UNIT 5

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

Junior Level:

Learn the embryology, anatomy and physiology of common neonatal surgical diseases:

1. Describe the cardiac, pulmonary, blood volume, and gastrointestinal changes of post-partum transitional physiology.

2. Describe relevant mechanisms (conductive, convective, evaporative, and radiant) of neonatal thermoregulation.

3. Describe how neonatal renal function (decreased concentrating ability) affects the pharmacokinetics of commonly used drugs and antibiotics.

4. Describe factors influencing neonatal immunologic immaturity and how this increases susceptibility to common neonatal pathogens.

5. Describe appropriate fluid and electrolyte management of the full-term neonate.

6. Describe the nutritional requirements of the full-term neonate, and calculate appropriate enteral and parenteral nutritional support.

7. Describe the embryology of neonatal organ systems and their common congenital anomalies, including:

a. Craniocervical: dermoid cysts, branchial cleft cysts, and fistulas

b. Foregut: esophageal atresia/tracheoesophageal fistula, duodenal atresia

c. Respiratory: cystic adenomatoid malformation, congenital diaphragmatic hernia

d. Cardiac: common cyanotic and acyanotic cardiac malformations

e. Midgut: intestinal atresia, malrotation, meconium ileus

f. Hindgut: Hirschsprung’s disease, imperforate anus, meconium plug syndrome, small left colon syndrome

g. Body wall defects: gastroschisis, omphalocele, umbilical and inguinal hernias

h. Renal: ureteral obstruction, vesicoureteral reflux

i. Lower GU tract: urethral valves, hypospadias

8. Explain the pathophysiology of necrotizing enterocolitis.

9. Describe the arterial and venous anatomy of the neonate.

Diagnose common neonatal problems and describe surgical procedures for their correction:

1. Describe the diagnosis, preoperative evaluation, and management of the common congenital anomalies listed above.

2.   Outline the technical principles involved in the following procedures:
a.   Gastrostomy
b.   Colostomy
c.   Inguinal and umbilical herniorrhaphy
d.   Circumcision
e.   Central venous access

3.   Explain the perioperative care of neonates, including:
a.   Basic ventilator management
b.   Fluid, electrolyte, and nutritional management
c.   Correction of coagulopathies
d.   Indications for transfusion
e.   Diagnosis of sepsis and antibiotic use

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

Junior Level:

1. Perform a comprehensive evaluation of a neonate with suspected surgically correctable conditions.

2. Establish percutaneous venous and arterial access in neonates over 2 kg.

3.   Assist or perform under supervision:
a.   Peripheral venous and arterial cutdown access
b.   Placement of umbilical catheters
c.   Placement of central venous access
d.   Tube thoracostomy
e.   Incision and drainage of cysts and abscesses
f.    Hernia reduction

4.   Participate in the perioperative care of the neonate by recording appropriate assessments and treatment plans in daily progress notes, including:
a.   Ventilator management
b.   Fluid, electrolyte, and nutritional management
c.   Antibiotic use

5. Complete oral or written examination of topics listed in junior level knowledge objectives.

6. Assist or perform surgical repairs of congenital diseases listed in junior-level knowledge objectives.

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

Senior Level:

The senior-level resident should function as an effective consultant to the nursery, and be able to provide expertise in the evaluation and definitive treatment of elective surgical conditions as well as be able to perform emergent surgical procedures (including but not limited to vascular access, orotracheal intubation, tube thoracostomy, exploratory laparotomy, and exploratory thoracotomy) with little or no immediate supervision. The senior-level resident should be prepared to direct the management of the pediatric surgical service, including the education of junior residents and medical students on surgical clerkships.

Learn the embryology, anatomy, and physiology of basic and advanced neonatal surgical diseases. The resident is responsible for all conditions listed above in junior-level objectives, plus:

1. Describe the pathophysiology and evaluation of:

a.   Respiratory distress                    e.   Bilious emesis
b.   Cyanosis                                   f.   Abdominal distention
c.   Gastroesophageal reflux              g.   Bloody diarrhea
d.   Jaundice                                    h.   Body wall defects

2. Describe the complications and appropriate treatment of necrotizing enterocolitis.

3. Describe appropriate fluid and electrolyte management of the premature neonate.

4. Describe the nutritional requirements of premature neonates, and calculate appropriate enteral and parenteral nutritional support.

