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Proposed core content for pediatric emergency medicine fellowship training of emergency medicine graduates
PEDIATRICS/CONCEPTS
Proposed Core Content for Pediatric Emergency Medicine Fellowship Training of Emergency Medicine Graduates From the Division of Emergency Medicine, University of Pittsburgh;* the Department of Pediatrics, Children's Hospital of Pittsburgh;t and the Department of Emergency Medicine, Medical College of Pennsylvania.
Christopher King, MD *t Gwendolyn J Nilsen, MD* Fred M Henrntig, MD* David K Wagner, MD*
Receivedfor publication December 6, 1993. Revision received March 17, 1994. Acceptedfor publication March 27, 1994. Copyright 9 by the American College of Emergency Physicians.
The establishment of pediatric emergency medicine as a subspecialty of emergency medicine has engenderedthe need for closer examination and development of guidelines for fellowship training. Core content and curriculum documents pertaining to fellowship training in pediatric emergency medicine for pediatric graduates have been published previously. However, the educational needs of emergency medicine graduates for such training are significantly different from those of pediatric graduates in several important respects. We believe that emergency physicians should take an active role in the creation and refinement of educational guidelines for fellowship training in pediatric emergency medicine for emergency medicine graduates. For this reason, we present a proposed core content outline in the hope that it will serve to foster this process. [King C, Nilsen GJ, Henretig FM, Wagner DK: Proposed core content for pediatric emergency medicine fellowship training of emergency medicine graduates. Ann Emerg/WedNovember 1994;24:825-835.] INTRODUCTION Pediatric emergency medicine is the first subspeciahy to be established by the American Board of Emergency Medicine. The initial subboard examination was administered in November 1992. Eligibility requirements for subspeciahy certification by emergency physicians can be fulfilled either through fellowship training and/or defined practice activities or through dual certification m pediatrics and emergency medicine until July 1, 1996. After that date, completion of a formal 2-year fellowship program will be required for board eligibility. All pediatric graduates who seek board certification in this subspeciahy as granted by the American Board of Pediatrics will be required to complete 3 years of fellowship training, as opposed to the prior requirement of 2 years, beginning in 1995. The primary purpose of this proposed core content" outline is to aid the definition of this new subspeciahy in
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emergency medicine. Our hope is that this outline will serve as a resource for the establishment and further development of pediatric emergency medicine fellowship programs within academic divisions/departments of emergency medicine, as well as for pediatric-based programs that recruit emergency medicine graduates. We also wish to provide a potential "working document" for future committees officially charged with fellowship curriculum development in pediatric emergency medicine for emergency medicine graduates. Such a committee recently has been established for this purpose by the American Academy of Pediatrics. Selection of topics to be included in this core content outline was based on a number of defined criteria. Potential topics for consideration were taken from standard pediatric and emergency medicine reference texts, the core content of emergency medicine, ~ and the core content of pediatric emergency medicine for pediatric graduates. 2 For reasons discussed previously, 3 the core content requirements in pediatric emergency medicine for emergency medicine graduates were thought to be similar in many ways to those published for pediatric graduates, but substantially different in others. The principal criteria used to evaluate potential topics were as follows: areas that are important in the practice of pediatric emergency medicine that are not covered adequately in an emergency medicine residency (eg, growth and development, and nutrition); areas covered during an emergency medicine residency that are important enough in pediatric emergency medicine to require additional emphasis (eg, pediatric resuscitation and child abuse); and areas that are well covered from an adult perspective during an emergency medicine residency but that differ significantly with regard to pediatric applications (eg, psychobehavioral issues, and sedation and pain management). Topic selection was based on consensus agreement of the four authors during extensive discussions in meetings held over approximately 8 months. A primary limitation of this document is the comparatively small size of the participant group. However, we believe that the diverse experience of the authors in education and pediatric emergency medicine fellowship training is such that they are qualified to produce this first effort. The participants included a pediatrician who is board certified in pediatric emergency medicine (Dr Henretig), a pediatric surgeon and emergency physician (Dr Wagner), an emergency physician with fellowship training in teaching and education (Dr Nilsen), and an emergency physician who is fellowship trained and board eligible in pediatric emergency medicine (Dr King). This outline is in no way intended to represent "all" or "the only" topics that should be included in a pediatric emergency medicine fellowship program. In many instances,
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only broad subject areas are presented rather than the numerous individual topics that could be subsumed under a given heading. Fellows who choose to pursue a particular area of interest in more depth undoubtedly will seek a greater level of detail than can be offered here. Program directors and teaching faculty should exercise their discretion in planning the most efficient use of the resources at their institution in addressing the particular educational needs of each fellow. PEDIAT RIC EMERGENCY MEDICINE CORE CONTE NT CATEGORIES 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0
11.0 12.0 13.0 14.0 15.0 16.0 17.0 18.0 19.0 20.0 21.0 22.0 23.0 24.0 25.0 26.0 27.0 28.0 29.0
Abdominal and Gastrointestinal Disorders Adolescent Medicine Anesthesia/Sedation/Pain Management Cardiovascular Disorders Child Abuse Cutaneous Disorders Endocrine, Metabolic, and Nutritional Disorders Environmental Disorders Fluid and Electrolyte Disorders Growth and Development Head and Neck Disorders Hematologic and Oncologic Disorders Immunologic Disorders Systemic Infectious Disorders Musculoskeletal Disorders (Nontraumatic) Neonatology Nervous System Disorders Pediatric Resuscitation Psychosocial Issues and Behavioral Disorders Renal Disorders Thoracic and Respiratory Disorders Toxicology and Clinical Pharmacology Traumatic Disorders Urogenital/Gynecologic Disorders Administrative Aspects of Pediatric Emergency Care Research Teaching Pediatric Prehospital Care and Interhospital Transport Procedures/Skills
PEDIATRIC EMERGENCY MEDICINE PROPOSED CARE CONTENT
1.0 Abdominal and Gastrointestinal Disorders 1.1 Congenital anomalies
