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In case of oesophageal intubation

19 Ago

Just published Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies

Thanks to a prestigious panel of international authors. Great job and definitely solid indication about how to prevent and recognise accidental oesophageal intubation.

Just some of the key recommendations

  • Exhaled carbon dioxide monitoring and pulse oximetry should be available and used for all episodes of airway management.
  • Routine use of a videolaryngoscope is recommended whenever feasible.
  • Inability to detect sustained exhaled carbon dioxide requires oesophageal intubation to be actively excluded.
  • Tube removal should be undertaken if any of the following are true:
    • Oesophageal placement cannot be excluded
    • Sustained exhaled carbon dioxide cannot be restored
    • Oxygen saturation deteriorates at any point before restoring sustained exhaled carbon dioxide

Refer to the full text guidelines for more.
Here is the link to Safe Airway Society livestream event.
Must read, must follow. Free open access.

Let’s go outside

The following are personal considerations on peculiar aspects about management of accidental oesophageal intubation in prehospital environment and come from my personal clinical experience.

Beware they are just personal considerations and practical tricks and tips and are not intended to substitute the above guidelines. 

They are intended to suggest an alternative mental and technical approach when dealing with oesophageal intubation on uncontrolled patients in difficult environment.

Some general considerations

  1. Prehospital uncontrolled patients are not on empty stomach so are at high risk of regurgitation/inhalation
  2. Even few ventilation efforts in case of oesophageal intubation pone the patient at high risk of regurgitation/inhalation 
  3. Suctioning in prehospital setting is not always ready avalliate (mind your environment) or maximally performant (mind your equipment) 
  4. First attempt in prehospital setting must be always the best one. Think before trying a second attempt in case of failure. Implement your plan or change plan.
  5. Apply the Indication, Suitability, Feasibility approach while supporting oxygenation, ventilation and protection.

DO NOT REMOVE THE OT TUBE STRAIGHT FORWARD IN CASE OF ACCIDENTAL OESOPHAGEAL INTUBATION IN PREHOSPITAL ENVIRONMENT.

The way I like it. The way I do it.

  1. Live the “oesophageal” OT tube in (overcuffed) and if it’s possible apply a continuous suctioning to exclude the oesophagus and protect the airways 
  2. Place a SGA to restore oxygenation and ventilation (trough BMV or NIV)
  3. After restoring oxygenation (SaO2 >94%) and ventilation (EtCO2 40 mmHg) if suitable and feasible (see below) proceed to a second attempt of tracheal intubation (must be videolaryngoscope+bougie)
  4. If the second attempt succeeds remove the “oesophageal” OT
  5. If the second attempt is not suitable or feasible transport to nearest hospital (patient is well oxygenated and ventilated via SGA and protected via oesophageal exclusion) for further stabilisation (you can replace the oesophageal OT tube with a large bore oro-gastric tube or insert the orogastric tube trough the SGA dedicated channel)
  6. If you can’t restore oxygenation and ventilation via SGA or you can’t place a SGA remove the oesophageal OT tube and try to oxygenate and ventilate (remember patient is not protected) via BVM and NC (double oxygenation) 
  7. If even BVM fails declare CICO 
Suitability 
  • Do I have a plan to implement regarding the  first attempt
  • Can I improve my environment (Setting) moving the patient to a more comfortable place/position 
  • Is the time to nearest hospital short/long 
Feasibility 
  • Am I in the right mental mood after 1st attempt (me) to try a better second one
  • Is my team ready for a second attempt (team) 
  • Do I have the right equipment to implement my second attempt (Equipment)

The visual algorithm

The Video

By Mario Rugna

Pulseless electrical activity following traumatic cardiac arrest: Sign of life or death?

11 Giu

On May 2019 was published an article we review today, cause the authors conclusions are pretty astonishing and worth a deeper look.

Israr, S & Cook, AD & Chapple, KM & Jacobs, JV & McGeever, KP & Tiffany, BR & Schultz, SP & Petersen, SR & Weinberg, JA. (2019). Pulseless electrical activity following traumatic cardiac arrest: Sign of life or death?. Injury. 10.1016/j.injury.2019.05.025.