5.   Describe the embryology of basic anomalies (listed above) and more complex congenital anomalies, including:
a.   Craniocervical: choanal atresia, cleft lip and palate
b.   Foregut: laryngotracheal cleft, duodenal web and duplication,

annular pancreas, preduodenal portal vein, biliary atresia
c. Respiratory: congenital lobar emphysema and sequestrations

d. Cardiac: complex cyanotic and acyanotic cardiac malformations

Midgut: intestinal duplication, volvulus, meconium peritonitis
Hindgut: neuronal intestinal dysplasia, total colonic and ultrashort Hirschsprung’s disease, cloacal exstrophy
Body wall defects: pentalogy of Cantrell, Jeune’s thoracic dystrophy
Renal: renal agenesis, fusion and ectopia; bladder exstrophy, prune-belly syndrome
Lower GU tract: ambiguous genitalia, urogenital sinus abnormalities

Diagnose common neonatal problems and describe surgical procedures for their correction:

1. Describe the diagnosis, preoperative evaluation, operative management, and postoperative care of the congenital anomalies listed above.

2.   Describe the immediate care, operative correction, and postoperative management of life-threatening anomalies:
a.   Congenital diaphragmatic hernia
b.   Midgut volvulus
c.   Necrotizing enterocolitis
d.   Gastroschisis
e.   Prune-belly syndrome

3. Describe respiratory support of the neonate, including high frequency ventilation and extracorporeal membrane oxygenation.

4. Describe neonatal nutritional assessment and supervision of long-term nutritional support for neonates with short-gut syndrome.

5. Describe indications for and technical aspects of endoscopic evaluation of the neonate.

6. Describe indications for and technical aspects of intubation, tube thoracostomy, and percutaneous central venous access in the neonate.

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

Senior Level:

1. Describe the capabilities and limitations of various diagnostic modalities used in neonatal care.

2. Formulate a care plan for neonates with problems such as:

a.   Respiratory distress                    e. Bilious emesis
b.   Cyanosis                                   f. Abdominal distention
c.   Gastroesophageal reflux              g. Bloody diarrhea
d.   Jaundice                                    h. Body wall defects

3. Perform or assist in all major surgical procedures performed on the pediatric surgical service.

4. Personally conduct comprehensive preoperative evaluation and postoperative management for all critically ill neonates, and direct junior residents in the management of routine surgical problems.

5. Complete oral or written examination of topics listed in senior-level knowledge objectives.

The Neonatal Surgery unit was revised by John C. Fitzpatrick, MD, Jeffrey C. Pence, MD, and Joseph J. Tepas, III, MD, from the Curriculum, third edition.

SELECTED BIBLIOGRAPHY:

Avery GB, Fletcher MA, MacDonald MG (eds). Neonatology: Pathophysiology and Management of the Newborn (4^th ed). Philadelphia: JB Lippincott Company, 1994.

Avery ME, First LR (eds). Pediatric Medicine (2nd ed). Baltimore: Williams & Wilkins, 1994.

Carlson BM. Human Embryology and Developmental Biology. Baltimore: Mosby-Year Book, Inc., 1994.

Fuhrman BP, Zimmerman JJ (eds). Pediatric Critical Care (2^nd ed). Baltimore: Mosby-Year Book, Inc., 1998.

O’Neill JA, Rowe MI, Grosfeld JL, Fonkalsrud EW, Coran AG (eds). Pediatric Surgery (5th ed). St. Louis: Mosby-Year Book, Inc., 1998.

Stringer MD, Oldham KT, Mouriquand PDE, Howard ER (eds). Pediatric Surgery and Urology: Long Term Outcomes. Philadelphia: WB Saunders Company, Ltd., 1998.

