, sarcoidosis)
  • Muscular dystrophies
  • Neuromuscular disease (Friedreich ataxia, Noonan disease)
  • Toxins (alcohol, anthracyclines, radiation)
  • Tachyarrhythmia

Pathophysiology

Progressive disorder initiated by a form of myocardial injury either sudden (MI or myocarditis) or chronic insults (familial, metabolic, HTN, valve disease, shunting) that result in maladaptive compensatory mechanisms.

These mechanisms include activation of the sympathetic nervous system and activation of the RAS system which overtime lead to pump dysfunction and circulatory collapse.

Differential Diagnosis

Other entities that may look like acute decompensated heart failure:

  • Acute coronary syndrome
  • Interstitial lung disease
  • Pneumonia
  • ARDS
  • Other sources of volume overload such as CKD/ESRD vs cirrhosis, pulmonary hypertension, PE, cardiac tamponade, constrictive or restrictive pericarditis

Patient History

Ask about the signs and symptoms:

  • Worsening dyspnea at rest or exertion?
  • Fatigue?
  • Orthopnea?
  • PND?
  • Weight gain?
  • Increased edema?
  • Lightheadedness?
  • indigestion?
  • Chest heaviness?
  • Fever?
  • Chest pain?
  • Timing of symptom onset?

Ask about triggers of acute decompensation:

  • dietary indiscretion? foods high in Na like lunch meats, chips, canned foods, fast foods?
  • missed medication doses (diuretic)?
  • are they weighing themself daily? adjusting diuretics?
  • any signs or symptoms that an ischemic event has occurred?
  • do they consume alcohol excessively?

Physical Exam

  • Weight gain (if possible look at previous discharge weights)
  • Elevated jugular venous pulsations (Key!), hepatojugular reflux
  • Orthopnea
  • Pulmonary rales
  • Third and/or fourth heart sound
  • Pedal edema
  • Sacral edema in patients who are mostly in bed

Work Up

Laboratory

  • Renal function panel, liver function panel (CMP): Patients who are volume overloaded due to acute decompensated heart failure often have an acute kidney injury and hepatic congestion.
  • Potassium, calcium (CMP), magnesium. May need to check more frequently (e.g. bid) especially if pt will be diuresed.
  • CBC: Anemia is present in up to 40% of patient with heart failure.
  • Consider pro-BNP if volume exam not helpful; compare to prior.
  • If patient is presenting newly with HF and/or etiology is unclear:
    • troponin and lipid profile, especially if HFrEF the pt may need further work up for ischemic disease
    • TSH
    • in the right patient, consider iron studies (hemochromatosis), serum ceruloplasmin (Wilson’s), trypanosoma cruzi IgG (chagas), blood alcohol level or CDT etc.

Imaging

  • ECG, chest x-ray, echocardiography

Other imaging and diagnostic modalities that can be considered based on the patient’s history:

  • Cardiac MR
  • Nuclear imaging
  • Right heart catheterization
  • Left heart catheterization
  • CT angiogram.
  • Endomyocardial biopsy

 

Triage

Strongly consider step-down or ICU if evidence of decompensation with hypoperfusion (cold and wet):

Altered mental status, Cold extremities, evidence of organ hypoperfusion: increasing lactate or rising creatine, narrow pulse pressures

Risk Stratification

The American College of Cardiology/American Heart Association (ACC/AHA) Heart Failure Classification is a system used to classify heart failure into four stages based on the severity of symptoms and degree of functional impairment.

The four stages of heart failure in the ACC/AHA classification are:

  1. Stage A: At high risk of developing heart failure due to underlying conditions or risk factors such as hypertension, diabetes, or coronary artery disease.

  2. Stage B: Structural heart disease is present, but there are no symptoms of heart failure. This stage includes patients with a history of myocardial infarction (heart attack) or left ventricular remodeling after a cardiac injury.

  3. Stage C: Structural heart disease is present, and there are symptoms of heart failure such as fatigue, shortness of breath, and decreased exercise tolerance. This stage includes patients with past or current symptoms of heart failure who are responding to treatment.

  4. Stage D: Advanced heart failure that is refractory to standard treatments. This stage includes patients with severe symptoms of heart failure at rest, despite maximal medical therapy. Patients in this stage may require advanced interventions such as heart transplant or mechanical circulatory support.

The ACC/AHA Heart Failure Classification is based on a combination of factors, including clinical symptoms, physical examination findings, imaging studies, and laboratory tests. This classification system is useful for guiding treatment decisions and predicting outcomes in patients with heart failure. It can also help clinicians identify patients at high risk for developing heart failure and initiate preventive interventions to improve outcomes.