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1.1.1 Tracheoesophageal fistula 1.1.2 Esophageal atresia 1.1.3 Esophageal vascular ring 1.2 Esophageal foreign bodies 1.3 Gastroesophageal reflux 1.4 Gastroenteritis 1.4.1 Viral 1.4.2 Bacterial 1.5 Umbilical lesions and cord separation 1.6 Constipation 1.7 Hernias 1.7.1 Inguinal 1.7.2 Umbilical 1.8 Inflammatory bowel disease 1.9 Colic 1.10 Cow~ milk allergy 1.11 Malabsorption syndromes 1.12 Biliary tract disease 1.13 Hepatitis 1.14 Aganglionic megacolon (Hirschsprung's disease) 1.15 Antibiotic-associated colitis 1.16 Rectal prolapse 1.17 Anorectal abscess 1.18 Gastrointestinal bleeding 1.18.1 Fissure 1.18.2 Varices 1.18.3 Gastritis 1.18.4 Colitis 1.18.5 Meckel's diverticulum 1.18.6 Polyp 1.18.7 Ulcer 1.19 Intestinal obstruction 1.19.1 Incarcerated hernia 1.19.2 Intussusception 1.19.3 Malrotation/volvulus 1.19.4 Pyloric stenosis 1.20 Acute abdominal pain 1.20.1 Appendicitis 1.20.2 Constipation 1.20.3 Pancreatitis 1.20.4 Henoch-Schonlein purpura 2.0 Adolescent Medicine 2.1 Pregnancy/sexuality 2.2 Contraception 2.3 Domestic violence 2.4 Teenage suicide 2.5 Substance abuse 3.0 Anesthesia/Sedation/Pain Management 3.1 Minor pain
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3.2 3.3 3.4 3.5
Nonpharmacologic management of pain Moderate and severe pain Conscious sedation Special techniques 3.5.1 Multiple trauma 3.5.2 Head trauma 3.5.3 Burns 3.5.4 Agitated patients 3.6 Drugs 3.6.1 Atropine (preparalytic) 3.6.2 Ketamine 3.6.3 Analgesics 3.6.3.1 Fentanyl 3.6.3.2 Morphine 3.6.3.3 Tetracaine-adrenalinecocaine (TAC) 3.6.4 Paralytics 3.6.4.1 Succinylcholine 3.6.4.2 Vecuronium 3.6.4.3 Pancuromum 3.6.5 Sedatives 3.6.5.1 Chloral hydrate 3.6.5.2 Midazolam 3.6.5.3 Nitrous oxide 3.6.5.4 Thiopental 4.0 Cardiovascular Disorders 4.1 Congenital heart disease 4.1.1 Tetralogy of Fallot 4.1.2 Transposition of the great arteries 4.1.3 Truncus arteriosus 4.1.4 Patent ductus arteriosus 4.1.5 Aortic coarctation 4.2 Hypoxemic attacks 4.3 Hypertension 4.4 Pediatric electrocardiogram interpretation 4.5 Cardiac arrhythmias 4.6 Congestive heart failure 4.7 Cardiotonic drugs 4.7.1 Adenosine 4.7.2 Furosemide 4.7.3 Nitroprusside 4.7.4 Verapamil 4.8 Pericardial disease 4.9 Myocarditis 4.10 Infectious endocarditis 5.0 Child Abuse 5.1 Neglect 5.2 Emotional abuse 5.3 Physical abuse 5.3.1 Burns
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CORE C O N T E N T King, et al
5.3.2 Skeletal injuries 5.3.3 Shaken baby syndrome 5.4 Sexual molestation/rape 5.5 Munchausen syndrome by proxy 6.0 Cutaneous Disorders 6.1 Atopic dermatitis 6.2 Alopecia 6.3 Ichthyosis 6.4 Seborrheic dermatitis 6.5 Contact dermatitis 6.6 Diaper dermatitis 6.7 Cutaneous drug reactions 6.8 Erythema multiforme 6,9 Stevens-Johnson syndrome 6.10 Scabies 6.11 Pediculosis 6.12 Fungal infections 6.13 Impetigo 6.14 Cellulitis 6.15 Urticaria 6.16 Pityriasis rosea 6.17 Panniculitis 6.18 Molluscum contagiosum 6.19 Cutaneous herpes infections 6.20 Staphylococcal scalded skin syndrome 6.21 Toxic epidermal necrolysis 6.22 Disorders of pigmentation 6.23 Vascular lesions 6.24 Cutaneous nevi 6.25 Viral exanthems 7.0 Endocrine, Metabolic, and Nutritional Disorders 7.1 Adrenal gland disorders 7.1.1 Adrenocortical insufficiency 7.1.2 Congenital adrenal hyperplasia 7.2 Diabetes/diabetic ketoacidosis 7.3 Hypoglycemia 7.4 Hypothalamus and pituitary gland disorders 7.4.1 Hypopituitarism 7.4.2 Syndrome of inappropriate antidiuretic hormone 7.4.3 Diabetes insipidus 7.4.4 Disorders of sexual development 7.5 Thyroid gland disorders 7.5.1 Hypothyroidism 7.5.2 Thyroiditis 7.5.3 Hyperthyroidism 7.5.4 Thyroid storm 7.6 Disorders of gonadal endocrine function 7.7 Parathyroid gland disorders 7.8 Inborn errors of metabolism
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7.9 Rickets 7.10 Nutritional requirements 7.10.1 Caloric requirements 7.10.2 Fluid and electrolyte requirements 7.10.3 Breast feeding 7.10.4 Formula feeding 7.11 Malnutrition and associated diseases 7.12 Vitamin deficiencies 8.0 Environmental Disorders 8.1 Heat illness 8.2 Hypothermia and cold injuries 8.3 Submersion incidents (drowning and neardrowning) 8.4 Electrical injuries 8.5 Envenomations 8.6 Radiation injuries 9.0 Fluid and Electrolyte Disorders 9.1 Normal homeostasis and associated disorders 9.1.1 Water 9.1.2 Sodium 9.1.3 Potassium 9.1.4 Calcium 9.1.5 Magnesium 9.1,6 Hydrogen ion 9.1.7 Bicarbonate 9.1.8 Chloride 9,1.9 Phosphorus 9.2 Parenteral fluid therapy 9.2.1 Maintenance therapy 9.2.2 Deficit therapy 9.2.3 Therapy in specific disease states 9.2.3.1 Diarrhea 9.2.3.2 Pyloric stenosis 9.2.3.3 Hypernatremic and hyponatremic dehydration 10.0 Growth and Development 10.1 Prenatal development 10.1.1 Fetal growth and maturity 10.1.2 Fetal distress 10.1.3 Maternal disease and the fetus 10.1.4 Identification and treatment of fetal disease 10.1.5 Genetic abnormalities and chromosomal syndromes 10.2 Premature and term-infant growth and development 10.3 Well-baby care 10.4 Vaccination 10.5 Parameters of physical growth and development
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10.6 10.7 10.8 10.9 10.10 10.11
Variability of body proportions Techniques of physical measurement Failure to thrive Parameters of neurodevelopmental status Parameters of psychosocial development Parameters of sexual development and behavior 10.12 Dental development 10.13 Early childhood 10.14 Preschool years 10.15 Early school years 10.16 Adolescence 11.0 Head and Neck Disorders 11.1 Periorbital/buccal cellulitis 11.2 Oral thrush 11.3 Acute necrotizing gingivostomatitis 11.4 Viral stomatitis 11.5 Soft-tissue lesions of the head and neck 11.60phthalmologic emergencies 11.6.1 Acute dacryocystitis 11.6.2 Amblyopia 11.6.3 Strabismus 11.6.4 Cataracts 11.6.5 Conjunctivitis 11.6.6 Retinal hemorrhage 11.6.7 Glaucoma 11.6.8 Optic neuritis 11.6.9 Orbital cellulitis 11.70torhinolaryngologic emergencies 11.7.1 Aural/nasal/pharyngeal foreign bodies 11.7.2 Caustic ingestions 11.7.3 Inhalation injuries 11.7.4 Cholesteatoma 11.7.5 Epistaxis 11.7.6 Cervical adenitis 11.7.7 Epiglottitis 11.7.8 Laryngotracheobronchitis (croup) 11.7.9 Bacterial tracheitis 11.7.10 Mastoiditis 11.7.11 Pharyngitis 11.7.12 Otitis externa 11.7.13 Otitis media 11.7.14 Peritonsillar abscess 11.7.15 Retropharyngeal abscess 11.7.16 Sinusitis 11.7.17 Sleep apnea 11.7.18 Subglottic stenosis 11.8 Dental emergencies 11.8.1 Milk bottle caries 11.8.2 Postextraction complications
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11.8.2.1 Hemorrhage 11.8.2.2 Infection 11.8.2.3 Alveolar osteitis 11.8.3 Dentoalveolar abscess 11.8.4 Pericoronitis 12.0 Hematologic and Oncologic Disorders 12.1 Anemia 12.1.1 Inadequate production of red blood cells 12.1.2 Microcytic anemias 12.1.3 Hemolytic anemias 12.2 Polycythemia 12.3 Pancytopenias 12.4 Neutropenia 12.5 Diseases of the lymphatic system 12.6 Disseminated intravascular coagulation 12.7 Henoch-Schonlein purpura 12.8 Hemolytic uremic syndrome 12.9 Immune-mediated neonatal purpura 12.10 Nonimmune thrombocytopenia and abnormalities of platelet function 12.11 Hemorrhagic and thrombotic diseases 12.11.1 Hemophilia 12.11.2 Thrombotic thrombocytopenic purpura 12.11.3 Idiopathic thrombocytopenic purpura 12.12 Sickle hemoglobinopathies 12.13 Thalassemia 12.14 Methemoglobinemia 12.15 Transfusion reactions 12.16 Major childhood cancers 12.16.1 Leukemia 12.16.2 Non-Hodgkin's lymphomas 12.16.3 Hodgkin's disease 12.16.4 Histiocytic diseases 12.16.5 Rhabdomyosarcoma 12.16.6 Neuroblastoma 12.16.7 Wilm's tumor 12 17 Chemotherapeutic drug toxicities 13.0 Immunologic Disorders 13.1 Immunodeficiency syndromes 13.1.1 Human immunodeficiency virus disease 13.1.2 Functional hyposplenism 13.1.3 Drug-induced disorders 13.2 Allergic emergencies 13.2.1 Asthma 13.2.2 Anaphylaxis 13.2.3 Serum sickness
