Upload
larrylentino
View
5.418
Download
6
Tags:
Embed Size (px)
DESCRIPTION
Citation preview
CMASTCMAST 11
Hypovolemic Shock Hypovolemic Shock ManagementManagement
COMBAT MEDIC ADVANCED SKILLS TRAINING (CMAST)
22CMASTCMAST 22
IntroductionIntroduction
Basic life-saving steps for the soldier Basic life-saving steps for the soldier medic include:medic include:
– A-B-Cs.A-B-Cs.
– Shock and fluid resuscitationShock and fluid resuscitation..
33CMASTCMAST 33
Fluid ResuscitationFluid Resuscitation
Control hemorrhage first.Control hemorrhage first. Casualties with significant injuries should Casualties with significant injuries should
have a single 18 ga IV with saline lock in a have a single 18 ga IV with saline lock in a peripheral vein initiated.peripheral vein initiated.
Casualties without significant injuries do Casualties without significant injuries do not need an IV but should be encouraged not need an IV but should be encouraged to drink fluids.to drink fluids.
44CMASTCMAST 44
Saline Lock KitSaline Lock Kit
55CMASTCMAST 55
Saline LockSaline Lock
66CMASTCMAST 66
Saline LockSaline Lock
77CMASTCMAST 77
Saline LockSaline Lock
88CMASTCMAST 88
Saline LockSaline Lock
99CMASTCMAST 99
Saline LockSaline Lock
1100
CMASTCMAST 1100
Fluid ResuscitationFluid Resuscitation If unable to start a peripheral IV consider If unable to start a peripheral IV consider
initiating a sternal I/O.initiating a sternal I/O.
F.A.S.T.1
1111
CMASTCMAST 1111
F.A.S.T.1F.A.S.T.1
1122
CMASTCMAST 1122
Intraosseous AccessIntraosseous Access
Sternal vs. tibial.Sternal vs. tibial. Majority of wounds are Majority of wounds are
extremity wounds (> 60%).extremity wounds (> 60%). Tibial cortex is very thick.Tibial cortex is very thick. Sternum protected by body Sternum protected by body
armor.armor. Sternum is uniform from Sternum is uniform from
person to person.person to person.
1133
CMASTCMAST 1133
Intraosseous AccessIntraosseous Access Indications:Indications:
─ Inadequate peripheral accessInadequate peripheral access─ Need for rapid access for medications, Need for rapid access for medications,
fluid or bloodfluid or blood─ Failed attempts at peripheral or central Failed attempts at peripheral or central
venous accessvenous access
1144
CMASTCMAST 1144
Intraosseous AccessIntraosseous Access Typical protocol precautions:Typical protocol precautions: F.A.S.T.1 not recommended if:F.A.S.T.1 not recommended if:
─ Casualty is of small stature:Casualty is of small stature:Weight is less than 50 kg.Weight is less than 50 kg.
Pathological small size Pathological small size
─ Fractured manubrium/sternum - flailFractured manubrium/sternum - flail─ Significant tissue damage at siteSignificant tissue damage at site─ Severe osteoporosisSevere osteoporosis─ Previous sternotomy and/or scarPrevious sternotomy and/or scar
1155
CMASTCMAST 1155
Flow CapabilitiesFlow Capabilities
30 ml/min by gravity.30 ml/min by gravity. 125 ml/min utilizing 125 ml/min utilizing
pressure infusion.pressure infusion. 250 ml/min using 250 ml/min using
syringe forced syringe forced infusion.infusion.
1166
CMASTCMAST 1166
Administering BloodAdministering Blood
Blood is 4 times more viscous than NaCl.Blood is 4 times more viscous than NaCl. Result is 1/4 normal rate of flow when Result is 1/4 normal rate of flow when
administering blood using gravity.administering blood using gravity. Infusion catheter internal pressure during Infusion catheter internal pressure during
gravity infusion = ~75 mmHg.gravity infusion = ~75 mmHg. Catheter can take up to 1,500 mmHg.Catheter can take up to 1,500 mmHg. Solution? Solution?