Authors Conclusions: Following pre-hospital traumatic cardiac arrest, PEA on arrival portends death. Although Cardiac Wall Motion (CWM) is associated with survival to admission, it is not associated with meaningful survival. Heroic resuscitative measures may be unwarranted for PEA following pre-hospital traumatic arrest, regardless of CWM.Trauma death 2.jpg

What kind of study is this?

retrospective, cohort study consisting of adult trauma patients (n. 277 patients ≥18 years of age) admitted to one of two American College of Surgeons verified level 1 trauma centers in Maricopa County, Arizona within the same hospital system between February 2013 to September 2017 and January 2015 to December 2017.

Pre-hospital management by emergency medical transport services was guided by advanced life support protocols. 

Both hospitals for management of Traumatic Cardiac Arrest (TCA) followed the Western Trauma Association Guidelines

The following variables were collected from each patient:

  • Age
  • Gender
  • Duration of pre-hospital CPR
  • Survival to admission vs. pronouncement of death in ED
  • Disposition at hospital discharge

Results

  • 277 trauma patients that underwent pre-hospital CPR for TCA
  • Mean patient age was 43.1
  • Mechanism of injury was penetrating in 99 patients (35.7%), the most common of which was due to ballistic injuries, the rest where blunt trauma.
  • 52.0% of the patients were intubated prior to hospital arrival
  • 235 patients received epinephrine in route (84.8%)
  • Pre-hospital resuscitation duration, 20.0 (15.0 – 25.0) minutes

Outcomes

20 patients were identified on arrival to have had ROSC. 18 of these patients survived to hospital admission and 4 of them were discharged alive from hospital

147 patients were identified on arrival in asystole. Among these patients none were discharged alive from hospital.

The remaining 110 patients presented with PEA. 10 patients survived to admission, 9.1%, but only one, 0.9% was discharged from alive from hospital.

P-FAST was performed in 79 of the 110 patients with PEA (71.8%)

Presence of CWM was significantly associated with survival to hospital admission (2 but not to hospital discharge (zero with or without CWM).

Authors conclusions

  • Resuscitative efforts are unlikely to reverse the course of this pathophysiology, warranting sound clinical judgement from the treating physician concerning the decision to continue or desist, relative to mechanism of injury and clinical presentation.
  • CWM (signifying a beating heart and thereby pseudo PEA) was not associated with meaningful survival.
  • Nonetheless, we conclude that P-FAST is a useful tool for distinguishing PEA with cardiac standstill, which is in all likelihood terminal (and continued resuscitation would become an attempt at reanimation), versus pseudo PEA, whereby the heart is actually still beating, representative of a veritable sign of life, and ongoing resuscitative attempts may be considered appropriate despite the unfavorable prognosis.

My considerations on methodology and results

  1. Conventional ACLS protocol, as performed in the study, IS NOT the standard of care in TCA.
  2. No clinical intervention to address reversible causes where performed (or mentioned) in the field.
  3. The only clinically oriented manoeuvre performed in the field was tracheal intubation in just half of the patients (52.0% of the patients were intubated).
  4. Prehospital resuscitation time (20 minutes mean time) was spent performing non useful and potentially  dangerous interventions (closed chest compressions, epinephrine administration) for TCA.
  5. Patients with PEA and documented CWM (but not only them) at their arrival in ED has been hypo perfused during the entire pre-hospital resuscitation time and lost most of their chances for good clinical outcome.

So in my opinion this study and it’s conclusions are biased by a wrong approach to Traumatica Cardiac Arrest in the prehospital phase.

Emergency providers, when treating patients in traumatic cardiac arrest, need to perform interventions addressing the possible REVERSIBLE causes:

  1. Exanguination/Massive Hemorrage (Pelvic Binding, TXA administration, Tourniquet or direct compression)
  2. Hypoxia (Tracheal Intubation)
  3. Tension Pneumo (Double Thoracostomy)
  4. Hypovolemia (Blood or fluid resuscitation)

Emergency providers need to rely on direct (central pulse palpation, Ultrasuond) or indirect (EtCO2, Plethysmography) signs of perfusion to guide their clinical interventions.