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13.2.4 Allergic rhinitis 13.3 Transplantation emergencies 14.0 Systemic Infectious Disorders 14.1 Antibiotic therapy principles 14.2 Communicable childhood diseases and infection control 14.3 Systemic infections 14.3.1 Sepsis 14.3.2 Septic shock 14.3.3 Measles 14.3.4 Lyme disease 14.3.5 Cat scratch disease 14.3.6 Kawasaki disease 14.3.7 Rubella 14.3.8 Varicella-zoster 14.3.9 Roseola 14.3.10 Infectious mononucleosis 14.3.11 Erythema infectiosum (fifth disease) 14.3.12 Infant botulism 14.3.13 Tetanus 14.3.14 Toxic shock syndrome 14.3.15 Rocky Mountain spotted fever 14.3.16 Rabies 14.4 Occult bacteremia 14.5 Parasitic infections 14.6 Fungal infections 14.7 Diseases associated with specific infectious agents 14.7.1 Bacteria 14.7.1.1 Haemophilus influenzae 14.7.1.2 Chlamydia 14.7.1.3 Group B Streptococcus 14.7.1.4 Listeria 14.7.1.5 Neisseria gonorrhoeae 14.7.1.6 Neisseria meningitidis 14.7.1.7 Staphylococcus aureus 14.7.1.8 Streptococcuspneumoniae 14.7.2 Viruses 14.7.2.1 Epstein-Barr virus 14.7.2.2 Cytomegalovirus 14.7.2.3 Influenza 14.7.2.4 Parainfluenza 14.7.2.5 Adenovirus 14.7.2.6 Enterovirus 14.7.2.7 Human immunodeficiency virus 14.7.2.8 Herpes 14.7.2.9 Respiratory syncytial virus 14.7.2.10 Rotavirus 14.7.3 Other
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14,7.3.1 Myoplasm 14.7.3.2 Chlamydia 15.0 Musculoskeletal Disorders (Nontraumatic) 15.10steomyelitis 15.2 Septic arthritis 15.3 Metabolic bone abnormalities 15.4 Achondroplasia 15.5 Marfan's syndrome 15.60sgood-Schlatter disease 15.70steochondritis dissecans 15.8 Spine disorders i5.8.1 Kyphosis 1 5 8 2 Scoliosis 15.8.3 Lordosis 15,8.4 Spondylolisthesis 15.8.5 Diskitis 15.9 Hip disorders 15.9.1 Perthes disease 15.9.2 Slipped capital femoral epiphysis 15.9.3 Toxic synovitis 15.10 Torticollis 15.11 Muscular dystrophies I5.12 Myopathies 15.13 Myositis 15.14 Rheumatologic disorders 15.14.1 Inflammatory arthritides 15.14.2 Connective tissue diseases 15.14.3 Juvenile rheumatoid arthritis 15.14.4 Rheumatic fever 16.0 Neonatology 16.1 Assessment of high-risk infants 16,1.1 Multiple pregnancies 16,1.2 Prematurity and intrauterine growth retardation 16.1.3 Post-term infants 16.1.4 Large for gestational age 16.1.5 Maternal drug use 16.2 Birth injuries 16.3 Congenital anomalies 16.4 Neonatal resuscitation 16.4.1 Asphyxia 16.4.2 Heart rate 16.4.3 Medications 16.4.3.1 Glucose 16.4.3.2 Naloxone 16.4.3.3 Epinephrine 16.4.3.4 Atropine 16.4.4 Postresuscitation management 16.4.5 Special situations 16.4.5.1 Pneumothorax
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16.4.5.2 Meconium aspiration 16.4.5.3 Diaphragmatic hernia 16.4.5.4 Omphalocele/ gastroschisis 16.4.5.5 Tracheoesophageal fistula 16.4.5.6 Choanal atresia 16.5 Apnea of prematurity 16.6 Neonatal seizures 16.7 TORCH syndrome 16.8 Respiratory distress syndrome 16.9 Neonatal dysrhythmias and cardiac anomalies 16.10 Gastrointestinal 16.10.1 Necrotizing enterocolitis 16.10.2 Midgut volvulus 16.1i Neonatal sepsis 16.12 Transient tachypnea of the newborn 17.0 Nervous System Disorders 17.1 Congenital anomalies of the nervous system 17.1.1 Spina bifida occulta 17.1.2 Hydrocephalus 17.1.3 Craniosynostosis 17.2 Ataxia 17.3 Acute encephalopathies 17.3.1 Acquired immunodeficiency disease encephalopathy 17.3.2 Lead encephalopathy 17.3.3 Hypertensive encephalopathy 17.4 Coma 17.5 Headache 17.5.1 Migraine 17.5.2 Pseudotumor cerebri 17.6 Increased intracranial pressure 17.7 Reye's syndrome 17.8 Seizures 17.8.1 Febrile 17.8.2 Nonfebrile 17.8.3 Neonatal 17.8.4 Status epilepticus 17.9 Meningitis 17.9.1 Aseptic 17.9.2 Bacterial 17.10 Encephalitis 17.11 Brain abscess 17.12 Neurocutaneous syndromes 17.12.1 Neurofibromatosis 17.12.2 Tuberous sclerosis 17.13 Syncope 17.14 Stroke syndromes 17.15 Arteriovenous malformation and aneurysm
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17.16 Coma scales for infants/children 17.17 Neoplasm 17.18 Disorders of motor function 17.18.1 Acute hemiplegia of childhood 17.18.2 Transverse myelitis 17.18.3 Acute polyneuritis 17.18.4 Myasthenia gravis 17.18.5 Guillain-Barre syndrome 17.18.6 Myoglobinuria 17.19 Disorders of balance and coordination 17.19.1 Acute cerebellar ataxia 17.19.2 Viral labyrinthitis 17.19.3 Benign paroxysmal vertigo 17.20 Cranial nerve dysfunction 17.20.1 Optic neuritis 17.20.20culomotor palsy 17.20.3 Abducens palsy 17.20.4 Bell's palsy 17.21 Neurosurgical emergencies 17.21.1 Ventriculoperitoneal shunt malfunction 17.21.2 Ventriculoperitoneal shunt refection 17.21.3 Intracranial hemorrhage 17.21.4 Spinal cord compression 18.0 Pediatric Resuscitation 18.1 Cardiac arrest 18.2 Drugs 18.2.1 Atropine 18.2.2 Bretylium 18.2.3 Dobutamine 18.2.4 Dopamine 18.2.5 Epinephrine 18.2.6 Lidocaine 18.2.7 Magnesium 18.3 Shock 18.3.1 Hypovolemia t8.3.2 Distributive shock 18.3.3 Cardiogenic shock 18.3.4 Anaphylaxis 18.4 Postresuscitation management 18.5 Stabilization and preparation for transport 18.6 Discontinuation of life support 18.7 Cerebral resuscitation 18.8 Sudden infant death syndrome 19.0 Psychosocial Issues and Behavioral Disorders 19.1 Attention deficit disorder 19.2 Disruptive behavioral disorders 19.3 Eating disorders 19.4 Enuresis 19.5 Encopresis
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19.6 19.7 19.8 19.9 19.10 19.11 19.12 19,13 19.14
Suicide and attempted suicide Hyperventilation syndrome Tics School phobia Breath-holding spells Psychosomatic complaints Acute psychosis Anxiety disorders Affective disorders 19.14.1 Childhood depression 19.14.2 Dysthymic disorder 19.14.3 Bipolar disorder 19.15 Autism 19.16 Conversion reactions 19.17 Family considerations regarding death and catastrophic illness Renal Disorders 20.0 20.1 Calculus disease 202 Congenital kidney abnormalities 20.2.1 Polycystic kidney disease 20.2.2 Horseshoe kidney 20.2.3 Congenital absence of kidney 20.3 Nephrotic syndrome 20.4 Hemolytic-uremic syndrome 20.5 Glomerulonephrids 20.6 Pyelonephritis 207 Renal tubular acidosis 20.8 Renal failure 20.9 Cystitis 20.10 Disorders of the bladder 20.11 Vesicoureteral reflux 20.12 Posterior ureteral valves 21.0 Thoracic and Respiratory Disorders 21.1 Congenital anomalies of the trachea and upper airway 21.2 Airway foreign bodies 21.3 Acute respiratory failure 21.4 Smoke inhalation 21.5 Bronchitis 2t.6 Bronchiolitis 21.7 Pneumonia 21.7.1 Viral 21.7.2 Bacterial 21.7.3 Aspiration 21.7.4 Chlamydia 21.7.5 Mycoplasma 21.8 Bronchopulmonary dysplasia 21.9 Adult respiratory distress syndrome 21.10 Asthma 2 t. 11 Congenital lung anomalies
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21.12 Congenital lobar emphysema 21.13 Diaphragmatic defects 21.14 Pneumothorax 21.15 Pneumomediastinum 21.16 Pulmonary edema 21.17 Pleuritis 21.18 Sarcoidosis 21.19 Cystic fibrosis 22.0 Toxicology and Clinical Pharmacology 22.1 Prevention and parent education (childproofing the home) 22.2 General approach to the poisoned child 22.3 Major toxic ingestions and exposures 22.3.1 Acetaminophen 22.3.2 Alcohols 22.3.3 Antihistamines 22.3.4 Anticoagulants 22.3.5 Anticonvulsants 22.3.6 Aspirin 22.3,7 Carbon monoxide 22.3.8 Cardiac drugs 22.3.9 Caustic agents 22.3.10 Cocaine 22.3.11 Disc batteries 22.3.12 Hallucinogens 22.3.13 Heavy metals and chelation 22.3.14 Household poisons 22.3.15 Hydrocarbons 22.3.16 Iron 22.3.17 Lead 22.3.18 Methemoglobinemia 22.3.19 Oral hypoglycemics 22.3.20 Organophosphate/carbamate 22.3.21 Phenothiazines 22.3.22 Salicylates 22.3.23 Theophylline 22.3.24 Tricyclic antidepressants 22.4 Effects of age on pediatric poisonings 22.5 Drug interactions/adverse reactions 22.5.1 Drug fever 22.5.2 Serum sickness 23.0 Traumatic Disorders 23.1 Injury prevention 23.2 Major trauma resuscitation 23.3 Diagnosis and management by anatomic areas 23.3.1 Head and neck 23.3.1.1 Ocular injuries 23.3.1.2 Oral burns 23.3.1.3 Tooth avulsion 23.3.1.4 Tooth displacement