─ Use pressure infusionUse pressure infusion
CMASTCMAST 1177
F.A.S.T.1 is considered a short-tem device and F.A.S.T.1 is considered a short-tem device and should not to be left in place for should not to be left in place for > 24 hours> 24 hours..
1188
CMASTCMAST 1188
Perpendicular InsertionPerpendicular Insertion
F.A.S.T.1 must be inserted perpendicular to F.A.S.T.1 must be inserted perpendicular to the surface of the manubrium.the surface of the manubrium.
Device penetrates bone only 6 mm.Device penetrates bone only 6 mm. Perpendicular relationship to the surface of Perpendicular relationship to the surface of
the manubrium critical for catheter to enter the manubrium critical for catheter to enter marrow space.marrow space.
Rich vasculature drains manubrium… Rich vasculature drains manubrium… F.A.S.T.1 is equivalent to a peripheral IV.F.A.S.T.1 is equivalent to a peripheral IV.
1199
CMASTCMAST 1199
Perpendicular InsertionPerpendicular Insertion Confirm landmarks:Confirm landmarks:
– Manubrium is Manubrium is upper aspect of upper aspect of sternal structuresternal structure
– Articulates with Articulates with body of sternum at body of sternum at the “Angle of the “Angle of Louis”Louis”
2200
CMASTCMAST 2200
Perpendicular InsertionPerpendicular Insertion
Note that there are Note that there are three planes relative three planes relative to the casualty:to the casualty:
1-Surface of ground1-Surface of ground
2-Surface of body of 2-Surface of body of the sternumthe sternum
3-Surface of the 3-Surface of the manubriummanubrium
1
3
2
2211
CMASTCMAST 2211
Perpendicular InsertionPerpendicular Insertion
Manubrium surface Manubrium surface angle is your point of angle is your point of focus.focus.
Perpendicular means Perpendicular means at right angles to the at right angles to the surface of the surface of the manubrium.manubrium.
2222
CMASTCMAST 2222
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure
Procedure:Procedure:– Prepare site using aseptic techniquePrepare site using aseptic technique
• BetadineBetadine• AlcoholAlcohol
2233
CMASTCMAST 2233
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure
Insertion:Insertion:– Finger at suprasternal notchFinger at suprasternal notch– Align finger with patch indentationAlign finger with patch indentation– Emplace patchEmplace patch
2244
CMASTCMAST 2244
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure
Insertion:Insertion:– Place introducer needle cluster in target areaPlace introducer needle cluster in target area
• Assure firm gripAssure firm grip• Introducer device Introducer device
must be must be perpendicular to perpendicular to the surface of the the surface of the manubriummanubrium
Insertion:Insertion:– Place introducer needle cluster in target areaPlace introducer needle cluster in target area
• Assure firm gripAssure firm grip• Introducer device Introducer device
must be must be perpendicular to perpendicular to the surface of the the surface of the manubriummanubrium
2255
CMASTCMAST 2255
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure Insertion:Insertion:
– Insert using increasing pressure till device Insert using increasing pressure till device releases (~20-30 pounds) releases (~20-30 pounds)
NOTENOTE: If more force than that is needed, it’s not : If more force than that is needed, it’s not perpendicular)perpendicular)
– Maintain Maintain perpendicular perpendicular alignment to the alignment to the manubrium manubrium throughoutthroughout
Insertion:Insertion:– Insert using increasing pressure till device Insert using increasing pressure till device
releases (~20-30 pounds) releases (~20-30 pounds) NOTENOTE: If more force than that is needed, it’s not : If more force than that is needed, it’s not
perpendicular)perpendicular)– Maintain Maintain
perpendicular perpendicular alignment to the alignment to the manubrium manubrium throughoutthroughout
2266
CMASTCMAST 2266
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure
Insertion:Insertion:– Following device release, infusion tube Following device release, infusion tube
separates from introducerseparates from introducer– Remove introducer by pulling straight backRemove introducer by pulling straight back– Cap introducer Cap introducer
using post-use using post-use cap suppliedcap supplied
Insertion:Insertion:– Following device release, infusion tube Following device release, infusion tube
