Tag Archives: Guidelines

Sepsis: Sepsis 3, Surviving Sepsis Campaign what now?

23 Gen

From a practical clinical point of view, after the 2016 update of the SSC (Surviving Sepsis Campaign) guidelines we have two references when comes to deal with a potential septic patient. Question Marks Sphere Ball Many Questions Asked

2016 Sepsis 3 definition and early management.

2016 Surviving Sepsis Campaign

Let’s see how to treat, based on top evidences, a real patient in the the pre-hospital and emergency department time window. 

But, first of all,  the definitions:

  • Definitions

Both the guidelines now agree that:

Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection

Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) despite adequate volume resuscitation”

  • Early identification

    1. SIRS criteria. The new 2016 SSC guidelines do not indicate any criteria for early identification of sepsis, so SIRS criteria no longer exists.
    2. qSOFA score (G.C.S. of 13 or less, SBP of 100 mm Hg or less, and RR 22/min or greater): Good negative and positive prediction value(similar to that sepsiscouchof the full SOFA score outside the ICU). Non specific for sepsis. It’s the actual early identification tool for sepsis to use out-of-hospital end in emergency department. It performs quite good to identify patients at risk of negative evolution. A qSOFA score ≥2 indicates a high mortality risk comparing to a qSOFA ≤1.
      sofa-score-1024x743
    3. SOFA score: indicates organ disfunction (when the score is >2 points) consequent to the infection and defines sepsis. Is a validated ICU tool to asses risk and mortality chance. Is not a tool to use out-of-hospital or in ED.
    4. The Pre-hospital Sepsis Score (PSS) or Miami Sepsis Score: As out-of-hospital professional I love pre-hospital early warning tools.I like to mention PSS cause is well validated to early recognise sepsis in the field. PSS includes Shock Index (HR/SBP) that is really sensible to identify critical evolution chance, RR that is included in qSOFA and other sepsis score plus body temperature (obligatory) that identifies an infection. Is for me the good compromise, in the field, between good positive and negative predictive value. A PSS of 1 point identifies a low risk patient, 2 points moderate risk, 3-4 points high risk patients.pss
  • Early management

    1. Early goal directed therapy: no longer recommended. CVP is no longer required and fluid response to initial volemic reanimation has to be clinically and dynamically assessed (passive leg raise, fluid challenges)
    2. Fluid resuscitation: 30 ml/Kg(in the first 3 hrs) to restore normal emodynamics values (MAP >65 mmHg). Lactate is a risk assessment tool (>2 mmol/L) and is no longer recommended to guide resuscitation efforts. Crystalloids are the fluids of choice. 
    3. Vasopressors: indicated if initial fluid resuscitation doesn’t reach the target. Norepinephrine is the pressor of choice. Epinephrine the second line agent in case Norepinephrine is not sufficiente to reach the target.Stop giving Dopamine.
    4. Bloodcultures: immediately and preferably before starting antibiotics but without delaying  antibacterial therapy. 
    5. Antibiotics: no double cover routinely but broad spectrum mono therapy is the recommended choice.
    6. Corticosteroids: consider just if patient is fully volume resuscitated and vasopressors are unsuccessful to maintain emodynamic stability.

Take home points for early phase management

Early Identification
Use either:
  • qSOFA (preferred in ED) cut off ≥2 points
  • PSS (preferred in the field) cut off ≥2 points.
Initial Management (target to a MAP >65)
  • Emodynamic stabilisation
    • 1st Fluid 30 ml/Kg of crystalloids.
    • 2nd Norepinephrine up to 35-90 μg/min (if 1st step failed).
    • Add Epinephrine up to 20-50 μg/min to achieve MAP target (if first 2 step failed).
  • Take blood cultures (if feasible before antibiotics but without delaying antibiotics).
  • Do not delay early broad spectrum antibiotic mono therapy.

 

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References 

 

 

 

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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Forget ALS Guidelines when dealing with PEA. Part 2.

23 Set

If you were interested in Forget ACLS Guidelines when dealing with Pulseless Electric Activity Part 1 here is the Part 2 of the presentation.

In Part 1 we discussed about diagnosis and diagnostic tools. Here are suggested alternative way to evaluate and treat patients with PEA.

MEDEST you tubeAs usual all your comments will be welcome.

NICE released Major Trauma Guidelines Draft.