The New York Heart Association (NYHA) Functional Classification is a system used to classify heart failure into four stages based on the severity of symptoms and degree of functional impairment. The classification system was developed in 1928 and is still widely used today.

New York Heart Association functional classification

The NYHA Functional Classification is based on the patient’s subjective symptoms and limitations related to physical activity. It is often used in clinical practice to assess the severity of heart failure, guide treatment decisions, and predict outcomes. Patients with more severe symptoms are more likely to have poorer outcomes, and may require more aggressive treatment or consideration of advanced interventions, such as heart transplantation or mechanical circulatory support.

It’s important to note that the NYHA Functional Classification is just one aspect of the overall assessment of heart failure and should be used in conjunction with other clinical and diagnostic findings.

The Seattle Heart Failure Model (SHFM) is a clinical prediction model that provides an estimate of the probability of death and other adverse outcomes in patients with heart failure. It was developed to help clinicians make more informed decisions about treatment and to assist in risk stratification of patients with heart failure. The SHFM incorporates a wide range of patient characteristics, including demographics, clinical symptoms, laboratory values, and medication use, to predict the likelihood of various outcomes, such as mortality, hospitalization, and quality of life. The model is based on data from over 11,000 patients with heart failure and has been validated in several independent cohorts. To use the SHFM, a clinician inputs data on the patient’s age, sex, symptoms, medical history, laboratory values, and medication use into a web-based calculator. The model then generates a personalized estimate of the patient’s probability of death and other outcomes at 1 year and 5 years. The SHFM also provides a range of other information, such as the estimated survival time, probability of hospitalization, and predicted quality of life. The SHFM has been shown to have good accuracy in predicting outcomes in patients with heart failure, and it can be useful in guiding treatment decisions and in risk stratification of patients. However, it is important to note that the SHFM is just one tool among many that can be used in the management of heart failure, and it should be used in conjunction with clinical judgment and other diagnostic and prognostic tools.  

The MAGGIC (Meta-Analysis Global Group in Chronic Heart Failure) risk score is a prognostic model that is used to predict mortality in patients with chronic heart failure. It was developed using a large international database of over 39,000 patients with heart failure from 30 different studies.

The MAGGIC risk score takes into account a range of patient characteristics and clinical features that have been shown to be predictive of mortality in heart failure, including age, sex, systolic blood pressure, NYHA functional class, heart rate, serum sodium, serum creatinine, ejection fraction, etiology of heart failure, and use of certain medications such as ACE inhibitors, beta blockers, and diuretics.

The MAGGIC risk score assigns points to each of these variables based on their estimated contribution to mortality risk. The total number of points is then used to estimate the patient’s probability of mortality at 1 year and up to 5 years. The MAGGIC risk score has been shown to have good discrimination and calibration in predicting mortality in patients with heart failure.

The MAGGIC risk score is useful for identifying high-risk patients who may benefit from closer monitoring and more aggressive treatment, as well as for guiding clinical decision-making and communication with patients and families about prognosis. However, it is important to note that the MAGGIC risk score is just one tool among many that can be used in the management of heart failure, and it should be used in conjunction with clinical judgment and other diagnostic and prognostic tools.

CHA2DS2-VASc score: The CHA2DS2-VASc score is a tool used to estimate the risk of stroke in patients with atrial fibrillation. Since atrial fibrillation is a common comorbidity in heart failure, this score can be useful in managing heart failure patients with concurrent atrial fibrillation.

The CHA2DS2-VASc score is a clinical prediction rule that is primarily used to estimate the risk of stroke in patients with non-valvular atrial fibrillation. It is not specifically used in the management of heart failure, but rather in the management of comorbidities that may be present in patients with heart failure.

Patients with heart failure are at an increased risk of developing atrial fibrillation and other cardiovascular diseases, such as stroke, myocardial infarction, and peripheral vascular disease. As such, the CHA2DS2-VASc score can be used in the management of heart failure as a tool to identify patients who are at an increased risk of developing these conditions, and to guide clinical decision-making regarding the use of prophylactic therapies such as anticoagulation.

The CHA2DS2-VASc score takes into account a range of patient characteristics and clinical features that have been shown to be predictive of stroke and other cardiovascular events, including age, sex, history of stroke or transient ischemic attack, hypertension, diabetes, heart failure, and vascular disease. The score assigns points to each variable based on its estimated contribution to the risk of stroke or other cardiovascular events.