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23.3.1.5 Tooth fractures 23.3.1.6 Cerebral herniation syndromes 23.3.1.7 Intracranial hemorrhage syndromes 23.3.1.8 Skull fractures 23.3.1.9 Concussion 23.3.1.10 Cerebral contusion 23.3.1.11 Cervical-spine fractures 23.3.1.12 Spinal-cord injuries 23.3.2 Chest 23.3.2.1 Tracheal and bronchial injuries 23.3.2.2 Esophageal injuries 23.3.2.3 Rib fractures 23.3.2.4 Cardiac tamponade 23.3.2.5 Flail chest 23.3.2.6 Open-chest injuries 23.3.2.7 Hemo/pneumothorax 23.3.3 Abdomen 23.3.3.1 Duodenalhematoma 23.3.3.2 Solid viscus injury 23.3.3.3 Hollow viscus injury 23.3.4 Genitourinary 23.3.4.1 Renal injuries 23.3.4.2 Urethral injuries 23.3.4.3 Testicular trauma 23.3.4.4 Straddle injuries 23.3.5 Extremity 23.3.5.1 Childhood fractures 23.3.5.1.1 Epiphyseal (Salter-Harris) 23.3.5.1,2 Toms 23.3.5.1,3 Greenstick 23.3.5.1,4 Supracondylar 23.3.5.1.5 "Toddler's" fracture 23.3.5.2 Radialhead subluxation (nursemaid's elbow) 24.0 Urogenital/Gynecologic Disorders 24.1 Genital tract/Female 24.1.1 Congenital vaginal obstruction 24.1.2 Ovarian torsion 24.1.3 Vulvovaginitis 24.1.4 Hematocolpos 24.1.5 Hydrocolpos 24.1.6 Labial adhesion 24.1.7 Urethral prolapse 24.2 Genital tract/Male 24.2.1 Penile disorders
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24.2.1.1 Balanoposthitis 24.2.1.2 Phimosis 24.2.1.3 Paraphimosis 24.2.1.4 Priapism 24.2.2 Testicular disorders 24.2.2.1 Acute scrotum 24.2.2.1.1 Epididymitis 24.2.2.1.2 Orchitis 24.2.2.1.3 Testicular torsion 24.2.2.1.4 Testicular tumor 24.2.2.1.5 Torsion of the appendix testis 24.2.2.2 Hydrocele 24.2.2.3 Varicocele 24.2.2.4 Undescended testis 24.3 Sexually transmitted diseases 24.4 Breast masses 24.5 Mastitis 25.0 Administrative Aspects of Pediatric Emergency Care 25.1 Institutional affiliations 25.2 Departmental administration 25.2.1 Patient services 25.2.2 Personnel management 25.2.3 Quality assurance 25.2.4 Medical records 25.3 Ethics 25,4 Child advocacy 25,5 Hospital administration and organizational structures 25,6 Third-party reimbursement 25.7 Legal aspects of pediatric emergency care 25.7.1 Telephone advice 25.7.2 Consent and refusal of consent 25.7.3 Leaving against medical advice 25.7.4 Liability 25.8 Political interest groups 25.9 Public health issues 25.10 Public relations 25.11 Medical organizations 25.11.1 General emergency medicine 25.11.2 Pediatric emergency medicine 25.12 Practice management 25.12.1 Structure 25.12.2 Scheduling 25.12.3 Billing/reimbursement 25,12.4 Contract negotiation 26.0 Research 26.1 Biostatistics 26.2 Epidemiology 26.3 Critical evaluation of the medical literature
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26.4 Computer applications 26.5 Research methodology 26.5.1 Types of studies 26.5.2 Study design and implementation 26.6 Bench techniques 26.7 Grant applications 27.0 Teaching 27.1 Principles and practice 27.1.1 Bedside 27.1.2 Small-group 27.1.3 Workshops 27.1.4 Lectures 27.1.5 Scientific presentations 27.2 Preparing teaching tools 27.3 Use of library services 28.0 Pediatric Prehospital Care and Interhospital Transport 28.1 Access to care 28.2 Services and governance of emergency medical services for children (EMS-C) systems 28.3 Communications 28.4 Medical command 28.5 Preparation tor interhospital transport 28.6 Selecting a mode of transport 29.0 Procedures/Skills 29.1 General emergency procedures 29.1.1 Restraint techniques 29.1.2 Intramuscular injections 29.1.3 Use of pediatric monitoring and resuscitation equipment 29.1.4 Assessment of vital signs 29.2 Cardiopulmonary life support procedures 29.2.1 Basic life support 29.2.2 Aiiway adjuncts and oxygen delivery 29.2.3 Bag-valve-mask ventilation 29.2.4 Tracheal intubation 29.2.5 Percutaneous transtracheal ventilation 29.2.6 Central venous access 29.2.7 Venous cutdown catheterization 29.2.8 Intraosseous infusion 29.3 Trauma life support procedures 29.3.1 Cervical-spine immobilization and imaging techniques 29.3.2 Cricothyrotomy 29.3.3 Diagnostic peritoneal lavage 29.3.4 Thoracotomy 29.3.5 Needle thoracostomy and chest tube placement 29.4 Anesthesia and sedation procedures 29.4.1 Rapid-sequence induction 29.4.2 Conscious sedation
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29.4.3 29.5 Special 29.5.1 29.5.2 29.5.3 29.5.4
Pain management techniques procedures for neonates Neonatal resuscitation procedures Managing meconium aspiration Umbilical vessel catheterization Emergency management of congenital anomalies 29.5.5 Heel sticks 29.6 Neurologic and neurosurgical procedures 29.6.1 Lumbar puncture 29.6.2 Evaluation of ventriculoperitoneal shunt function 29.6.3 Diagnostic and therapeutic tap of the ventriculoperitoneal shunt 29.6.4 Subdural tap 29.6.5 Ventricular tap 29.70phthalmologic procedures 29.7.1 Use of the slit lamp 29.7.2 Tonometry 29.80tolaryngologic procedures 29.8.1 Management of foreign bodies of the upper airway, nose, and ear 29.8.2 Tympanocemesis 29.8.3 Use of the flexible fiberoptic laryngoscope 29.9 Dental procedures 29.9.1 Management of soft-tissue injuries of the mouth and perioral area 29.9.2 Management of dental fractures and avulsions 29.10 Cardiovascular procedures 29.10.1 Obtaining the pediatric electrocardiogram 29.10.2 Maneuvers for converting stable supraventricular tachycardias 29.10.3 Accessing indwelling lines 29.10.4 Arterial line insertion 29.11 Pulmonary procedures 29.11.1 End-tidal/transcutaneous carbon dioxide monitoring 29.11.2 Peak flow measurement 29.11.3 Use of nebulizers, spacers, and multidose inhalers 29.11.4 Tracheal suctioning 29.11.5 Replacement of tracheostomy cannula 29.11.6 Thoracentesis 29.11.7 Use of pediatric mechanical ventilators 29.12 Gastrointestinal procedures
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29.13
29.14
29.15
29.16
29.17
29.18 29.19
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29.12.1 Management of esophageal foreign bodies 29.12.2 Paracentesis 29.12.3 Hernia reduction 29.12.4 Umbilical granuloma care 29.12.5 Oral rehydration 29.12.6 Rectal prolapse reduction 29.12.7 Management of gastrointestinal bleeding Genitourinary procedures 29.13.1 Prepubertal rectal, vaginal examination 29.13.2 Adolescent vaginal examination 29.13.3 Forensic examination of the sexual assault victim 29.13.4 Bladder catheterization 29.13.5 Suprapubic bladder aspiration 29.13.6 Management of testicular torsion 29.13.7 Management of paraphimosis 29.13.8 Zipper injuries 29.13.9 Removing vaginal foreign bodies Orthopedic procedures 29.14.1 Joint immobilization techniques for infants and children 29.14.2 Reduction of joint dislocations/ subluxations Minor surgical procedures 29.15.1 Management of fingertip avulsions and nailbed injuries 29.15.2 Removal of a hair tourniquet Laboratory skills 29.16.1 Obtaining biologic specimens 29.16.2 Common emergency department laboratory tests 29.16.3 Skin testing Toxicologic/environmental procedures 29.17.1 Gastric emptying 29.17.2 Whole-bowel irrigation 29.17.3 Cooling and warming procedures Emergency department ultrasonography for infants and children Transport procedures 29.19.1 Ground transport procedures 29.19.2 Aeromedical transport procedures
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REFERENCES 1 American Collegeof EmergencyPhysicians,American Boardof EmergencyMedicine, Society for Academic EmergencyMedicine: Core content for emergencymedicine.Ann EmergMed 1991;20:920-934. 2. Curriculum SubcommitteeSection of EmergencyMedicine, American Academyof Pediatrics: Pediatric EmergencyMedicine (PEM)Fellowship Curriculum Statement. PediatrEmergCare 1991;7:48-53. 3. King C, Nilsen GJ, Henretig FM, et al: Proposedfellowship training program in pediatric emergencymedicinefor emergencymedicine graduates.Ann EmergMed 1993;22:542-546. The authors thank Drs Don Yealy and Dan Issacman for reviewing this manuscript.