separates from introducerseparates from introducer– Remove introducer by pulling straight backRemove introducer by pulling straight back– Cap introducer Cap introducer
using post-use using post-use cap suppliedcap supplied
2277
CMASTCMAST 2277
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure Insertion:Insertion:
– Connect infusion tube to tube on the target Connect infusion tube to tube on the target patchpatch
– Assure patency by use of syringe administer Assure patency by use of syringe administer 5 ml blast of saline5 ml blast of saline• Clears any Clears any
tissue debris in tissue debris in the infusion the infusion cathetercatheter
Insertion:Insertion:– Connect infusion tube to tube on the target Connect infusion tube to tube on the target
patchpatch– Assure patency by use of syringe administer Assure patency by use of syringe administer
5 ml blast of saline5 ml blast of saline• Clears any Clears any
tissue debris in tissue debris in the infusion the infusion cathetercatheter
2288
CMASTCMAST 2288
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure
Insertion:Insertion:─ Connect IV line to target patch tubeConnect IV line to target patch tube─ Open IV and ensure good solution flow Open IV and ensure good solution flow
2299
CMASTCMAST 2299
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure
Insertion:Insertion:– Emplace the dome over the siteEmplace the dome over the site
3300
CMASTCMAST 3300
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure
Insertion:Insertion:– Be certain that remover device is attached to Be certain that remover device is attached to
(and transported with) the casualty(and transported with) the casualty
3311
CMASTCMAST 3311
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure Problems areas:Problems areas:
– Infiltration - usually due to insertion not being Infiltration - usually due to insertion not being perpendicular to the manubriumperpendicular to the manubrium
– Inadequate flow or no flow -Inadequate flow or no flow -• Infusion tube occludedInfusion tube occluded• 1 ml saline flush recommended1 ml saline flush recommended• Infusion catheter inserted at other than a Infusion catheter inserted at other than a
perpendicular angle to the manubrium perpendicular angle to the manubrium surfacesurface
3322
CMASTCMAST 3322
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure
Removal procedure:Removal procedure:– Stabilize target patch with one handStabilize target patch with one hand– Remove dome with the otherRemove dome with the other
3333
CMASTCMAST 3333
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure
Removal procedure:Removal procedure:– Terminate IV fluid flowTerminate IV fluid flow– Disconnect infusion tubeDisconnect infusion tube
3344
CMASTCMAST 3344
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure Removal procedure:Removal procedure:
– Hold infusion tube Hold infusion tube perpendicular to the perpendicular to the manubriummanubrium
– Maintain slight traction Maintain slight traction on the infusion tubeon the infusion tube
– Insert the remover while Insert the remover while continuing to hold infusion continuing to hold infusion tube in slight tractiontube in slight traction
Removal procedure:Removal procedure:– Hold infusion tube Hold infusion tube
perpendicular to the perpendicular to the manubriummanubrium
– Maintain slight traction Maintain slight traction on the infusion tubeon the infusion tube
– Insert the remover while Insert the remover while continuing to hold infusion continuing to hold infusion tube in slight tractiontube in slight traction
3355
CMASTCMAST 3355
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure Removal procedure:Removal procedure:
– Advance removerAdvance remover– THIS IS A THREADED THIS IS A THREADED
DEVICEDEVICE– Gentle counterclockwise Gentle counterclockwise
movement at first may help movement at first may help in seating remover in seating remover
– Make sure you feel the Make sure you feel the threads seatthreads seat
3366
CMASTCMAST 3366
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure Removal procedure:Removal procedure:
– Turn it clockwise until Turn it clockwise until remover no longer turnsremover no longer turns
– This firmly engages This firmly engages remover into metal remover into metal (proximal) end of the (proximal) end of the infusion tubeinfusion tube
3377
CMASTCMAST 3377
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure Removal procedure:Removal procedure:
– Remove infusion Remove infusion tubetube
– Use only “T” shaped Use only “T” shaped knob and pull knob and pull perpendicular to the perpendicular to the manubriummanubrium
– Hold target patch Hold target patch during removalduring removal
– DO NOT pull on the DO NOT pull on the Luer fitting or the Luer fitting or the tube itselftube itself
Removal procedure:Removal procedure:– Remove infusion Remove infusion
tubetube– Use only “T” shaped Use only “T” shaped
knob and pull knob and pull perpendicular to the perpendicular to the manubriummanubrium
– Hold target patch Hold target patch during removalduring removal
– DO NOT pull on the DO NOT pull on the Luer fitting or the Luer fitting or the tube itselftube itself
3388
CMASTCMAST 3388
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure Removal procedure:Removal procedure:
– Remove target patchRemove target patch
3399
CMASTCMAST 3399
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure Removal procedure:Removal procedure:
– Dress infusion site using aseptic techniqueDress infusion site using aseptic technique– Dispose of remover and infusion tube using Dispose of remover and infusion tube using
contaminated sharps protocolcontaminated sharps protocol
4400
CMASTCMAST 4400
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure Removal procedure:Removal procedure:
– Problems encountered during removalProblems encountered during removal• Performed properly…should be none!Performed properly…should be none!• Be certain threads on remover engage Be certain threads on remover engage
threads at distal end of infusion catheterthreads at distal end of infusion catheter• Moving remover around with tip as axis Moving remover around with tip as axis
while in the infusion catheter may shear off while in the infusion catheter may shear off end of removal toolend of removal tool
4411
CMASTCMAST 4411
F.A.S.T.1 ProcedureF.A.S.T.1 Procedure Removal procedure:Removal procedure:
– If removal fails or proximal metal ends If removal fails or proximal metal ends separates:separates:• Anesthetize with local - make small incisionAnesthetize with local - make small incision• Remove using clamp and close as Remove using clamp and close as
appropriateappropriate
NOTENOTE: This is “serious injury” as defined by : This is “serious injury” as defined by the FDA and is a reportable eventthe FDA and is a reportable event
4422
CMASTCMAST 4422
Intravenous SolutionsIntravenous Solutions Different types of IV fluids can be used Different types of IV fluids can be used
for different medical conditionsfor different medical conditions
Generally categorized Generally categorized as:as:– Colloid or CrystalloidColloid or Crystalloid
4433
CMASTCMAST 4433
ColloidsColloids Contain protein, sugar or other high Contain protein, sugar or other high
molecular weight molecules; used to expand molecular weight molecules; used to expand intravascular volume.intravascular volume.– Whole blood (most common)Whole blood (most common)– Packed red blood cellsPacked red blood cells– Fresh frozen plasma Fresh frozen plasma – Plasma Protein FractionPlasma Protein Fraction– Hypertonic Saline & Dextran (HSD)Hypertonic Saline & Dextran (HSD)– Hextend is a 6% hetastarch solution Hextend is a 6% hetastarch solution
in a balanced electrolyte solutionin a balanced electrolyte solution
4444
CMASTCMAST 4444
CrystalloidsCrystalloids Solutions that do not contain protein or other Solutions that do not contain protein or other
large molecules; sodium is the primary osmotic large molecules; sodium is the primary osmotic agent.agent.
These fluids do not remain in the vascular These fluids do not remain in the vascular system very long.system very long.– Normal Saline (NS, 0.9% NaCl)Normal Saline (NS, 0.9% NaCl)– Lactated Ringers (LR)Lactated Ringers (LR)
4455
CMASTCMAST 4455
FluidsFluids Fluid distribution.Fluid distribution.
– Intracellular space = 2/3 of body weight.Intracellular space = 2/3 of body weight.– Extracellular space = 1/3 of body weight.Extracellular space = 1/3 of body weight.
• Interstitial space 80% Interstitial space 80% • Vascular space 20%Vascular space 20%
ICFICF
ICFICFECFECF
4466
CMASTCMAST 4466
FluidsFluids 1,000 ml of Ringers Lactate (2.4 lbs) will 1,000 ml of Ringers Lactate (2.4 lbs) will
expand the intravascular volume by expand the intravascular volume by 200-250 ml within 1 hour.200-250 ml within 1 hour.
Why only 200-250 ml left?Why only 200-250 ml left?