While the CHA2DS2-VASc score is not specifically designed for use in heart failure, it is an important tool that can be used to guide clinical decision-making in the management of patients with heart failure and comorbidities. It can help identify patients who may benefit from prophylactic therapies and other interventions aimed at reducing the risk of stroke and other cardiovascular events.

 

Heart failure with reduced ejection fraction (HFrEF) is a condition where the heart muscle weakens and can’t pump blood effectively. Treatment for HFrEF usually involves a combination of lifestyle changes, medication, and other interventions.

The HFrEF therapy calculator is a tool that can help healthcare professionals determine the most appropriate treatment plan for patients with HFrEF. The calculator takes into account the patient’s age, sex, blood pressure, kidney function, and other factors, and recommends medications and doses that have been shown to be effective in treating HFrEF.

The calculator is based on guidelines developed by the American College of Cardiology, American Heart Association, and Heart Failure Society of America. These guidelines recommend a combination of medications that target different aspects of heart failure, including angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta blockers, and aldosterone antagonists.

The HFrEF therapy calculator takes into account the patient’s current medications and adjusts the recommendations accordingly. It also provides guidance on when to start or stop certain medications, and how to titrate the doses to achieve the maximum benefit while minimizing side effects.

The Renal Risk Score is a tool that helps predict the risk of developing acute kidney injury in patients with heart failure who are undergoing intravenous diuretic therapy.

The renal risk score is a tool that is primarily used to estimate a patient’s risk of developing acute kidney injury (AKI) after undergoing cardiac surgery. However, the risk of AKI is also a concern in patients with heart failure, particularly those who are hospitalized or receiving treatment with certain medications.

In patients with heart failure, the risk of AKI is often related to factors such as low cardiac output, fluid overload, and the use of medications that can affect kidney function. Some of these medications include diuretics, angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin receptor blockers (ARBs), and nonsteroidal anti-inflammatory drugs (NSAIDs).

Several studies have looked at the use of the renal risk score in patients with heart failure. One study, published in the journal Circulation Heart Failure in 2014, found that the renal risk score was able to predict the risk of AKI in patients hospitalized with heart failure. The study also found that patients with higher renal risk scores were more likely to require dialysis or have a longer hospital stay.

Another study, published in the Journal of Cardiac Failure in 2018, evaluated the use of the renal risk score in patients with heart failure who were receiving treatment with sacubitril/valsartan, a medication used to treat heart failure with reduced ejection fraction. The study found that the renal risk score was able to predict the risk of AKI in these patients and could be used to guide dosing of the medication to minimize the risk of kidney injury.

Overall, while the renal risk score was developed for use in patients undergoing cardiac surgery, it may also be a useful tool for predicting the risk of AKI in patients with heart failure. By identifying patients at higher risk of AKI, healthcare providers can take steps to minimize the risk of kidney injury and improve outcomes for these patients.

Treatment

Acute Decompensated Heart Failure

IV diuresis:

Determine home regimen and try to give an increased dose. Patients with anasarca DO NOT ABSORB ORAL MEDS. Remember patients who are naïve to diuretics may not require high doses for good urine output. As a rule of thumb, the furosemide dose can be initially calculated at 40 (mg) X serum creatinine. Titration will be performed according to initial response. Common diuretics include furosemide, torsemide, metolazone, and Chlorothiazide. For ESRD patients who no longer make urine, volume removal will be via ultrafiltration and may need to be done more aggressively as tolerated by BP. Be sure to check electrolytes twice a day and aggressively supplement (keep K around 4 and magnesium around 2.4. Check daily weights (standing if possible) and monitor Ins and Outs.

Afterload reduction in systolic heart failure:

If no kidney injury is detected you can consider an ACE-Inhibitor, otherwise hydralazine with/or without nitrates. In more severe cases, one may consider sodium nitroprusside

Inotropy: Usually in severe cases or if effective diuresis is not achieved despite other efforts.