Reprint no. 47/1/59816 Address for reprints: Christopher King, MD Division of EmergencyMedicine 200 Lothrop Street Room D-L45 Pittsburgh, Pennsylvania15213
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Proposed Core Content for Pediatric Emergency Medicine Fellowship Training of Emergency Medicine Graduates From the Division of Emergency Medicine, University of Pittsburgh;* the Department of Pediatrics, Children's Hospital of Pittsburgh;t and the Department of Emergency Medicine, Medical College of Pennsylvania.
Christopher King, MD *t Gwendolyn J Nilsen, MD* Fred M Henrntig, MD* David K Wagner, MD*
Receivedfor publication December 6, 1993. Revision received March 17, 1994. Acceptedfor publication March 27, 1994. Copyright 9 by the American College of Emergency Physicians.
The establishment of pediatric emergency medicine as a subspecialty of emergency medicine has engenderedthe need for closer examination and development of guidelines for fellowship training. Core content and curriculum documents pertaining to fellowship training in pediatric emergency medicine for pediatric graduates have been published previously. However, the educational needs of emergency medicine graduates for such training are significantly different from those of pediatric graduates in several important respects. We believe that emergency physicians should take an active role in the creation and refinement of educational guidelines for fellowship training in pediatric emergency medicine for emergency medicine graduates. For this reason, we present a proposed core content outline in the hope that it will serve to foster this process. [King C, Nilsen GJ, Henretig FM, Wagner DK: Proposed core content for pediatric emergency medicine fellowship training of emergency medicine graduates. Ann Emerg/WedNovember 1994;24:825-835.] INTRODUCTION Pediatric emergency medicine is the first subspeciahy to be established by the American Board of Emergency Medicine. The initial subboard examination was administered in November 1992. Eligibility requirements for subspeciahy certification by emergency physicians can be fulfilled either through fellowship training and/or defined practice activities or through dual certification m pediatrics and emergency medicine until July 1, 1996. After that date, completion of a formal 2-year fellowship program will be required for board eligibility. All pediatric graduates who seek board certification in this subspeciahy as granted by the American Board of Pediatrics will be required to complete 3 years of fellowship training, as opposed to the prior requirement of 2 years, beginning in 1995. The primary purpose of this proposed core content" outline is to aid the definition of this new subspeciahy in
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CORE CONTENT
,Kinget al
emergency medicine. Our hope is that this outline will serve as a resource for the establishment and further development of pediatric emergency medicine fellowship programs within academic divisions/departments of emergency medicine, as well as for pediatric-based programs that recruit emergency medicine graduates. We also wish to provide a potential "working document" for future committees officially charged with fellowship curriculum development in pediatric emergency medicine for emergency medicine graduates. Such a committee recently has been established for this purpose by the American Academy of Pediatrics. Selection of topics to be included in this core content outline was based on a number of defined criteria. Potential topics for consideration were taken from standard pediatric and emergency medicine reference texts, the core content of emergency medicine, ~ and the core content of pediatric emergency medicine for pediatric graduates. 2 For reasons discussed previously, 3 the core content requirements in pediatric emergency medicine for emergency medicine graduates were thought to be similar in many ways to those published for pediatric graduates, but substantially different in others. The principal criteria used to evaluate potential topics were as follows: areas that are important in the practice of pediatric emergency medicine that are not covered adequately in an emergency medicine residency (eg, growth and development, and nutrition); areas covered during an emergency medicine residency that are important enough in pediatric emergency medicine to require additional emphasis (eg, pediatric resuscitation and child abuse); and areas that are well covered from an adult perspective during an emergency medicine residency but that differ significantly with regard to pediatric applications (eg, psychobehavioral issues, and sedation and pain management). Topic selection was based on consensus agreement of the four authors during extensive discussions in meetings held over approximately 8 months. A primary limitation of this document is the comparatively small size of the participant group. However, we believe that the diverse experience of the authors in education and pediatric emergency medicine fellowship training is such that they are qualified to produce this first effort. The participants included a pediatrician who is board certified in pediatric emergency medicine (Dr Henretig), a pediatric surgeon and emergency physician (Dr Wagner), an emergency physician with fellowship training in teaching and education (Dr Nilsen), and an emergency physician who is fellowship trained and board eligible in pediatric emergency medicine (Dr King). This outline is in no way intended to represent "all" or "the only" topics that should be included in a pediatric emergency medicine fellowship program. In many instances,
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only broad subject areas are presented rather than the numerous individual topics that could be subsumed under a given heading. Fellows who choose to pursue a particular area of interest in more depth undoubtedly will seek a greater level of detail than can be offered here. Program directors and teaching faculty should exercise their discretion in planning the most efficient use of the resources at their institution in addressing the particular educational needs of each fellow. PEDIAT RIC EMERGENCY MEDICINE CORE CONTE NT CATEGORIES 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0
11.0 12.0 13.0 14.0 15.0 16.0 17.0 18.0 19.0 20.0 21.0 22.0 23.0 24.0 25.0 26.0 27.0 28.0 29.0
Abdominal and Gastrointestinal Disorders Adolescent Medicine Anesthesia/Sedation/Pain Management Cardiovascular Disorders Child Abuse Cutaneous Disorders Endocrine, Metabolic, and Nutritional Disorders Environmental Disorders Fluid and Electrolyte Disorders Growth and Development Head and Neck Disorders Hematologic and Oncologic Disorders Immunologic Disorders Systemic Infectious Disorders Musculoskeletal Disorders (Nontraumatic) Neonatology Nervous System Disorders Pediatric Resuscitation Psychosocial Issues and Behavioral Disorders Renal Disorders Thoracic and Respiratory Disorders Toxicology and Clinical Pharmacology Traumatic Disorders Urogenital/Gynecologic Disorders Administrative Aspects of Pediatric Emergency Care Research Teaching Pediatric Prehospital Care and Interhospital Transport Procedures/Skills
PEDIATRIC EMERGENCY MEDICINE PROPOSED CARE CONTENT
1.0 Abdominal and Gastrointestinal Disorders 1.1 Congenital anomalies