– Sodium diffuses out of the blood vessels into Sodium diffuses out of the blood vessels into the extravascular (interstitial) space rapidly.the extravascular (interstitial) space rapidly.
4477
CMASTCMAST 4477
HextendHextend 500ml of Hextend500ml of Hextend®® weighs 1.3lbs will weighs 1.3lbs will
expand the intravascular volume by 800ml expand the intravascular volume by 800ml within 1 hour, and will sustain this within 1 hour, and will sustain this expansion for 8 hours.expansion for 8 hours.
How does this happen?How does this happen?
Large sugar molecule-pulls fluid from the Large sugar molecule-pulls fluid from the extra vascular (interstitial) space into the extra vascular (interstitial) space into the vessels.vessels.
4488
CMASTCMAST 4488
FluidsFluids One liter of Hextend = 6-8 liters of RL.One liter of Hextend = 6-8 liters of RL. Is it a better resuscitation fluid?Is it a better resuscitation fluid? No, it is better for hypovolemia because of No, it is better for hypovolemia because of
its weight and cube advantage for the its weight and cube advantage for the soldier medic.soldier medic.
Ringers lactate is better for dehydration.Ringers lactate is better for dehydration. Soldier medics must carry some of each.Soldier medics must carry some of each.
4499
CMASTCMAST 4499
Resuscitation IndicatorsResuscitation Indicators How do you determine who needs fluids?How do you determine who needs fluids? Blood Pressure.Blood Pressure. Peripheral (radial) pulse.Peripheral (radial) pulse. Can BP be measured in a combat environment?Can BP be measured in a combat environment?
– HelicoptersHelicopters– TracksTracks– Battlefield conditionsBattlefield conditions
5500
CMASTCMAST 5500
Hypotensive ResuscitationHypotensive Resuscitation
Casualties should only be resuscitated to Casualties should only be resuscitated to a blood pressure of 80 mmHg.a blood pressure of 80 mmHg.
If blood vessels have clotted can you raise If blood vessels have clotted can you raise the blood pressure high enough to pop the the blood pressure high enough to pop the clot off?clot off?
– YES at a BP of @ 93 mmHg YES at a BP of @ 93 mmHg
5511
CMASTCMAST 5511
Resuscitation IndicatorsResuscitation Indicators
The systolic blood pressure may be The systolic blood pressure may be approximated by palpating specific pulses: approximated by palpating specific pulses:
─ Palpable carotid pulse = 60 mmHgPalpable carotid pulse = 60 mmHg─ Palpable femoral pulse = 70 mmHgPalpable femoral pulse = 70 mmHg─ Palpable radial pulse = 80 mmHgPalpable radial pulse = 80 mmHg
5522
CMASTCMAST 5522
Fluid ResuscitationFluid Resuscitation
Superficial wounds (>50% injured); no Superficial wounds (>50% injured); no immediate IV fluids needed. Oral fluids immediate IV fluids needed. Oral fluids should be encouraged.should be encouraged.
5533
CMASTCMAST 5533
Fluid ResuscitationFluid Resuscitation
Any significant extremity or truncal wound Any significant extremity or truncal wound (neck, chest, abdomen, pelvis).(neck, chest, abdomen, pelvis).
If the casualty is coherent and has a If the casualty is coherent and has a palpable radial pulse (BP 80 mmHg), palpable radial pulse (BP 80 mmHg), initiate a saline lock, hold fluids and initiate a saline lock, hold fluids and reevaluate as frequently as the situation reevaluate as frequently as the situation permits.permits.
5544
CMASTCMAST 5544
Fluid ResuscitationFluid Resuscitation If casualty has a palpable radial pulse, why If casualty has a palpable radial pulse, why
initiate a saline lock?initiate a saline lock?
─ By establishing intravenous access now, By establishing intravenous access now, when they have an adequate BP, it is easier when they have an adequate BP, it is easier than when they have a lower/absent BP.than when they have a lower/absent BP.