Dobutamine or milrinone

Remember to hold beta blockers in acute decompensated heart failure

Chronic Heart Failure Therapies

Mortality reducing agents:

  • ACE inhibitors/ARBs
    • start in all pt’s with current or prior sx’s of HFrEF unless contraindicated; try ACEi first and then try ARB if not tolerated
    • caution in pts with ↓SBP, renal insufficiency, or ↑serum potassium (>5.0 mEq/L). Angioedema occurs in < 1% of pts with ACE inhibitors.
  • ANRIs (angiotensin receptor–neprilysin inhibitor: valsartan/sacubitril)
    • start in pt’s with NYHA class II-III HFrEF who tolerate an ACE inhibitor or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality. Harmful if started concomitantly with ACEi/ARB – wait 36 hrs after stopping ACEi/ARB to inititate
  • Beta blockers (metoprolol succinate, bisoprolol, and carvedilol)
    • start in all pt’s with current or prior sx’s of HFrEF unless contraindicated
  • ISDN + Hydralazine
    • clear benifit in African American pt’s with NYHA class III-IV HFrEF
    • likely beneficial for all pt’s with HFrEF, though utility somewhat limited by TID dosing
  • Aldosterone receptor blockers (eplerenone, spironolactone)
    • recommended in patients with NYHA class II–IV HF and who have LVEF of 35% or less

HF Hospitalization Reducing Agents

  • Digoxin
  • Ivabradine (inhibits the If current in the SA node, ↓HR)
    • can use in NYHA class II-III stable chronic HFrEF (LVEF ≤35%) who tolerate maximum BB in NSR with HR of 70 bpm or more at rest[2]

Advanced Therapies

  • Left ventricular assist device (right heart must be able to tolerate this)
  • Heart transplantation

References

  1. Khot UN, Jia G, Moliterno DJ, et al. Prognostic importance of physical examination for heart failure in non-ST-elevation acute coronary syndromes: the enduring value of Killip classification. JAMA. 2003;290(16):2174-81. [PMID:14570953]
  2. Yancy CW, et al: 2016 ACC/AHA/HFSA Focused Update on NewPharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for theManagement of Heart Failure, Journal of the American College of Cardiology (2016), doi: 10.1016/j.jacc.2016.05.011.
  3. Griffin BP, Callahan TD, Menon V, et al. Manual of Cardiovascular Medicine. Lippincott Williams & Wilkins. 2013 4th edition; Heart Failure and Transplant 125-159
  4. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):e147-239. [PMID:23747642]

Resources

Advanced and Difficult Airway Course Content

Airway Anatomy and Assessment

  • Overview of airway anatomy
  • Indications of normal airway
  • Identification of difficult airway characteristics
  • Application of assessment for anticipation

Indications for Airway Management

  • Predictors of airway failure
  • Identification of clinical risk factors
  • When to intervene

Non-Invasive Airway Interventions

  • Progressive Oxygenation
  • Pulmonary Mechanics
  • Measured oxygenation techniques
  • CPAP and BIPAP

Invasive Airway Management

  • Rescue airway interventions
  • Laryngeal mask airway
  • Posterior pharyngeal airway adjuncts
  • Endotracheal intubation

Airway Options

  • Identification and selection of the correct airway device
  • Discussion of equipment options and their uses
  • Preparation for induction and intubation

Intubation Drugs

  • A pharmacology review of induction agents
  • Selection of the best drug combinations for induction
  • Safe decision-making

Induction and Intubation

  • Application of each prior learning topic to provide safe intubation
  • Stepwise, thorough discussion about safe airway induction and intubation
  • Correct techniques for endotracheal tube insertion

Confirming Tube Placement

  • Processes to ensure an endotracheal tube is correctly placed
  • Discussion about reintubation and confirmation
  • Application to difficult airway management

Difficult Airway Equipment

  • Intubating LMA, Lighted Stylet, Light Wand, Video Laryngoscope and more
  • Learn how to select the correct equipment for the situation
  • Double set-up indications

The Difficult Airway 

  • Application of difficult airway algorithms to fit the correct clinical conditions
  • A stepwise process discussion to maximize airway success
  • Indications and procedure for emergent cricothyrotomy

Ultrasound Course Content

Introduction to Ultrasound

  • Ultrasound Physics
  • Probe functions and types
  • Methods of scanning (sliding, rocking, other movements and techniques)
  • Probe Settings (depth, “knobology”)
  • Hand movements and dexterity

Biliary Ultrasound

  • Liver and Gall Bladder
  • Identification of anatomy
  • Abnormal Findings and Diagnostic Criteria
  • Interpretation of findings and Management

DVT Ultrasound

  • Lower extremity venous anatomy and scanning technique
  • Expected normal and abnormal findings
  • Interpretation of doppler and compressibility images
  • Clinical decision-making and follow-up

eFAST Ultrasound

  • Trauma-focused exam 
  • Includes abdomen, bladder, cardiac, and pulmonary imaging
  • Diagnostic criteria and decision-making
  • Includes common and subtle findings

Ocular Ultrasound

  • Technique and probe placement
  • Retinal detachment, foreign bodies, lens dislocation, vitreous hemorrhage, retrobulbar hematoma, and papilledema
  • Next clinical steps