Resuscitation of Traumatic Cardiac Arrest patients in not futile just need to be performed in the right way.

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References

Israr, S & Cook, AD & Chapple, KM & Jacobs, JV & McGeever, KP & Tiffany, BR & Schultz, SP & Petersen, SR & Weinberg, JA. (2019). Pulseless electrical activity following traumatic cardiac arrest: Sign of life or death?. Injury. 10.1016/j.injury.2019.05.025.

 

 

1 Year in Review. 2018 Guidelines you must know.

13 Dic

So 2018 is at the end and we give, as every year, a look back to literature and articles of this finishing year.

This is the first step of 1 YEAR IN REVIEW the classical MEDEST appointment with all that matter in emergency medicine literature.

So let’s start with Guidelines but first I want to cite an important point of view about Clinical practice Guidelines and they future development:

Clinical practice guidelines will remain an important part of medicine. Trustworthy guidelines not only contain an important review and assessment of the medical literature but establish norms of practice. Ensuring that guidelines are up-to-date and that the development process minimizes the risk of bias are critical to their validity. Reconciling the differences in major guidelines is an important unresolved challenge.”

Paul G. Shekelle, MD, PhD. Clinical Practice Guidelines What’s Next?

And now here it is, divided by topics, the most important new 2018 Guidelines. Click on the link to read more.
  • Airway management

Guidelines for the management of tracheal intubation in critically ill adults
Guidelines for the management of tracheal intubation in critically ill adults PP presentation

  • Trauma

Management of severe traumatic brain injury (first 24 hours)
Spinal Motion Restriction in the Trauma Patient –A Joint Position Statement
Guidelines for Prehospital Fluid Resuscitation in the Injured Patient
Re-thinking resuscitation: leaving blood pressure cosmetics behind and moving forward to permissive hypotension and a tissue perfusion-based approach
  • Cardiac

2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay

  •  Stroke

2018 Guidelines for the Early Management of Patients with acute ischemic stroke.A Guideline for Healthcare Professionals From the American HeartAssociation/American Stroke Association

  • Others

Health Professions Council of South Africa. Clinical Practice Guidelines

 

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Prehospital Emergency Procedures: Scalpel, Finger, Bougie. That’s all you need!

13 Lug

In Emergency Medicine “Simplicity” is synonymous of efficiency, efficacy and reproducibility.

More the time frame is stressful more we need procedures that are efficient, efficacious and standardised, in one word SIMPLE.

Critcothyrodotomy and chest drain are procedures usually performed in high stressing scenarios and more simply they are more chance of success they have.

I don’t like complicate kits. They need training of course but even a calm and protected environment, and the middle of a street or a busy ER room aren’t nothing like that. 

I don’t like blindly performed procedures but prefer trusting my own senses and sensibility when performing high invasive procedures that, mostly of the times, are a lifesaving last chance.

So this is the best way I know to perform a surgical access to the airway and to drain a highly unstable tense pneumo: using simple instruments, always present in every emergency pack, and trusting my own tactile sensitivity.

surgical-airway-sfb

In those following videos you can see live records of the procedures. They were captured during a recent cadaver lab where I had the honour to join Jim DuCanto, Yen Chow, Carmine Della Vella and Fabrizio Tarchi in teaching airway management and clinical emergency procedures.

Hope you enjoy.

 

 

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Fluid resuscitation in bleeding trauma patient: are you aware of wich is the right fluid and the right strategy?

23 Apr

DCR copy

The fluids of choice in prehospital field are, in most cases, cristalloids (Norma Saline or Lactate Ringer).

But what is the physiological impact of saline solutions when administered in large amounts (as the latest ATLS guidelines indicates) to hypotensive trauma patients?

Is aggressive Fluid resuscitation the right strategy to be pursued?