5555
CMASTCMAST 5555
Fluid ResuscitationFluid Resuscitation Significant blood loss from any wound, and Significant blood loss from any wound, and
the soldier has no radial pulse or is not the soldier has no radial pulse or is not coherent coherent --STOP THE BLEEDINGSTOP THE BLEEDING-- by by whatever means available - tourniquet, direct whatever means available - tourniquet, direct pressure, hemostatic dressings, or pressure, hemostatic dressings, or hemostatic powder etc. hemostatic powder etc.
Start 500 ml of HextendStart 500 ml of Hextend®®. If mental status . If mental status improves and radial pulse returns, maintain improves and radial pulse returns, maintain saline lock and hold fluids. saline lock and hold fluids.
5566
CMASTCMAST 5566
Fluid ResuscitationFluid Resuscitation
If no response is seen give an additional 500 ml If no response is seen give an additional 500 ml of Hextendof Hextend® ® and monitor vital signs. If no and monitor vital signs. If no response is seen after 1,000 ml of Hextendresponse is seen after 1,000 ml of Hextend®®, , consider triaging supplies and attention to more consider triaging supplies and attention to more salvageable casualties.salvageable casualties.
Why?Why?─ Resources: How many more casualties do you have Resources: How many more casualties do you have
and how much fluid is available?and how much fluid is available?
5577
CMASTCMAST 5577
Fluid ResuscitationFluid Resuscitation
If casualties are not resuscitated with 1,000ml of If casualties are not resuscitated with 1,000ml of Hextend they are probably still bleeding. If Hextend they are probably still bleeding. If excess fluids are given they will die faster than a excess fluids are given they will die faster than a casualty who received no fluids.casualty who received no fluids.
Why? Increased BP and coagulation factors Why? Increased BP and coagulation factors diluted as BP rises hemorrhage increasesdiluted as BP rises hemorrhage increases
Why then does ATLS recommend 2 large-bore Why then does ATLS recommend 2 large-bore IVs and fluid run wide open? The transit time to IVs and fluid run wide open? The transit time to definitive care is only a few minutes.definitive care is only a few minutes.
5588
CMASTCMAST 5588
Why does hypothermia happen?Why does hypothermia happen?
5599
CMASTCMAST 5599
HypothermiaHypothermia
Casualties who are hypovolemic quickly Casualties who are hypovolemic quickly become hypothermic.become hypothermic.
Body temperatures below 91°Body temperatures below 91° F F causes causes the vicious triad.the vicious triad.– HypothermiaHypothermia– AcidosisAcidosis– CoagulopathyCoagulopathy
6600
CMASTCMAST 6600
HypothermiaHypothermia When this vicious triad occurs the When this vicious triad occurs the
casualty’s blood will not clot. casualty’s blood will not clot.
Prevention is the best method.Prevention is the best method.
6611
CMASTCMAST 6611
Field Expedient WarmingField Expedient Warming Warm IV fluids in cold environment.Warm IV fluids in cold environment.
6622
CMASTCMAST 6622
HypothermiaHypothermia Prior to evacuation, casualties must be Prior to evacuation, casualties must be
wrapped in a blanket to prevent heat loss wrapped in a blanket to prevent heat loss during transport (even if the temperature is during transport (even if the temperature is 120°120° F F) especially true with air evacuation) especially true with air evacuation
6633
CMASTCMAST 6633
Hypothermia Prevention and Hypothermia Prevention and Management KitManagement Kit™™
Contents:1 x Heat Reflective Shell1 x Self Heating, Four Cell Shell Liner 1 x Heat Reflective Skull Cap
6644
CMASTCMAST 6644
Hypothermia Prevention and Hypothermia Prevention and Management Kit™ (HPMK)Management Kit™ (HPMK)
Ready for TransportReady for Transport
6655
CMASTCMAST 6655
6 – Cell
“Ready-Heat” Blanket
4- Cell
“Ready-Heat” Blanket
Blizzard “Survival
Wrap
6666
CMASTCMAST 6666
Summary Summary
Identify hypovolemic shock.Identify hypovolemic shock.
Ensure hemorrhage control first.Ensure hemorrhage control first.
Provide treatment for hypovolemic shock Provide treatment for hypovolemic shock using hypotensive resuscitation principles.using hypotensive resuscitation principles.
6677
CMASTCMAST 6677
Questions?Questions?