Pelvic Ultrasound

  • Probe placement and scanning technique
  • Uterine, ovarian, and adnexal pathology
  • Next clinical steps

Pulmonary Ultrasound

  • Small groups, team led with hands-on guidance and findings
  • Review and individual practice sessions with instructors
  • Additional ultrasound applications
  • Wrap-Up and Closing

Renal Ultrasound

  • Anatomy and probe placement
  • Ultrasonic anatomy and expected findings
  • Clinical correlation and management

Soft Tissue Ultrasound

  • Probe selection and settings
  • Foreign body, cellulitis, abscess, and cyst identification
  • Next clinical steps

Ultrasound for Vascular Access

  • Anatomy of peripheral and central veins
  • Application of Ultrasound to assist with line placement
  • Visualization of landmarks and expected clinical findings

Abdominal Aorta Ultrasound

  • Anatomy and ultrasound placement
  • Expected normal and abnormal findings
  • Next clinical steps and application

3-Day Clinical Skills & Procedure Workshop + The Airway Course

Day 1 Morning

Airway Anatomy and Assessment

  • How to assess an airway
  • Identification of landmarks
  • Predicting a difficult airway
  • Special scenarios
  • Airway classification and grading

Indications for Airway Management

  • Clinical conditions
  • Respiratory status
  • Anatomy
  • Predictors of airway need
  • Common approaches

Non-Invasive and Invasive Airway Management

  • Escalation of intervention
  • Sequential oxygenation
  • BIPAP
  • CPAP
  • Endotracheal Intubation
  • Airway Adjuncts (LMA, OPA)

Airway Options and Medications

  • Types of airway devices
  • Airway equipment
  • Laryngoscopes
  • Fiberoptic and Video Scopes
  • Induction agents and dosing

Induction and Intubation

  • Procedure organization and setup
  • Stepwise airway protocols
  • Anatomy
  • Endotracheal Intubation
  • Hands-On Procedure Practice

Tube Confirmation and Difficult Airway Management

  • Confirmatory tests
  • Defining an intact airway
  • How to manage a failed airway
  • Difficult airway algorithm and management
  • Fiberoptic laryngoscopy
  • Laryngeal mask airway
  • Video laryngoscope

Day 1 Afternoon

procedure

Difficult Airway Algorithm and Simulation

  • Application of the difficult airway algorithm
  • Simulated patient scenarios
  • Intubation with video laryngoscopy
  • Hands-On airway procedure lab
  • Individual review with instructor
  • Certification Examination

Day 2 Morning

Cardiac

Cardiac Disorders

  • Course Introduction
  • Cardiac Overview
  • EKG Interpretation
  • Acute MI (recognition, management)
  • Common Dysrhythmias
  • Electrolyte Abnormalities and rhythm impacts
  • Condition blocks
  • Bundle Branch Blocks
  • Application to practice
Pulmonary

Pulmonary Disorders

  • Pulmonary Overview
  • Basic Airway Assessment
  • Pneumothorax
  • Asthma Management
  • COPD Management
  • Supplemental Oxygenation
  • Wells Criteria
  • PERC Rule
  • Using D-Dimer
  • Pulmonary Embolism
  • Treatment of Pulmonary Embolism

Introduction to Radiology – Chest and Abdomen

 
  • Overview of Radiograph Interpretation
  • Chest, Shoulder, Clavicle Radiographs
  • Systemic Reading Process
  • Abnormal Radiographs
  • Radiographic Signs of Major Diseases
  • Suggested treatment guidelines based on findings
  • Radiographic Signs of High Impact Injuries
  • Foreign body ingestion, aspiration, and insertion
  • Pediatric foreign body aspiration and management

Day 2 Afternoon

procedure

Procedure Overview

  • Procedural Overview
  • Needle Decompression
  • Chest Tube Insertion
  • Tracheostomy Replacement
  • Shoulder Reduction and Immobilization
  • Upper Extremity Joint Aspiration
  • Trigger Point Injection
  • Nail Trephination
  • Nail Removal
  • Foreign Body and Fish Hook Removal
    Introduction to Suture Techniques
     
suturing

The Suturing Course

  • Suture Clinic and Equipment Introduction
  • Knot Tying
  • Simple Interrupted
  • Simple Running
  • Mattress
  • Subcutaneous/Multiple Layer Closure
  • Staples
  • Skin Adhesive
  • Surgeon’s Knot
  • Buried Knot
  • Billing and Documentation for Sutures
  • Local Injections and Digital Blocks
 
procedure

Procedure Workshop

  • Knee Injection and Aspiration
  • Shoulder Injection
  • Needle Decompression
  • Chest Tube Insertion