8 Ago
NICE-1024x131
The National Institute for Health and Care Excellence (NICE) published a Guidelines Draft on Major Trauma. The great thing about is that everyone can consult the draft and send suggestion (but only if you work for a stackholder organization) about the recommendations and scientific evidences contained.
Consult the documents at the links below:

Here are some highlights with a particular regard to pre-hospital environment recommendations:

Airway management

RSI and orotracheal intubation is the preferred method to manage airways (when compromised) in a trauma patient.
In prehospital setting RSI and OTI has to be performed on scene in less than 30 min from the initial call. Backup plan is SGA (in patients with reduced level of consciousness and no glottic reflexes) or basic airways maneuver plus adjuncts (patients with GAG reflexes still present), and transfer to Trauma Center (within 60 min) to manage airways. If Trauma Center is more than 60 minutes away, reach local hospital to perform RSI and than transfer the patient.

“The GDG had a strong belief that RSI of anaesthesia and intubation delivered by a competent person is the gold standard of care when maintaining the airway of both adults and children and made a recommendation for RSI of anaesthesia and
intubation accordingly.”

“The GDG suggested that the second best device for airway management was the supraglottic device. This device provides less protection than RSI of anaesthesia and intubation against aspiration; however this device provides greater protection than
basic airway adjuncts, and can be administered safely by in the pre-hospital environment by paramedics or physicians staff.”

“Supraglottic devices can only be used in patients without airway reflexes to avoid stimulating vomiting or laryngospasm,, and
are therefore only appropriate for use in patients with a reduced level of consciousness.”

“For patients with airway reflexes, where a supraglottic device cannot be used, the GDG recommended the use of basic airway manoeuvres and adjuncts until such time as RSI of anaesthesia and intubation is available.”

“The GDG therefore concluded that where possible, RSI should be delivered at scene and within a timeframe than minimised
pre-hospital time. Pre-hospitals systems should develop to make this widely available. Where pre-hospital RSI is not possible within a 30-minute window, the GDG recommended transporting the patient with supraglottic or basic airway adjuncts to a MTC within 60 minutes, otherwise to a TU”

Pre-hospital Tension Pneumothorax

  • Closed pneumo
Perform chest decompression of a suspected tension pneumothorax only in haemodynamically unstable patients or in pts who have respiratory compromise.
Perform open thorachostomy to drain tension pneumothorax in haemodynamically unstable patients (preferred on simple needle decompression).
Simple open thorachostomy can be performed only in intubated (and positive pressure ventilated) patients. In all other cases insert a chest drain to prevent a sucking chest open wounds
  • Open pneumo
No more vented or 3-sided occlusive dressing in open (sucking) pneumothorax: use a simple occlusive dressing to treat an open pneumothorax in the pre-hospital setting

“The GDG limited the recommendation to intervene to people who are haemodynamically unstable or have severe respiratory compromise. The GDG agreed that people who have signs of a tension pneumothorax but are haemodynamically normal can wait until hospital for a more definitive diagnosis and possible decompression.”

“Needle decompression is a simpler technique to perform than insertion of a chest drain but is associated with a number of complications. These include the cannula blocking, the catheter not being long enough and therefore, not penetrating the
thoracic parietal pleura, or incorrect placement of the needle, all of which result in the decompression not being successful. The GDG agreed by consensus that open thoracostomy is more effective and stable than needle decompression.”

“An open thoracostomy can only be used on intubated patients. A surgical incision is made, blunt dissection is performed, and the pleura penetrated. The wound is then left open. This is a rapid way of decompressing a tension pneumothorax in a critically injured trauma patient who is intubated. The positive pressure ventilation prevents the thoracostomy wound from acting as an open, ‘sucking’, chest wound”

“The GDG agreed that given the lack of evidence, no recommendation could be made around whether an occlusive dressing for an open pneumothorax should be vented or three-sided. Additionally, the GDG accepted there was no evidence to make a
recommendation around supplementing the dressing with a chest drain in the prehospital setting.The GDG decided through expert consensus to recommend using a simple occlusive dressing to treat an open pneumothorax in the pre-hospital setting. The GDG emphasised the importance of a ‘simple’ dressing that provides an airtight seal that is fast and straightforward to apply. The priority should be transporting the patient to a hospital where a chest drain can be inserted.”

Haemorrhage control

First line intervention is direct pressure with simple dressing.
If direct pressure failed use tourniquets (no difference between mechanical or penumatic ones) as backup method. Is controversial when tourniquets has to be used (as first line) over direct pressure
Use Tranexamic acid in suspected haemorrahagic patients as soon as possible but never beyond 3 hrs from trauma

“In the absence of any evidence in favour of haemostatic dressings, the GDG did not believe that they offered any improvement over and above standard dressings with direct pressure.”