The triad of post-trauma lethal evolution is:

  • Hypotermia
  • Acidosis
  • Coagulopathy

Aggressive fluid resuscitation with cristalloids, and saline solutions in particular, can be detrimental in many ways:

  1. Cristalloids tend to displace the already formed clots and improves bleeding
  2. Normal Saline produce hypercloremic acidosis worsening coagulation and precipitating renal and immune dysfunction
  3. Cristalloids diluts the coagulation factors and precipitate the coagulation system (dilution coagulopathy)
  4. Cristalloids rapidilly shift in intercellular space worsening SIRS process and interstitial edema (brain edema, bowel wall edema) with consequent compartment hypertension

So wich is the perfect fluid to infuse in trauma?

The perfect fluid doesn’t exists.

Balanced saline and Hypertonic saline are promisng prospective but there are still no good quality evidences about their benefit on clinical outcomes.

Colloids has no place in fluid resuscitation of trauma patients.

The fluid of choice, regarding the actual evidences and indications, is Lactate Ringer.

More than on the type of fluid the attention of researchers and clinicians is oriented on the strategy to pusue in those cases.

Hypotensive resuscitation, part of damage control resuscitation, is at the moment the strategy of choice in trauma bleeding patients.

Restrictive fluids administration is the way to achieve this goal.

The target systolic BP has to be diferentiated depending on the type of trauma

  • 60–70 mmHg for penetrating trauma
  • 80–90 mmHg for blunt trauma without TBI
  • 100–110 mmHg for blunt trauma with TBI.

More important do not delay definitive treatment.

ASAP give blood products (PRBC, FFP etc…) to contrast post-trauma coagulopathy and send the patients in OR to fix treatable causes of bleeding

The following are a collection of  un essentials resources on haemostatic resuscitation after trauma

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2016 NICE Major Trauma Guidelines. The pre-hospital recommendations.

21 Feb

NICE released the 2016 Major trauma Guidelines.

Many interesting recommendations where made for pre-hospital and in hospital providers about several topics

  • Airway management

  • Chest trauma

  • Haemorrage control

  • Circulatory access

  • Volume resuscitation

  • Fluid replacement

  • Pain management

  • Documentation

  • Training

Here is the Excerpt regarding the pre-hospital settings

Download the full guidelines for in-hospital recommendations and full description of Guidelines process and rationale behind every single recommendation

Download the full Guidelines at:

Major trauma: assessment and initial management

NICE guidelines [NG39] Published date: February 2016

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The pregnant patient

30 Gen

The management of a pregnant women has been always a challenge for physicians.

The different physiology of pregnancy, makes clinical choices and treatment different than in usual adult patient, and needs attentions and practice that override standard care.

In emergency medicine, where standards and protocols are a way to think and to act, a change in routine care, together with the time dependency of the decision making process, makes the pregnant patient an effective challenge.

So here is the need of specific guidelines focused on pregnant patient for specific clinical emergency situations.

In this post we discuss two guidelines about the management of a pregnant trauma patient and cardiac arrest in a pregnant women, with an eye of regard on the aspects of the recommendations for prehospital care.

Guidelines for the Management of a Pregnant Trauma Patient (Open Access)

Approved by Executive and Board of the Society of Obstetricians and Gynaecologists of Canada

J Obstet Gynaecol Can June 2015;37(6):553–571

Airway
  • Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan. (III-C)
  • A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content.(III-C)
Breathing
  • Oxygen supplementation should be given to maintain maternal oxygen saturation >95% to ensure adequate fetal oxygenation. (II-1B)
  • If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual. (III-C)
Circulation
  • Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women should be used only for intractable hypotension that is unresponsive to fluid resuscitation. (II-3B)
  • After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava to increase venous return and cardiac output in the acutely injured pregnant woman. This may be achieved by manual displacement (Lateral Uterus Displacement L.U.D.) of the uterus or left lateral tilt (obsolete n.d.r). Care should be taken to secure the spinal cord (if indicated n.d.r.) when using left lateral tilt. (II-1B)
Transfer to health care facility
  • Transfer or transport to a maternity facility (triage of a labour and delivery unit) is advocated when injuries are neither life nor limb threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks’ gestational age or considered to be non-viable. When the injury is major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of gestational age. (III-B)
Perimortem Caesarean section
  • A Caesarean section should be performed for viable pregnancies (≥ 23 weeks) no later than 4 minutes (when possible) following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage. (III-B)