Day 3 Morning

Cervical Spine Injuries

  • Long Board and Collar Removal
  • NEXUS Criteria
  • Unstable Fractures
  • Mechanisms of Common Fractures
  • Immobilization
  • Ordering the Correct Studies
  • Correct Consult and Referral
 

Thoracic and Lumbar Spine Injuries

  • Spine form and function
  • Mechanisms of Injury
  • Unstable Fractures
  • Mechanisms of Common Fractures
  • Cauda Equina Syndrome
  • Epidural Abscess
  • Ordering the Correct Studies
  • Correct Consult and Referral
 
Extremity

Upper and Lower Extremity Injuries

  • Speaking Orthopedics
  • Common Patterns of Fractures
  • Common Dislocation and Reduction Techniques
  • Splinting Techniques and Compartment Syndrome
  • Clavicle, Shoulder, Humerus, Elbow, Radius. Ulna. Paired fractures, Wrist and Carpal Bones, Hand
  • Amputations
  • When to Consult Orthopedics
  • When to Consider Transfer/EMS
  • What to send home

Day 3 Afternoon

skin

Skin Conditions Not to Miss

  • Skin and Soft Tissue Conditions
  • Emergent Rash Identification
  • Cellulitis
  • Abscess Incision and Drainage
  • DVT Identification and Decisions Rules
  • Burn Care and Referral Criteria
  • What Not to Send Home
procedure

Procedure Workshop

  • Procedure Clinic
  • Lumbar Puncture
  • Splinting Workshop
  • Intraosseous Access
  • Central Venous Catheter Insertion

3-Day Clinical Skills & Procedure Workshop + The Ultrasound Course

Day 1 Morning

Introduction to Ultrasound

  • Ultrasound Physics
  • Probe functions and types
  • Methods of scanning (sliding, rocking, other movements and techniques)
  • Probe Settings (depth, “knobology”)
  • Hand movements and dexterity
ultrasound

Abdominal Ultrasound

  • Aorta (all views, normal anatomy, pathology)
  • Biliary Quadrant (gallbladder, stones, techniques)
  • Kidney (hydronephrosis, pyelonephritis)
  • Trans-abdominal Pelvis
procedure

Trauma Ultrasound

  • eFAST exam
  • Right upper quadrant imaging
  • Left upper quadrant imaging
  • Bladder Imaging
  • Cardiac Imaging
  • Lung Imaging
procedure

Free Scan with Live Models

  • Small groups, team led with hands-on guidance and findings

Day 1 Afternoon

Specialty Ultrasound

  • Ocular Ultrasound (retinal detachment, foreign bodies)
  • Foreign body imaging
  • Ultrasound-Guided IV and Central access technique
  • Lower Extremity Vascular Ultrasound
procedure

Afternoon Free Scan

  • Small groups, team led with hands-on guidance and findings
  • Review and individual practice sessions with instructors
  • Additional ultrasound applications
  • Wrap-Up and Closing

Day 2 Morning

Cardiac

Cardiac Disorders

  • Course Introduction
  • Cardiac Overview
  • EKG Interpretation
  • Acute MI (recognition, management)
  • Common Dysrhythmias
  • Electrolyte Abnormalities and rhythm impacts
  • Condition blocks
  • Bundle Branch Blocks
  • Application to practice
Pulmonary

Pulmonary Disorders

  • Pulmonary Overview
  • Basic Airway Assessment
  • Pneumothorax
  • Asthma Management
  • COPD Management
  • Supplemental Oxygenation
  • Wells Criteria
  • PERC Rule
  • Using D-Dimer
  • Pulmonary Embolism
  • Treatment of Pulmonary Embolism

Introduction to Radiology – Chest and Abdomen

 
  • Overview of Radiograph Interpretation
  • Chest, Shoulder, Clavicle Radiographs
  • Systemic Reading Process
  • Abnormal Radiographs
  • Radiographic Signs of Major Diseases
  • Suggested treatment guidelines based on findings
  • Radiographic Signs of High Impact Injuries
  • Foreign body ingestion, aspiration, and insertion
  • Pediatric foreign body aspiration and management