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1.1.1 Tracheoesophageal fistula 1.1.2 Esophageal atresia 1.1.3 Esophageal vascular ring 1.2 Esophageal foreign bodies 1.3 Gastroesophageal reflux 1.4 Gastroenteritis 1.4.1 Viral 1.4.2 Bacterial 1.5 Umbilical lesions and cord separation 1.6 Constipation 1.7 Hernias 1.7.1 Inguinal 1.7.2 Umbilical 1.8 Inflammatory bowel disease 1.9 Colic 1.10 Cow~ milk allergy 1.11 Malabsorption syndromes 1.12 Biliary tract disease 1.13 Hepatitis 1.14 Aganglionic megacolon (Hirschsprung's disease) 1.15 Antibiotic-associated colitis 1.16 Rectal prolapse 1.17 Anorectal abscess 1.18 Gastrointestinal bleeding 1.18.1 Fissure 1.18.2 Varices 1.18.3 Gastritis 1.18.4 Colitis 1.18.5 Meckel's diverticulum 1.18.6 Polyp 1.18.7 Ulcer 1.19 Intestinal obstruction 1.19.1 Incarcerated hernia 1.19.2 Intussusception 1.19.3 Malrotation/volvulus 1.19.4 Pyloric stenosis 1.20 Acute abdominal pain 1.20.1 Appendicitis 1.20.2 Constipation 1.20.3 Pancreatitis 1.20.4 Henoch-Schonlein purpura 2.0 Adolescent Medicine 2.1 Pregnancy/sexuality 2.2 Contraception 2.3 Domestic violence 2.4 Teenage suicide 2.5 Substance abuse 3.0 Anesthesia/Sedation/Pain Management 3.1 Minor pain
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3.2 3.3 3.4 3.5
Nonpharmacologic management of pain Moderate and severe pain Conscious sedation Special techniques 3.5.1 Multiple trauma 3.5.2 Head trauma 3.5.3 Burns 3.5.4 Agitated patients 3.6 Drugs 3.6.1 Atropine (preparalytic) 3.6.2 Ketamine 3.6.3 Analgesics 3.6.3.1 Fentanyl 3.6.3.2 Morphine 3.6.3.3 Tetracaine-adrenalinecocaine (TAC) 3.6.4 Paralytics 3.6.4.1 Succinylcholine 3.6.4.2 Vecuronium 3.6.4.3 Pancuromum 3.6.5 Sedatives 3.6.5.1 Chloral hydrate 3.6.5.2 Midazolam 3.6.5.3 Nitrous oxide 3.6.5.4 Thiopental 4.0 Cardiovascular Disorders 4.1 Congenital heart disease 4.1.1 Tetralogy of Fallot 4.1.2 Transposition of the great arteries 4.1.3 Truncus arteriosus 4.1.4 Patent ductus arteriosus 4.1.5 Aortic coarctation 4.2 Hypoxemic attacks 4.3 Hypertension 4.4 Pediatric electrocardiogram interpretation 4.5 Cardiac arrhythmias 4.6 Congestive heart failure 4.7 Cardiotonic drugs 4.7.1 Adenosine 4.7.2 Furosemide 4.7.3 Nitroprusside 4.7.4 Verapamil 4.8 Pericardial disease 4.9 Myocarditis 4.10 Infectious endocarditis 5.0 Child Abuse 5.1 Neglect 5.2 Emotional abuse 5.3 Physical abuse 5.3.1 Burns
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CORE C O N T E N T King, et al
5.3.2 Skeletal injuries 5.3.3 Shaken baby syndrome 5.4 Sexual molestation/rape 5.5 Munchausen syndrome by proxy 6.0 Cutaneous Disorders 6.1 Atopic dermatitis 6.2 Alopecia 6.3 Ichthyosis 6.4 Seborrheic dermatitis 6.5 Contact dermatitis 6.6 Diaper dermatitis 6.7 Cutaneous drug reactions 6.8 Erythema multiforme 6,9 Stevens-Johnson syndrome 6.10 Scabies 6.11 Pediculosis 6.12 Fungal infections 6.13 Impetigo 6.14 Cellulitis 6.15 Urticaria 6.16 Pityriasis rosea 6.17 Panniculitis 6.18 Molluscum contagiosum 6.19 Cutaneous herpes infections 6.20 Staphylococcal scalded skin syndrome 6.21 Toxic epidermal necrolysis 6.22 Disorders of pigmentation 6.23 Vascular lesions 6.24 Cutaneous nevi 6.25 Viral exanthems 7.0 Endocrine, Metabolic, and Nutritional Disorders 7.1 Adrenal gland disorders 7.1.1 Adrenocortical insufficiency 7.1.2 Congenital adrenal hyperplasia 7.2 Diabetes/diabetic ketoacidosis 7.3 Hypoglycemia 7.4 Hypothalamus and pituitary gland disorders 7.4.1 Hypopituitarism 7.4.2 Syndrome of inappropriate antidiuretic hormone 7.4.3 Diabetes insipidus 7.4.4 Disorders of sexual development 7.5 Thyroid gland disorders 7.5.1 Hypothyroidism 7.5.2 Thyroiditis 7.5.3 Hyperthyroidism 7.5.4 Thyroid storm 7.6 Disorders of gonadal endocrine function 7.7 Parathyroid gland disorders 7.8 Inborn errors of metabolism
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7.9 Rickets 7.10 Nutritional requirements 7.10.1 Caloric requirements 7.10.2 Fluid and electrolyte requirements 7.10.3 Breast feeding 7.10.4 Formula feeding 7.11 Malnutrition and associated diseases 7.12 Vitamin deficiencies 8.0 Environmental Disorders 8.1 Heat illness 8.2 Hypothermia and cold injuries 8.3 Submersion incidents (drowning and neardrowning) 8.4 Electrical injuries 8.5 Envenomations 8.6 Radiation injuries 9.0 Fluid and Electrolyte Disorders 9.1 Normal homeostasis and associated disorders 9.1.1 Water 9.1.2 Sodium 9.1.3 Potassium 9.1.4 Calcium 9.1.5 Magnesium 9.1,6 Hydrogen ion 9.1.7 Bicarbonate 9.1.8 Chloride 9,1.9 Phosphorus 9.2 Parenteral fluid therapy 9.2.1 Maintenance therapy 9.2.2 Deficit therapy 9.2.3 Therapy in specific disease states 9.2.3.1 Diarrhea 9.2.3.2 Pyloric stenosis 9.2.3.3 Hypernatremic and hyponatremic dehydration 10.0 Growth and Development 10.1 Prenatal development 10.1.1 Fetal growth and maturity 10.1.2 Fetal distress 10.1.3 Maternal disease and the fetus 10.1.4 Identification and treatment of fetal disease 10.1.5 Genetic abnormalities and chromosomal syndromes 10.2 Premature and term-infant growth and development 10.3 Well-baby care 10.4 Vaccination 10.5 Parameters of physical growth and development
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10.6 10.7 10.8 10.9 10.10 10.11
Variability of body proportions Techniques of physical measurement Failure to thrive Parameters of neurodevelopmental status Parameters of psychosocial development Parameters of sexual development and behavior 10.12 Dental development 10.13 Early childhood 10.14 Preschool years 10.15 Early school years 10.16 Adolescence 11.0 Head and Neck Disorders 11.1 Periorbital/buccal cellulitis 11.2 Oral thrush 11.3 Acute necrotizing gingivostomatitis 11.4 Viral stomatitis 11.5 Soft-tissue lesions of the head and neck 11.60phthalmologic emergencies 11.6.1 Acute dacryocystitis 11.6.2 Amblyopia 11.6.3 Strabismus 11.6.4 Cataracts 11.6.5 Conjunctivitis 11.6.6 Retinal hemorrhage 11.6.7 Glaucoma 11.6.8 Optic neuritis 11.6.9 Orbital cellulitis 11.70torhinolaryngologic emergencies 11.7.1 Aural/nasal/pharyngeal foreign bodies 11.7.2 Caustic ingestions 11.7.3 Inhalation injuries 11.7.4 Cholesteatoma 11.7.5 Epistaxis 11.7.6 Cervical adenitis 11.7.7 Epiglottitis 11.7.8 Laryngotracheobronchitis (croup) 11.7.9 Bacterial tracheitis 11.7.10 Mastoiditis 11.7.11 Pharyngitis 11.7.12 Otitis externa 11.7.13 Otitis media 11.7.14 Peritonsillar abscess 11.7.15 Retropharyngeal abscess 11.7.16 Sinusitis 11.7.17 Sleep apnea 11.7.18 Subglottic stenosis 11.8 Dental emergencies 11.8.1 Milk bottle caries 11.8.2 Postextraction complications
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11.8.2.1 Hemorrhage 11.8.2.2 Infection 11.8.2.3 Alveolar osteitis 11.8.3 Dentoalveolar abscess 11.8.4 Pericoronitis 12.0 Hematologic and Oncologic Disorders 12.1 Anemia 12.1.1 Inadequate production of red blood cells 12.1.2 Microcytic anemias 12.1.3 Hemolytic anemias 12.2 Polycythemia 12.3 Pancytopenias 12.4 Neutropenia 12.5 Diseases of the lymphatic system 12.6 Disseminated intravascular coagulation 12.7 Henoch-Schonlein purpura 12.8 Hemolytic uremic syndrome 12.9 Immune-mediated neonatal purpura 12.10 Nonimmune thrombocytopenia and abnormalities of platelet function 12.11 Hemorrhagic and thrombotic diseases 12.11.1 Hemophilia 12.11.2 Thrombotic thrombocytopenic purpura 12.11.3 Idiopathic thrombocytopenic purpura 12.12 Sickle hemoglobinopathies 12.13 Thalassemia 12.14 Methemoglobinemia 12.15 Transfusion reactions 12.16 Major childhood cancers 12.16.1 Leukemia 12.16.2 Non-Hodgkin's lymphomas 12.16.3 Hodgkin's disease 12.16.4 Histiocytic diseases 12.16.5 Rhabdomyosarcoma 12.16.6 Neuroblastoma 12.16.7 Wilm's tumor 12 17 Chemotherapeutic drug toxicities 13.0 Immunologic Disorders 13.1 Immunodeficiency syndromes 13.1.1 Human immunodeficiency virus disease 13.1.2 Functional hyposplenism 13.1.3 Drug-induced disorders 13.2 Allergic emergencies 13.2.1 Asthma 13.2.2 Anaphylaxis 13.2.3 Serum sickness