Take home points on modifications of assessment of trauma patients in presence (or suspect) of pregnancy

  1. When indicated a thoracostomy tube should be inserted 1 or 2 intercostal spaces upper than usual.

  2. Vasopressors has to be avoided in pregnancy.

  3. Perform L.U.D (Lateral Uterus Displacement) to relieve Inferior Vena Cava compression.

  4. Transport the severely injuried pregnant patient to an hospital with maternal facility if fetus is viable (≥ 23 weeks).

Cardiac Arrest in Pregnancy. A Scientific Statement From the American Heart Association (Open Access)

Circulation. 2015;132:00-00. DOI: 10.1161/CIR.0000000000000300
Cardiac Arrest in Pregnancy1
Chest Compressions in Pregnancy
  • There is no literature examining the use of mechanical chest compressions in pregnancy, and this is not advised at this time
  • Continuous manual LUD (left uterus dispalcement) should be performed on all pregnant women who are in cardiac arrest in which the uterus is palpated at or above the umbilicus to relieve aortocaval compression during resuscitation (Class I; Level of Evidence C).
  • If the uterus is difficult to assess (eg, in the morbidly obese), attempts should be made to perform manual LUD if technically feasible (Class IIb; Level ofEvidence C)
  • Cardiac Arrest in Pregnancy
Transporting Pregnant Women During Chest Compressions
  • Because an immediate cesarean delivery may be the best way to optimize the condition of the mother and fetus, this operation should optimally occur at the site of the arrest. A pregnant
    patient with in-hospital cardiac arrest should not be transported for cesarean delivery. Management should occur at the site of the arrest (Class I; Level of Evidence C). Transport to a facility that can perform a cesarean delivery may be required when indicated (eg, for out-of-hospital cardiac arrest or cardiac arrest that occurs in a hospital not capable of cesarean delivery)
Defibrillation Issues During Pregnancy
  • The same currently recommended defibrillation protocol should be used in the pregnant patient as in the nonpregnant patient. There is no modification of the recommended application of electric shock during pregnancy (Class I; Level of Evidence C).
Advanced Cardiovascular Life Support
Cardiac Arrest in Pregnancy 3
Breathing and Airway Management in Pregnancy
Management of Hypoxia
  • Hypoxemia should always be considered as a cause of cardiac arrest. Oxygen reserves are lower and the metabolic demands are higher in the pregnant patient compared with the nonpregnant patient; thus, early ventilatory support may be necessary (Class I; Level of Evidence C).
  • Endotracheal intubation should be performed by an experienced laryngoscopist (Class I; Level of Evidence C).
  • Cricoid pressure is not routinely recommended (Class III; Level of Evidence C).
  • Continuous waveform capnography, in addition to clinical assessment, is recommended as the most reliable method of confirming and monitoring correct placement of the ETT (Class I; Level of Evidence C) and is reasonable to consider in intubated patients to monitor CPR quality, to optimize chest compressions, and to detect ROSC (Class IIb; Level of Evidence C). Findings consistent with adequate chest compressions or ROSC include a rising Petco2 level or levels >10 mm Hg (Class IIa; Level of Evidence C).
  • Interruptions in chest compressions should be minimized during advanced airway placement (Class I; Level of Evidence C).
Arrhythmia-Specific Therapy During Cardiac Arrest
  • No medication should be withheld because of concerns about fetal teratogenicity (Class IIb; Level of Evidence C).
  • Physiological changes in pregnancy may affect the pharmacology of medications, but there is no scientific evidence to guide a change in current recommendations. Therefore, the usual drugs and doses are recommended during ACLS (Class IIb; Level of Evidence C).
Epinephrine and vasopressine
  • Administering 1 mg epinephrine IV/IO every 3 to 5 minutes during adult cardiac arrest should be considered. In view of the effects of vasopressin on the uterus and because both agents are considered equivalent, epinephrine should be the preferred agent (Class IIb; Level of Evidence C).
Fetal Assessment During Cardiac Arrest
  • Fetal assessment should not be performed during resuscitation (Class I; Level of Evidence C).
Delivery durin cardiac arrest
  • During cardiac arrest, if the pregnant woman (with a fundus height at or above the umbilicus) has not achieved ROSC with usual resuscitation measures with manual uterine displacement, it is advisable to prepare to evacuate the uterus while resuscitation continues (Class I; Level of Evidence C)
  • PMCD (Peri Mortem Cesarean Delivery) should be strongly considered for every mother in whom ROSC has not been achieved after ≈4 minutes of resuscitative efforts (Class IIa; Level of Evidence C).
  • If maternal viability is not possible (through eitherfatal injury or prolonged pulselessness), the procedure should be started immediately; the team does
    not have to wait to begin the PMCD (Class I; Level of Evidence C).
  • Assisted vaginal delivery should be considered when the cervix is dilated and the fetal head is at an appropriately low station (Class IIb; Level ofEvidence C)