Day 2 Afternoon

procedure

Procedure Overview

  • Procedural Overview
  • Needle Decompression
  • Chest Tube Insertion
  • Tracheostomy Replacement
  • Shoulder Reduction and Immobilization
  • Upper Extremity Joint Aspiration
  • Trigger Point Injection
  • Nail Trephination
  • Nail Removal
  • Foreign Body and Fish Hook Removal
    Introduction to Suture Techniques
     
suturing

The Suturing Course

  • Suture Clinic and Equipment Introduction
  • Knot Tying
  • Simple Interrupted
  • Simple Running
  • Mattress
  • Subcutaneous/Multiple Layer Closure
  • Staples
  • Skin Adhesive
  • Surgeon’s Knot
  • Buried Knot
  • Billing and Documentation for Sutures
  • Local Injections and Digital Blocks
 
procedure

Procedure Workshop

  • Knee Injection and Aspiration
  • Shoulder Injection
  • Needle Decompression
  • Chest Tube Insertion

Day 3 Morning

Cervical Spine Injuries

  • Long Board and Collar Removal
  • NEXUS Criteria
  • Unstable Fractures
  • Mechanisms of Common Fractures
  • Immobilization
  • Ordering the Correct Studies
  • Correct Consult and Referral
 

Thoracic and Lumbar Spine Injuries

  • Spine form and function
  • Mechanisms of Injury
  • Unstable Fractures
  • Mechanisms of Common Fractures
  • Cauda Equina Syndrome
  • Epidural Abscess
  • Ordering the Correct Studies
  • Correct Consult and Referral
 
Extremity

Upper and Lower Extremity Injuries

  • Speaking Orthopedics
  • Common Patterns of Fractures
  • Common Dislocation and Reduction Techniques
  • Splinting Techniques and Compartment Syndrome
  • Clavicle, Shoulder, Humerus, Elbow, Radius. Ulna. Paired fractures, Wrist and Carpal Bones, Hand
  • Amputations
  • When to Consult Orthopedics
  • When to Consider Transfer/EMS
  • What to send home

Day 3 Afternoon

skin

Skin Conditions Not to Miss

  • Skin and Soft Tissue Conditions
  • Emergent Rash Identification
  • Cellulitis
  • Abscess Incision and Drainage
  • DVT Identification and Decisions Rules
  • Burn Care and Referral Criteria
  • What Not to Send Home
procedure

Procedure Workshop

  • Procedure Clinic
  • Lumbar Puncture
  • Splinting Workshop
  • Intraosseous Access
  • Central Venous Catheter Insertion

1-Day Advanced and Difficult Airway Course Schedule

Day 1 Morning

Airway Anatomy and Assessment

  • How to assess an airway
  • Identification of landmarks
  • Predicting a difficult airway
  • Special scenarios
  • Airway classification and grading

Indications for Airway Management

  • Clinical conditions
  • Respiratory status
  • Anatomy
  • Predictors of airway need
  • Common approaches

Non-Invasive and Invasive Airway Management

  • Escalation of intervention
  • Sequential oxygenation
  • BIPAP
  • CPAP
  • Endotracheal Intubation
  • Airway Adjuncts (LMA, OPA)

Airway Options and Medications

  • Types of airway devices
  • Airway equipment
  • Laryngoscopes
  • Fiberoptic and Video Scopes
  • Induction agents and dosing

Induction and Intubation

  • Procedure organization and setup
  • Stepwise airway protocols
  • Anatomy
  • Endotracheal Intubation
  • Hands-On Procedure Practice

Tube Confirmation and Difficult Airway Management

  • Confirmatory tests
  • Defining an intact airway
  • How to manage a failed airway
  • Difficult airway algorithm and management
  • Fiberoptic laryngoscopy
  • Laryngeal mask airway
  • Video laryngoscope

Day 1 Afternoon

procedure

Difficult Airway Algorithm and Simulation

  • Application of the difficult airway algorithm
  • Simulated patient scenarios
  • Intubation with video laryngoscopy
  • Hands-On airway procedure lab
  • Individual review with instructor
  • Certification Examination

1-Day Ultrasound Course Schedule

Day 1 Morning

Introduction to Ultrasound

  • Ultrasound Physics
  • Probe functions and types
  • Methods of scanning (sliding, rocking, other movements and techniques)
  • Probe Settings (depth, “knobology”)
  • Hand movements and dexterity
ultrasound

Abdominal Ultrasound

  • Aorta (all views, normal anatomy, pathology)
  • Biliary Quadrant (gallbladder, stones, techniques)
  • Kidney (hydronephrosis, pyelonephritis)
  • Trans-abdominal Pelvis
procedure

Trauma Ultrasound

  • eFAST exam
  • Right upper quadrant imaging
  • Left upper quadrant imaging
  • Bladder Imaging
  • Cardiac Imaging
  • Lung Imaging
procedure

