Getting Ready for 2018

Wow! What an amazing year for PPE. Up and running and ready to roll in 5 expanded markets in record time. Thank you all for your support and interest in our programs! In celebration of our newest program location – Orlando – we are offering a special bonus for everyone who registers. If we can fill the June 8-9 class, we will pay for the course for one lucky student! Also, if that’s not enough, another lucky winner will go home with a new Apple iPad Mini! That’s right – two more reasons to sign up for amazing education with Provider Practice Essentials! Click HERE to register for the ORLANDO program now!

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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

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]
Swartz MN. Clinical practice. Cellulitis. N Engl J Med. 2004;350(9):904-12. [PMID:14985488]

Resources

Cardiology Essentials

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.

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

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

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?

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

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

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

Topic 1

ACC/AHA Heart Failure Classification

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:

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

New York Heart Association Functional Classification

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.

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.

Seattle Heart Failure Model

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.

MAGGIC Risk Score

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

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.

HFrEF therapy calculator

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.

Renal Risk Score

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.

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

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]
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.
Griffin BP, Callahan TD, Menon V, et al. Manual of Cardiovascular Medicine. Lippincott Williams & Wilkins. 2013 4th edition; Heart Failure and Transplant 125-159
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]

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

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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

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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

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 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 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 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

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 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

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 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 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

Abdominal Ultrasound

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

Trauma Ultrasound

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

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

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 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 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 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

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 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

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 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 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

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

Abdominal Ultrasound

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

Trauma Ultrasound

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

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

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 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 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 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

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 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

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 Conditions Not to Miss

Skin and Soft Tissue Conditions
Emergent Rash Identification
Cellulitis
Abscess Incision and Drainage
DVT Identification and decision rules
Burn Care and Referral Criteria
What Not to Send Home

Procedure Workshop

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

The Clinical Skills & Procedure Workshop + The Ultrasound Course

[tribe_events_list view="photo" category="POCUS3"]

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Conferences and Workshops

We make hands-on training fun and engaging!

Live programs are available in:

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

Heart Failure

Acute Decompensated Heart Failure

Chronic Heart Failure Therapies

HF Hospitalization Reducing Agents

Advanced Therapies

Course Content

Airway Anatomy and Assessment

Indications for Airway Management

Non-Invasive Airway Interventions

Invasive Airway Management

Airway Options

Intubation Drugs

Induction and Intubation

Confirming Tube Placement

Difficult Airway Equipment

The Difficult Airway

Ultrasound Course Content

Introduction to Ultrasound

Biliary Ultrasound

DVT Ultrasound

eFAST Ultrasound

Ocular Ultrasound

Pelvic Ultrasound

Pulmonary Ultrasound

Renal Ultrasound

Soft Tissue Ultrasound

Ultrasound for Vascular Access

Abdominal Aorta Ultrasound

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

Day 1 Morning

Airway Anatomy and Assessment

Indications for Airway Management

Non-Invasive and Invasive Airway Management

Airway Options and Medications

Induction and Intubation

Tube Confirmation and Difficult Airway Management

Day 1 Afternoon

Difficult Airway Algorithm and Simulation

Day 2 Morning

Cardiac Disorders

Pulmonary Disorders

Introduction to Radiology – Chest and Abdomen

Day 2 Afternoon

Procedure Overview

The Suturing Course

Procedure Workshop

Day 3 Morning

Cervical Spine Injuries

Thoracic and Lumbar Spine Injuries

Upper and Lower Extremity Injuries

Day 3 Afternoon

Skin Conditions Not to Miss

Procedure Workshop

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

Day 1 Morning

Introduction to Ultrasound

Abdominal Ultrasound

Trauma Ultrasound

Free Scan with Live Models

Day 1 Afternoon

Specialty Ultrasound

Afternoon Free Scan

Day 2 Morning