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

Junior Level:

1. Describe the development of children in terms of the following criteria:

a. Weight, length, and head size

b. Nutritional requirements

c. Renal function

d. Hormonal influences on development

e. Response to stress and infection

2. Classify congenital malformations of the newborn by type, origin, and the need for surgical intervention:

a. Head and neck: thyroglossal duct cyst, lymphadenopathy, cystic hygroma

b. Gastrointestinal: pyloric stenosis, appendicitis

c. Respiratory: tracheal lesions

d. Abdominal wall defects: omphalomesenteric and urachal malformations

e. Genitourinary: polycystic kidneys, undescended testis, torsion of the testis

f. Inborn and genetic errors: trisomy 13, trisomy 18, Down's syndrome

g. Orthopedic anomalies which commonly occur with other malformations

4. Summarize the basic approach to the diagnosis and management of more common surgical problems of infancy and childhood, such as:

a. Pyloric stenosis

b. Perforated appendicitis

c. Intussusception

5. Identify the technical aspects of the following procedures:

a. Excision of skin and subcutaneous lesions

b. Incision and drainage of abscesses

c. Lymph node biopsy

d. Chest tube placement

e. Oral intubation

f. Herniorrhaphy in older children

6. Describe the fundamental considerations in the pre- and post- operative care of infants and children in the cases listed above.

7. Explain the principles of diagnosis and treatment for common causes of gastrointestinal hemorrhage in the neonate, infant, child, and adolescent.

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

Junior Level:

1. Evaluate surgical conditions in the pediatric population through a comprehensive history, physical examination, and appropriate diagnostic studies.

2. Participate in the management of simple surgical problems in the pediatric population, including:

a. Integument

(1) Excision of skin and subcutaneous lesions

(2) Incision and drainage of abscesses

b. Head and Neck

(1) Excision of dermoid cysts and small skin lesions

(2) Lymph node biopsy

c. Thoracic

(1) Chest tube placement

d. Cardiovascular

(1) Central venous catheter placement

(2) Venous cutdown

(3) Arterial line placement

e. Gastrointestinal

(1) Pyloromyotomy

(2) Appendectomy

(3) Herniorrhaphy (umbilical; inguinal in patients 2 years and up)

f. Genitourinary

(1) Circumcision

(2) Orchiopexy

g. Gynecology

(1) Oophorectomy, simple

(2) Vaginoscopy for foreign body or biopsy

h. Musculoskeletal

(1) Ganglion cyst excision

(2) Excision of supernumerary digit

(3) Muscle biopsy

3. Develop a working relationship with members of the pediatric intensive care unit in managing postoperative pediatric patients.

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

Senior Level:

The senior-level resident should function as an effective consultant to the nursery, and be able to provide expertise in the evaluation and definitive treatment of elective surgical conditions as well as be able to perform emergent surgical procedures (including but not limited to vascular access, orotracheal intubation, tube thoracostomy, exploratory laparotomy, and exploratory thoracotomy) with little or no immediate supervision. The senior level resident should be prepared to direct the management of the pediatric surgical service, including the education of junior residents and medical students on surgical clerkships.

Learn the embryology, anatomy, and physiology of basic and advanced neonatal surgical diseases. The resident is responsible for all conditions listed above in junior-level objectives, plus:

1. Explain the approach to surgical management, (i.e., diagnosis, perioperative care, surgical therapy, and postoperative follow-up) of more complex surgical procedures for infants and children such as:

a. Large skin grafts and musculocutaneous flaps

b. Thoracotomy for pulmonary resection and vascular cardiac repair

c. Flexible endoscopy

d. Antireflux procedure

e. Bowel resection

f. Repair of hepatic, biliary, and pancreatic injury

g. Splenectomy and splenorrhaphy

h. Management of the seriously injured patient

2. Analyze the pathophysiology, diagnosis, and management options in the treatment of short-gut syndrome.

3. Demonstrate an understanding of the special psychological, social, and education issues confronting selected pediatric trauma/ postoperative patients.