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13.2.4 Allergic rhinitis 13.3 Transplantation emergencies 14.0 Systemic Infectious Disorders 14.1 Antibiotic therapy principles 14.2 Communicable childhood diseases and infection control 14.3 Systemic infections 14.3.1 Sepsis 14.3.2 Septic shock 14.3.3 Measles 14.3.4 Lyme disease 14.3.5 Cat scratch disease 14.3.6 Kawasaki disease 14.3.7 Rubella 14.3.8 Varicella-zoster 14.3.9 Roseola 14.3.10 Infectious mononucleosis 14.3.11 Erythema infectiosum (fifth disease) 14.3.12 Infant botulism 14.3.13 Tetanus 14.3.14 Toxic shock syndrome 14.3.15 Rocky Mountain spotted fever 14.3.16 Rabies 14.4 Occult bacteremia 14.5 Parasitic infections 14.6 Fungal infections 14.7 Diseases associated with specific infectious agents 14.7.1 Bacteria 14.7.1.1 Haemophilus influenzae 14.7.1.2 Chlamydia 14.7.1.3 Group B Streptococcus 14.7.1.4 Listeria 14.7.1.5 Neisseria gonorrhoeae 14.7.1.6 Neisseria meningitidis 14.7.1.7 Staphylococcus aureus 14.7.1.8 Streptococcuspneumoniae 14.7.2 Viruses 14.7.2.1 Epstein-Barr virus 14.7.2.2 Cytomegalovirus 14.7.2.3 Influenza 14.7.2.4 Parainfluenza 14.7.2.5 Adenovirus 14.7.2.6 Enterovirus 14.7.2.7 Human immunodeficiency virus 14.7.2.8 Herpes 14.7.2.9 Respiratory syncytial virus 14.7.2.10 Rotavirus 14.7.3 Other
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14,7.3.1 Myoplasm 14.7.3.2 Chlamydia 15.0 Musculoskeletal Disorders (Nontraumatic) 15.10steomyelitis 15.2 Septic arthritis 15.3 Metabolic bone abnormalities 15.4 Achondroplasia 15.5 Marfan's syndrome 15.60sgood-Schlatter disease 15.70steochondritis dissecans 15.8 Spine disorders i5.8.1 Kyphosis 1 5 8 2 Scoliosis 15.8.3 Lordosis 15,8.4 Spondylolisthesis 15.8.5 Diskitis 15.9 Hip disorders 15.9.1 Perthes disease 15.9.2 Slipped capital femoral epiphysis 15.9.3 Toxic synovitis 15.10 Torticollis 15.11 Muscular dystrophies I5.12 Myopathies 15.13 Myositis 15.14 Rheumatologic disorders 15.14.1 Inflammatory arthritides 15.14.2 Connective tissue diseases 15.14.3 Juvenile rheumatoid arthritis 15.14.4 Rheumatic fever 16.0 Neonatology 16.1 Assessment of high-risk infants 16,1.1 Multiple pregnancies 16,1.2 Prematurity and intrauterine growth retardation 16.1.3 Post-term infants 16.1.4 Large for gestational age 16.1.5 Maternal drug use 16.2 Birth injuries 16.3 Congenital anomalies 16.4 Neonatal resuscitation 16.4.1 Asphyxia 16.4.2 Heart rate 16.4.3 Medications 16.4.3.1 Glucose 16.4.3.2 Naloxone 16.4.3.3 Epinephrine 16.4.3.4 Atropine 16.4.4 Postresuscitation management 16.4.5 Special situations 16.4.5.1 Pneumothorax
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16.4.5.2 Meconium aspiration 16.4.5.3 Diaphragmatic hernia 16.4.5.4 Omphalocele/ gastroschisis 16.4.5.5 Tracheoesophageal fistula 16.4.5.6 Choanal atresia 16.5 Apnea of prematurity 16.6 Neonatal seizures 16.7 TORCH syndrome 16.8 Respiratory distress syndrome 16.9 Neonatal dysrhythmias and cardiac anomalies 16.10 Gastrointestinal 16.10.1 Necrotizing enterocolitis 16.10.2 Midgut volvulus 16.1i Neonatal sepsis 16.12 Transient tachypnea of the newborn 17.0 Nervous System Disorders 17.1 Congenital anomalies of the nervous system 17.1.1 Spina bifida occulta 17.1.2 Hydrocephalus 17.1.3 Craniosynostosis 17.2 Ataxia 17.3 Acute encephalopathies 17.3.1 Acquired immunodeficiency disease encephalopathy 17.3.2 Lead encephalopathy 17.3.3 Hypertensive encephalopathy 17.4 Coma 17.5 Headache 17.5.1 Migraine 17.5.2 Pseudotumor cerebri 17.6 Increased intracranial pressure 17.7 Reye's syndrome 17.8 Seizures 17.8.1 Febrile 17.8.2 Nonfebrile 17.8.3 Neonatal 17.8.4 Status epilepticus 17.9 Meningitis 17.9.1 Aseptic 17.9.2 Bacterial 17.10 Encephalitis 17.11 Brain abscess 17.12 Neurocutaneous syndromes 17.12.1 Neurofibromatosis 17.12.2 Tuberous sclerosis 17.13 Syncope 17.14 Stroke syndromes 17.15 Arteriovenous malformation and aneurysm
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17.16 Coma scales for infants/children 17.17 Neoplasm 17.18 Disorders of motor function 17.18.1 Acute hemiplegia of childhood 17.18.2 Transverse myelitis 17.18.3 Acute polyneuritis 17.18.4 Myasthenia gravis 17.18.5 Guillain-Barre syndrome 17.18.6 Myoglobinuria 17.19 Disorders of balance and coordination 17.19.1 Acute cerebellar ataxia 17.19.2 Viral labyrinthitis 17.19.3 Benign paroxysmal vertigo 17.20 Cranial nerve dysfunction 17.20.1 Optic neuritis 17.20.20culomotor palsy 17.20.3 Abducens palsy 17.20.4 Bell's palsy 17.21 Neurosurgical emergencies 17.21.1 Ventriculoperitoneal shunt malfunction 17.21.2 Ventriculoperitoneal shunt refection 17.21.3 Intracranial hemorrhage 17.21.4 Spinal cord compression 18.0 Pediatric Resuscitation 18.1 Cardiac arrest 18.2 Drugs 18.2.1 Atropine 18.2.2 Bretylium 18.2.3 Dobutamine 18.2.4 Dopamine 18.2.5 Epinephrine 18.2.6 Lidocaine 18.2.7 Magnesium 18.3 Shock 18.3.1 Hypovolemia t8.3.2 Distributive shock 18.3.3 Cardiogenic shock 18.3.4 Anaphylaxis 18.4 Postresuscitation management 18.5 Stabilization and preparation for transport 18.6 Discontinuation of life support 18.7 Cerebral resuscitation 18.8 Sudden infant death syndrome 19.0 Psychosocial Issues and Behavioral Disorders 19.1 Attention deficit disorder 19.2 Disruptive behavioral disorders 19.3 Eating disorders 19.4 Enuresis 19.5 Encopresis
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19.6 19.7 19.8 19.9 19.10 19.11 19.12 19,13 19.14
Suicide and attempted suicide Hyperventilation syndrome Tics School phobia Breath-holding spells Psychosomatic complaints Acute psychosis Anxiety disorders Affective disorders 19.14.1 Childhood depression 19.14.2 Dysthymic disorder 19.14.3 Bipolar disorder 19.15 Autism 19.16 Conversion reactions 19.17 Family considerations regarding death and catastrophic illness Renal Disorders 20.0 20.1 Calculus disease 202 Congenital kidney abnormalities 20.2.1 Polycystic kidney disease 20.2.2 Horseshoe kidney 20.2.3 Congenital absence of kidney 20.3 Nephrotic syndrome 20.4 Hemolytic-uremic syndrome 20.5 Glomerulonephrids 20.6 Pyelonephritis 207 Renal tubular acidosis 20.8 Renal failure 20.9 Cystitis 20.10 Disorders of the bladder 20.11 Vesicoureteral reflux 20.12 Posterior ureteral valves 21.0 Thoracic and Respiratory Disorders 21.1 Congenital anomalies of the trachea and upper airway 21.2 Airway foreign bodies 21.3 Acute respiratory failure 21.4 Smoke inhalation 21.5 Bronchitis 2t.6 Bronchiolitis 21.7 Pneumonia 21.7.1 Viral 21.7.2 Bacterial 21.7.3 Aspiration 21.7.4 Chlamydia 21.7.5 Mycoplasma 21.8 Bronchopulmonary dysplasia 21.9 Adult respiratory distress syndrome 21.10 Asthma 2 t. 11 Congenital lung anomalies
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21.12 Congenital lobar emphysema 21.13 Diaphragmatic defects 21.14 Pneumothorax 21.15 Pneumomediastinum 21.16 Pulmonary edema 21.17 Pleuritis 21.18 Sarcoidosis 21.19 Cystic fibrosis 22.0 Toxicology and Clinical Pharmacology 22.1 Prevention and parent education (childproofing the home) 22.2 General approach to the poisoned child 22.3 Major toxic ingestions and exposures 22.3.1 Acetaminophen 22.3.2 Alcohols 22.3.3 Antihistamines 22.3.4 Anticoagulants 22.3.5 Anticonvulsants 22.3.6 Aspirin 22.3,7 Carbon monoxide 22.3.8 Cardiac drugs 22.3.9 Caustic agents 22.3.10 Cocaine 22.3.11 Disc batteries 22.3.12 Hallucinogens 22.3.13 Heavy metals and chelation 22.3.14 Household poisons 22.3.15 Hydrocarbons 22.3.16 Iron 22.3.17 Lead 22.3.18 Methemoglobinemia 22.3.19 Oral hypoglycemics 22.3.20 Organophosphate/carbamate 22.3.21 Phenothiazines 22.3.22 Salicylates 22.3.23 Theophylline 22.3.24 Tricyclic antidepressants 22.4 Effects of age on pediatric poisonings 22.5 Drug interactions/adverse reactions 22.5.1 Drug fever 22.5.2 Serum sickness 23.0 Traumatic Disorders 23.1 Injury prevention 23.2 Major trauma resuscitation 23.3 Diagnosis and management by anatomic areas 23.3.1 Head and neck 23.3.1.1 Ocular injuries 23.3.1.2 Oral burns 23.3.1.3 Tooth avulsion 23.3.1.4 Tooth displacement