Take home points for resuscitation in trauma patient:

  1. The utilization of mechanical chest compressors is not recommended.

  2. Continuous LUD should be performed during resuscitation.

  3. No modification in energy level when electrical therapy is needed.

  4. No modification in timing and doses of ACLS drugs.

  5. Fetal assessment is not indicated during resuscitation.

  6. Peri Mortem Cesarean Delivery (PMCD) has to be performed without delay and at the site of cardiac arrest (no transport is indicated), after 4 minutes of ineffective resuscitation attempts.

 

References: 

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2014年第一届潇湘急诊重症与呼吸治疗国际论坛. 2014 Xiao Xiang International Forum on Emergency and Critical Care Medicine.

1 Ott

From 23 to 25 of September at Hunan Provincial People’s Hospital in Changsha (People’s Republic of China) was held the Xiao Xiang International Forum on Emergency and Critical Care Medicine and Reapiratory Therapy.

Many speakers from differents part of Asia and US talked about different and interesting topics. I was honored to be part of this group.

I want to thank my friend and colleague Zhang Yi Xiong for the great opportunity he gave me. I also thank him for the wonderful human experience I had meeting all the chinese colleagues who work in Emergency Depatment of  Provincial People’s Hospital.

Here is my presentation

You can also watch the presentation on line at the link below

http://prezi.com/x41ftjbiv17b/?utm_campaign=share&utm_medium=copy&rc=ex0share

Clik the links below to download the pdf and ppt version of the presentation

Emerging Trends in Prehospital Emergency Medicine.pdf

Emerging Trends in Prehospital Emergency Medicine.ppt

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Aggiornamento Linee Guida NICE sul trauma cranico

2 Feb

Il National Institute for Helath and care Excellence (NICE) ha aggiornato le Linee Guida per il triage ed il trattamento del trauma cranico dall’età pediatrica a quella adulta.

Dal trattamento preospedaliero agli algoritmi decisionali e diagnostici intraospedalieri, in forma chiara e concisa.

MEDEST you tube

ACEP Clinical Policies e Trauma Ultrasound eBook

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این سایت را به آن دکتوران و محصلین طب که شب و روز برای رفاه نوع انسان فداکاری می کنند ، جوانی و لذایذ زندگی را بدون چشمداشت به امتیاز و نفرین و آفرین قربان خدمت به بشر می کنند و بار سنگین خدمت و اصلاح را بدوش می کشند ، اهداء می کنم This site is dedicated to all Doctors and students that aver the great responsibility of People’s well-being upon their shoulders and carry on their onerous task with utmost dedication and Devotionاولین سایت و ژورنال انتــرنتی علـــمی ،تخـصصی ، پــژوهشــی و آمــوزشــی طبـــی در افغــانســـتان

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