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

Senior Level:

1. Evaluate pediatric patients for problems requiring more complex surgical intervention.

2. Participate in preoperative, operative, and postoperative care of more complex problems in pediatric surgery such as:

a. Integument

(1) Pedicle graft

(2) Large skin grafts for burns

(3) Subcutaneous mastectomy

b. Craniocervical

(1) Branchial cleft and thyroglossal duct cysts

(2) Cystic hygroma

c. Thoracic

(1) Laryngoscopy, bronchoscopy, esophagoscopy

(2) Tracheostomy

(3) Thoracotomy for biopsy, lung resection

(4) Diaphragm repair

d. Cardiovascular

(1) Resection of small vascular cutaneous lesions such as (A-V) malformation, hemangioma, or lymphangioma

(2) Repair of patent ductus arteriosus

(3) Repair of aortic anomaly/injury

(4) Support of a child with extracorporeal membrane oxygenation (ECMO)

e. Gastrointestinal

(1) Flexible endoscopy

(2) Antireflux procedure

(3) Bowel resection for inflammatory bowel disease, intussusception, intestinal duplications

(4) Hodgkin's staging

(5) Biopsy of tumor (open, laparoscopic or endoscopic)

(6) Laparotomy for trauma

(7) Splenectomy (laparoscopic or open), splenorrhaphy

(8) Repair of hepatic injury, renal and/or bladder injury

(9) Cholecystectomy (open or laparoscopic)

(10) Omphalomesenteric duct and urachal anomalies

f. Oncologic

(1) Neuroblastoma

(2) Wilms’ tumor

(3) Rhabdomyosarcoma

(4) Teratomas

(5) Germ cell tumors

(6) Hepatoblastoma

(7) Sarcomas

(8) Hodgkin’s and non-Hodgkin’s lymphomas

(9) ALL

g. Genitourinary

(1) Polycystic kidney

(2) Ambiguous genitalia

h. Musculoskeletal

(1) Torticollis

The Pediatric Surgery unit was written by Jeffrey C. Pence, MD, and John C. Fitzpatrick, MD, following the Curriculum, third edition, by James A. O'Neill, Jr., MD.

SELECTED BIBLIOGRAPHY:

Avery ME, First LR (eds). Pediatric Medicine (2nd ed). Baltimore: Williams & Wilkins, 1994.

Carlson BM. Human Embryology and Developmental Biology. Baltimore: Mosby-Year Book, Inc., 1994.

Cox CC, Marvin RG, Lally KP, et al. Physiologic problems in the pediatric surgical patient. In: Miller TA (ed), Modern Surgical Care: Physiologic Foundations and Clinical Applications (2^nd ed). St. Louis: Quality Medical Publishing, Inc., 1998;1337-1361.

Fuhrman BP, Zimmerman JJ (eds). Pediatric Critical Care (2^nd ed). Baltimore: Mosby-Year Book, Inc., 1998.

O’Neill JA, Rowe MI, Grosfeld JL, Fonkalsrud EW, Coran AG (eds). Pediatric Surgery (5th ed). St. Louis: Mosby-Year Book, Inc., 1998.

Stringer MD, Oldham KT, Mouriquand PDE, Howard ER (eds). Pediatric Surgery and Urology: Long Term Outcomes. Philadelphia: WB Saunders Company, Ltd., 1998.