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23.3.1.5 Tooth fractures 23.3.1.6 Cerebral herniation syndromes 23.3.1.7 Intracranial hemorrhage syndromes 23.3.1.8 Skull fractures 23.3.1.9 Concussion 23.3.1.10 Cerebral contusion 23.3.1.11 Cervical-spine fractures 23.3.1.12 Spinal-cord injuries 23.3.2 Chest 23.3.2.1 Tracheal and bronchial injuries 23.3.2.2 Esophageal injuries 23.3.2.3 Rib fractures 23.3.2.4 Cardiac tamponade 23.3.2.5 Flail chest 23.3.2.6 Open-chest injuries 23.3.2.7 Hemo/pneumothorax 23.3.3 Abdomen 23.3.3.1 Duodenalhematoma 23.3.3.2 Solid viscus injury 23.3.3.3 Hollow viscus injury 23.3.4 Genitourinary 23.3.4.1 Renal injuries 23.3.4.2 Urethral injuries 23.3.4.3 Testicular trauma 23.3.4.4 Straddle injuries 23.3.5 Extremity 23.3.5.1 Childhood fractures 23.3.5.1.1 Epiphyseal (Salter-Harris) 23.3.5.1,2 Toms 23.3.5.1,3 Greenstick 23.3.5.1,4 Supracondylar 23.3.5.1.5 "Toddler's" fracture 23.3.5.2 Radialhead subluxation (nursemaid's elbow) 24.0 Urogenital/Gynecologic Disorders 24.1 Genital tract/Female 24.1.1 Congenital vaginal obstruction 24.1.2 Ovarian torsion 24.1.3 Vulvovaginitis 24.1.4 Hematocolpos 24.1.5 Hydrocolpos 24.1.6 Labial adhesion 24.1.7 Urethral prolapse 24.2 Genital tract/Male 24.2.1 Penile disorders
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24.2.1.1 Balanoposthitis 24.2.1.2 Phimosis 24.2.1.3 Paraphimosis 24.2.1.4 Priapism 24.2.2 Testicular disorders 24.2.2.1 Acute scrotum 24.2.2.1.1 Epididymitis 24.2.2.1.2 Orchitis 24.2.2.1.3 Testicular torsion 24.2.2.1.4 Testicular tumor 24.2.2.1.5 Torsion of the appendix testis 24.2.2.2 Hydrocele 24.2.2.3 Varicocele 24.2.2.4 Undescended testis 24.3 Sexually transmitted diseases 24.4 Breast masses 24.5 Mastitis 25.0 Administrative Aspects of Pediatric Emergency Care 25.1 Institutional affiliations 25.2 Departmental administration 25.2.1 Patient services 25.2.2 Personnel management 25.2.3 Quality assurance 25.2.4 Medical records 25.3 Ethics 25,4 Child advocacy 25,5 Hospital administration and organizational structures 25,6 Third-party reimbursement 25.7 Legal aspects of pediatric emergency care 25.7.1 Telephone advice 25.7.2 Consent and refusal of consent 25.7.3 Leaving against medical advice 25.7.4 Liability 25.8 Political interest groups 25.9 Public health issues 25.10 Public relations 25.11 Medical organizations 25.11.1 General emergency medicine 25.11.2 Pediatric emergency medicine 25.12 Practice management 25.12.1 Structure 25.12.2 Scheduling 25.12.3 Billing/reimbursement 25,12.4 Contract negotiation 26.0 Research 26.1 Biostatistics 26.2 Epidemiology 26.3 Critical evaluation of the medical literature
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26.4 Computer applications 26.5 Research methodology 26.5.1 Types of studies 26.5.2 Study design and implementation 26.6 Bench techniques 26.7 Grant applications 27.0 Teaching 27.1 Principles and practice 27.1.1 Bedside 27.1.2 Small-group 27.1.3 Workshops 27.1.4 Lectures 27.1.5 Scientific presentations 27.2 Preparing teaching tools 27.3 Use of library services 28.0 Pediatric Prehospital Care and Interhospital Transport 28.1 Access to care 28.2 Services and governance of emergency medical services for children (EMS-C) systems 28.3 Communications 28.4 Medical command 28.5 Preparation tor interhospital transport 28.6 Selecting a mode of transport 29.0 Procedures/Skills 29.1 General emergency procedures 29.1.1 Restraint techniques 29.1.2 Intramuscular injections 29.1.3 Use of pediatric monitoring and resuscitation equipment 29.1.4 Assessment of vital signs 29.2 Cardiopulmonary life support procedures 29.2.1 Basic life support 29.2.2 Aiiway adjuncts and oxygen delivery 29.2.3 Bag-valve-mask ventilation 29.2.4 Tracheal intubation 29.2.5 Percutaneous transtracheal ventilation 29.2.6 Central venous access 29.2.7 Venous cutdown catheterization 29.2.8 Intraosseous infusion 29.3 Trauma life support procedures 29.3.1 Cervical-spine immobilization and imaging techniques 29.3.2 Cricothyrotomy 29.3.3 Diagnostic peritoneal lavage 29.3.4 Thoracotomy 29.3.5 Needle thoracostomy and chest tube placement 29.4 Anesthesia and sedation procedures 29.4.1 Rapid-sequence induction 29.4.2 Conscious sedation
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29.4.3 29.5 Special 29.5.1 29.5.2 29.5.3 29.5.4
Pain management techniques procedures for neonates Neonatal resuscitation procedures Managing meconium aspiration Umbilical vessel catheterization Emergency management of congenital anomalies 29.5.5 Heel sticks 29.6 Neurologic and neurosurgical procedures 29.6.1 Lumbar puncture 29.6.2 Evaluation of ventriculoperitoneal shunt function 29.6.3 Diagnostic and therapeutic tap of the ventriculoperitoneal shunt 29.6.4 Subdural tap 29.6.5 Ventricular tap 29.70phthalmologic procedures 29.7.1 Use of the slit lamp 29.7.2 Tonometry 29.80tolaryngologic procedures 29.8.1 Management of foreign bodies of the upper airway, nose, and ear 29.8.2 Tympanocemesis 29.8.3 Use of the flexible fiberoptic laryngoscope 29.9 Dental procedures 29.9.1 Management of soft-tissue injuries of the mouth and perioral area 29.9.2 Management of dental fractures and avulsions 29.10 Cardiovascular procedures 29.10.1 Obtaining the pediatric electrocardiogram 29.10.2 Maneuvers for converting stable supraventricular tachycardias 29.10.3 Accessing indwelling lines 29.10.4 Arterial line insertion 29.11 Pulmonary procedures 29.11.1 End-tidal/transcutaneous carbon dioxide monitoring 29.11.2 Peak flow measurement 29.11.3 Use of nebulizers, spacers, and multidose inhalers 29.11.4 Tracheal suctioning 29.11.5 Replacement of tracheostomy cannula 29.11.6 Thoracentesis 29.11.7 Use of pediatric mechanical ventilators 29.12 Gastrointestinal procedures
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29.13
29.14
29.15
29.16
29.17
29.18 29.19
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29.12.1 Management of esophageal foreign bodies 29.12.2 Paracentesis 29.12.3 Hernia reduction 29.12.4 Umbilical granuloma care 29.12.5 Oral rehydration 29.12.6 Rectal prolapse reduction 29.12.7 Management of gastrointestinal bleeding Genitourinary procedures 29.13.1 Prepubertal rectal, vaginal examination 29.13.2 Adolescent vaginal examination 29.13.3 Forensic examination of the sexual assault victim 29.13.4 Bladder catheterization 29.13.5 Suprapubic bladder aspiration 29.13.6 Management of testicular torsion 29.13.7 Management of paraphimosis 29.13.8 Zipper injuries 29.13.9 Removing vaginal foreign bodies Orthopedic procedures 29.14.1 Joint immobilization techniques for infants and children 29.14.2 Reduction of joint dislocations/ subluxations Minor surgical procedures 29.15.1 Management of fingertip avulsions and nailbed injuries 29.15.2 Removal of a hair tourniquet Laboratory skills 29.16.1 Obtaining biologic specimens 29.16.2 Common emergency department laboratory tests 29.16.3 Skin testing Toxicologic/environmental procedures 29.17.1 Gastric emptying 29.17.2 Whole-bowel irrigation 29.17.3 Cooling and warming procedures Emergency department ultrasonography for infants and children Transport procedures 29.19.1 Ground transport procedures 29.19.2 Aeromedical transport procedures
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REFERENCES 1 American Collegeof EmergencyPhysicians,American Boardof EmergencyMedicine, Society for Academic EmergencyMedicine: Core content for emergencymedicine.Ann EmergMed 1991;20:920-934. 2. Curriculum SubcommitteeSection of EmergencyMedicine, American Academyof Pediatrics: Pediatric EmergencyMedicine (PEM)Fellowship Curriculum Statement. PediatrEmergCare 1991;7:48-53. 3. King C, Nilsen GJ, Henretig FM, et al: Proposedfellowship training program in pediatric emergencymedicinefor emergencymedicine graduates.Ann EmergMed 1993;22:542-546. The authors thank Drs Don Yealy and Dan Issacman for reviewing this manuscript.
Reprint no. 47/1/59816 Address for reprints: Christopher King, MD Division of EmergencyMedicine 200 Lothrop Street Room D-L45 Pittsburgh, Pennsylvania15213
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