Free Scan with Live Models

  • Small groups, team led with hands-on guidance and findings

Day 1 Afternoon

Specialty Ultrasound

  • Ocular Ultrasound (retinal detachment, foreign bodies)
  • Foreign body imaging
  • Ultrasound-Guided IV and Central access technique
  • Lower Extremity Vascular Ultrasound
procedure

Afternoon Free Scan

  • Small groups, team led with hands-on guidance and findings
  • Review and individual practice sessions with instructors
  • Additional ultrasound applications
  • Wrap-Up and Closing

The APP Clinical Skills and Procedure Workshop Schedule

Day 1 Morning

Cardiac

Cardiac Disorders

  • Course Introduction
  • Cardiac Overview
  • EKG Interpretation
  • Acute MI (recognition, management)
  • Common Dysrhythmias
  • Electrolyte Abnormalities and rhythm impacts
  • Condition blocks
  • Bundle Branch Blocks
  • Application to practice
Pulmonary

Pulmonary Disorders

  • Pulmonary Overview
  • Basic Airway Assessment
  • Pneumothorax
  • Asthma Management
  • COPD Management
  • Supplemental Oxygenation
  • Wells Criteria
  • PERC Rule
  • Using D-Dimer
  • Pulmonary Embolism
  • Treatment of Pulmonary Embolism

Introduction to Radiology – Chest and Abdomen

 
  • Overview of Radiograph Interpretation
  • Chest, Shoulder, Clavicle Radiographs
  • Systemic Reading Process
  • Abnormal Radiographs
  • Radiographic Signs of Major Diseases
  • Suggested treatment guidelines based on findings
  • Radiographic Signs of High Impact Injuries
  • Foreign body ingestion, aspiration, and insertion
  • Pediatric foreign body aspiration and management

Day 1 Afternoon

procedure

Procedure Overview

  • Procedural Overview
  • Needle Decompression
  • Chest Tube Insertion
  • Tracheostomy Replacement
  • Shoulder Reduction and Immobilization
  • Upper Extremity Joint Aspiration
  • Trigger Point Injection
  • Nail Trephination
  • Nail Removal
  • Foreign Body and Fish Hook Removal
    Introduction to Suture Techniques
     
suturing

The Suturing Course

  • Suture Clinic and Equipment Introduction
  • Knot Tying
  • Simple Interrupted
  • Simple Running
  • Mattress
  • Subcutaneous/Multiple Layer Closure
  • Staples
  • Skin Adhesive
  • Surgeon’s Knot
  • Buried Knot
  • Billing and Documentation for Sutures
  • Local Injections and Digital Blocks
 
procedure

Procedure Workshop

  • Knee Injection and Aspiration
  • Shoulder Injection
  • Needle Decompression
  • Chest Tube Insertion

Day 2 Morning

Cervical Spine Injuries

  • Long Board and Collar Removal
  • NEXUS Criteria
  • Unstable Fractures
  • Mechanisms of Common Fractures
  • Immobilization
  • Ordering the Correct Studies
  • Correct Consult and Referral
 

Thoracic and Lumbar Spine Injuries

  • Spine form and function
  • Mechanisms of Injury
  • Unstable Fractures
  • Mechanisms of Common Fractures
  • Cauda Equina Syndrome
  • Epidural Abscess
  • Ordering the Correct Studies
  • Correct Consult and Referral
 
Extremity

Upper and Lower Extremity Injuries

  • Speaking Orthopedics
  • Common Patterns of Fractures
  • Common Dislocation and Reduction Techniques
  • Splinting Techniques and Compartment Syndrome
  • Clavicle, Shoulder, Humerus, Elbow, Radius. Ulna. Paired fractures, Wrist and Carpal Bones, Hand
  • Amputations
  • When to Consult Orthopedics
  • When to Consider Transfer/EMS
  • What to send home

Day 2 Afternoon

skin

Skin Conditions Not to Miss

  • Skin and Soft Tissue Conditions
  • Emergent Rash Identification
  • Cellulitis
  • Abscess Incision and Drainage
  • DVT Identification and Decisions Rules
  • Burn Care and Referral Criteria
  • What Not to Send Home
procedure

Procedure Workshop

  • Procedure Clinic
  • Lumbar Puncture
  • Splinting Workshop
  • Intraosseous Access
  • Central Venous Catheter Insertion

The Clinical Skills & Procedure Workshop + The Ultrasound Course

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Offer Expires July 7. Excludes hotels and custom group programs.