Web reference

http://www.eapsa.org

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

1. Identify the anatomy and explain the physiology of the ear, nose, oral cavity, and throat.

2. Summarize the essential components of a focused history and physical examination for common otolaryngologic problems.

3. Discuss the significance of the cornerstones of the physical examination, including:

a. Visual inspection c. Palpation

b. Auscultation d. Percussion

4. Analyze the clinical management of ear, nose, and throat (ENT) patients in the intensive care unit (ICU), including:

a. Respiratory infection management

b. Airway management

c. Wound care

5. Describe and compare the pathophysiology of the following common ENT diseases:

a. Sinusitis c. Neck abscess

b. Sialadenitis d. Epiglottitis

6. Describe and explain the pathophysiology of presbycusis as it can be:

a. Conductive

b. Metabolic and toxic

c. Neural

d. Cochlear

e. Tumor-related

f. Age-dependent

7. Explain how physical examination differs for delineation of conductive versus neurosensory hearing loss.

8. Explain the principal causes of simple epistaxis and describe its management.

9. Evaluate patients with facial trauma and develop a treatment plan for the management of:

a. Fractures c. Hemotympanum

b. Lacerations d. Epistaxis

10. Describe the indications for tracheostomy in adults and children.

11. Discuss the indications for biopsy of lesions of the skin of the face, neck, and oral cavity.

12. Compare the use of the following procedures in evaluating ENT problems:

a. Radiography

b. Contrast studies

c. Ultrasound

13. Describe the indications for simple endoscopy and its diagnostic contributions such as:

a. Nasopharyngoscopy c. Esophagoscopy

b. Direct laryngoscopy

14. Summarize the characteristics of the common neoplasms of the ear, nose, and throat, and describe appropriate surgical intervention.

15. Outline the diagnostic approaches to otolaryngologic neoplasia, including:

a. Direct visualization c. Use of radiography

b. Indirect visualization d. Fine-needle biopsy

16. Describe diagnostic and therapeutic procedures utilized in treating the following:

a. Abscess c. Oral ulcer

b. Neck mass d. Salivary gland mass

17. Describe and demonstrate methods for removing foreign bodies from the trachea, bronchus, and esophagus.

18. Compare surgical approaches using surgical flaps for repair of ENT defects and trauma of the lip, alar rim, and helix.

19. Outline the diagnosis and repair of facial fractures of the mandible, nose, and frontal sinus.

20. Summarize diagnostic and therapeutic considerations in the management of caustic injury to the mouth, nasopharynx, trachea, and esophagus.

21. Discuss the management of airway in patients with terminal carcinoma of the thyroid and trachea.

22. Describe the signs and symptoms and discuss the health care significance to elderly patients from the pathophysiology of:

a. Tinnitus c. Cerumen impaction

b. Vertigo d. Basilar artery stenosis

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

1. Perform and record a focused ENT history and physical examination.

2. Manage the emergent/elective airway; using visual inspection, radiographic evaluation, indirect invasive and non-invasive visualization techniques (direct speculum and indirect mirror evaluations, direct fiberoptic and rigid evaluations); with consideration for:

a. Nose, nasal passages d. Larynx

b. Nasopharynx e. Trachea

c. Oropharynx

3. Be prepared to manage airway obstruction as the result of:

a. Edema d. Anaphylaxis

b. Secretion e. Foreign body

c. Benign and malignant tumors (including, vascular malformations and infectious processes)

4. Evaluate patients with facial trauma, including fractures, lacerations, hemotympanum, and epistaxis.

5. Perform tracheostomy on adults under direct supervision.

6. Perform biopsies of lesions of skin of face, neck, and oral cavity.

7. Perform evaluation of a neck mass, and provide appropriate treatment.

8. Correctly differentiate between the indications for and management of cricothyroidotomy and tracheostomy, demonstrating varying techniques and choice of instrumentation for emergent airway management and ventilation in each.

9. Interpret radiologic examinations of sinuses.

10. Perform simple endoscopy including:

a. Nasopharyngoscopy c. Esophagoscopy

b. Direct laryngoscopy

11. Evaluate head and neck tumor patients, and be prepared to perform a tumor biopsy.

12. Perform tracheostomy on children with supervision.

13. Evaluate radiologic studies of the head and neck, including computed axial tomography (CAT) scanning.

14. Evaluate and treat head and neck abscesses and other masses.

15. Remove esophageal foreign bodies endoscopically.

16. Perform diagnostic bronchoscopy.

17. Reconstruct facial and neck defects with transposition and myocutaneous flaps.

18. Manage facial fractures with appropriate consultation.

19. Evaluate and treat caustic injury.

20. Manage airway in patients with terminal thyroid or tracheal carcinoma.