“Whereas, immediate haemorrhage control can be achieved by direct pressure, the decision of when direct pressure should be
used over tourniquets was considered controversial as the GDG tried to weigh up the risk and cost of placing a tourniquet on a person who did not require it compared with those that do.”

Vascular access

In adults use IV access as first line and IO as rescue technique if IV failed
In children, when difficult vascular access is suspected, use IO access as first line technique

Fluid resuscitation

In pre-hospital environment the target for volume titration has to be maintaining a palpable central pulse (femoral or carotid)
In pre-hospital, if blood products are not available, small boluses of crystalloids are the preferred fluid volume replacement.

“The GDG discussed the situation when a pre-hospital practitioner is treating a patient in profound haemorrhagic shock but does not have access to blood products. In this case small boluses of crystalloids would be appropriate.”

Pain control

IV Morphine is the first line recommended agent. Ketamine (at pain relief doses) the second option.
Caution is recommended when Morphine is administered in a haemodinamically unstable patient.
Intranasal administration is the recommended route of administration when IV is not available.

“Two studies compared IV morphine with IV fentanyl and found no difference between the interventions for pain relief and adverse side effects.”

(Many) Things that I Like about these guidelines

  1. The airway management approach! Totally agree on RSI and OTI as gold standard in trauma, and if performed, better be fast. The 30 min target is a quite fair indication but, as any other straight timing, depends on  the circumstances. The thing I appreciate is the idea of DO IT IN THE SHORTEST TIME POSSIBLE. Great. And if plan A (Ventilation+Oxygenation) fails? Plan B (Oxygenate) SGA and rush to TC, if close, or to any other trauma unit. And if for any reason placing a SGA is not possible? Use BVM and adjuncts and rush again. Love it!
  2. Thoracostomy better than needle decompression, both in prehospital and in hospital, for tension pneumothorax drainage. We are all aware of the bunch of studies indicating as needle decompression is inadequate in most cases, and all the FOAMED drums are rumbling on these frequencies. But till now none (first of all the Archaic Trauma Life Support)  officially stated this in a guideline (that I’m aware to, at least). So WELCOME expert consensus of NICE GDG!
  3. Simple occlusive dressing in open pneumo. Straight and simple.
  4. The choice for prehospital fluid replacement goes on crystalloids only cause blood products are not available, but in the text is highlighted as both crystalloids and colloids are detrimental on coagulation process (so they are banned in hospital setting). The future is blood products even in prehospital environment!

(Few) Things that I don’t like about these guidelines

  1. The choice of open simple thoracostomy just in intubated pts has to be more clearly highlighted. I suggest as an adjunct to main (yellow background) recommendation. And so as to be for thoracostomy plus chest drainage in non intubated pts.
  2. Why they just mention Morphine (as opioid) for pain control and don’t include fentanyl in the main recommendation, if in the text is clearly indicated as all the available evidences show no differences between the two drugs in terms of clinical effects and adverse events? I think Fentanyl due to its wide diffusion (with great satisfaction) worths a mention!

Draft closes for comments on 21 of September.

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Endovascular therapy in Stroke: the 2015 AHA/ASA Updated Guidelines establish new eligibility criteria.

30 Giu

New evidences aroused in treatment of ischemic stroke from early 2015. Large and well conducted trials demonstrated the benefit of endovascular therapy (in association with thrombolysis) on primary clinical endpoints.

MEDEST post on Endovascular Treatment of Ischemic Stroke

Today AHA and ASA  updated the 2013 Stroke Guidelines for the Early Management of Patients With Acute Ischemic Stroke regarding Endovascular Treatment on the basis of this recent evidences.

Let’s resume the recommendations on Endovascular Interventions:

  • Patients who are elegible for intravenous r-tPA should receive r-tPA and in addition endovascular therapy with a stent retriever if they meet all the following criteria (Class I; Level of Evidence A). (New recommendation):
  1. Prestroke modified Ranking Scale score 0 to 1
  2. Acute ischemic stroke receiving intravenous r-tPA within 4.5 hours of onset according to guidelines from professional medical societies
  3. Causative occlusion of the internal carotid artery or proximal MCA (M1)
  4. Age ≥18 years
  5. NIHSS score of ≥6
  6. ASPECTS of ≥6
  7. Treatment can be initiated (groin puncture) within 6 hours of symptom onset
  • To ensure benefit, reperfusion should be achieved as early as possible and within 6 hours of stroke onset (Class I; Level of Evidence B-R). (Revised from the 2013 guideline); if treatment is initiated beyond 6 hours from symptom onset, the effectiveness of endovascular therapy is uncertain (Class IIb; Level of Evidence C). (New recommendation)
  • The benefits are uncertain, on carefully selected patients with acute ischemic stroke in whom treatment
    can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the M2 or M3 portion of the MCAs, anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries. (Class IIb; Level of Evidence C). (New recommendation)
  • Endovascular therapy with stent retrievers may be reasonable for some patients <18 years of age with acute ischemic stroke who have demonstrated large vessel occlusion in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset, but the benefits are not established in this age group (Class IIb; Level of Evidence C). (New recommendation)

Read the full text on AHA/ASA website:

2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment

Read also:

Medscape article: Groups Issue Guidance on Endovascular Repair of Ischemic Stroke (subscription required)

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2014 NICE Guidelines. Acute heart failure: diagnosing and managing acute heart failure in adults

18 Ott

L’uscita di nuove linee guida è sempre un’occasione importante per chi ogni giorno si prende cura di pazienti critici in regime di emergenza-urgenza.

Quando poi l’argomento di cui trattano è importante, e per alcuni aspetti anche controverso, fa ancora più piacere l’uscita di un documento di consenso che permette di avere un riferimento affidabile per la pratica clinica giornaliera.

D’altra parte per i professionisti sanitari le linee guida non devono essere una gabbia professionale, bensì il valore aggiunto che guida le scelte cliniche ma la cui interpretazione critica prelude anche a scelte diverse, ma conseapevoli, da quele indicate.

Le nuove linee guida NICE (National Institute for Healthcare and Ecellence) sulla diagnosi e cura dello scompenso cardiaco acuto (2014 Acute heart failure NICE Full text Guidelines) pongono da questo punto di vista alcuni spunti interessanti quando si tratta di indicazioni per il trattamento iniziale.

Avevamo già trattato in un precedente post il trattamento dell’edema polmonare acuto affrontando le evidenze attuali ed i retaggi culturali che ancora persistono nel suo trattamento.

Vediamo se queste linee guida accolgono o meno i cambiamenti culturali che le nuove evidenze ci propongono.

1.3 Initial pharmacological treatment
1.3.2 Do not routinely offer opiates to people with acute heart failure.
 
Assolutamente d’accordo che il trattamento con oppiacei (se non per aumentare la compliance nel paziente in NIV) è inutile ed a volte dannoso. La somministrazione sistematica di Morfina quindi dovrebbe essere eliminata dall’algoritmo sulla gestione dello scompenso acuto di cuore.
References:
 
1.3.3 Offer intravenous diuretic therapy to people with acute heart failure. Starttreatment using either a bolus or infusion strategy.
 
Ci aspettavamo una scelta più coraggiosa e moderna a questo proposito da parte degli autori. La netta distinzione in termini fisiopatologici ha oramai evidenziato come molti delle presentazioni acute più drammatiche dello scompenso cardiaco non sono assolutamente determinate dal meccanismo del “volume overload” ma piuttosto sul “fluid shift”. Al contrario le presentazioni dovute ad un sovraccarico di volume sono di genesi più refratta nel tempo e quindi con sintomi meno drammatici, e molto spesso si giovano di un trattamento a lungo termine (anche con diuretici) e non sicuramente d’urgenza.
L’utilizzo di diuretici in emergenza per il paziente con scompenso cardiaco ha una utilità molto limitata, è potenzialmente  dannoso e dovrebbe essere riservato solo ad un selezionato selezionato gruppo di pazienti in una fase successiva della del trattamento.
References:
1.3.7 Do not routinely offer nitrates to people with acute heart failure.
1.3.8 If intravenous nitrates are used in specific circumstances, such as for people with concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease, monitor blood pressure closely in a setting where at least level
2 care can be provided.
 
La pratica clinica quotidiana, specie dopo l’avvento della NIV, ci conferma che l’utilizzo dei nitrati (specie in infusione continua) ha assunto un ruolo ed una priorità secondaria rispetto al trattamento non farmacologico, ma relegare il loro uso solo ad alcune situazioni particolari sembra inutilmente riduttivo per una terapia che presenta molti benefici in questa condizione patologica (elencati nella tabella seguente)
 
Benefits of Nitrate Therapy in Heart Failure

S-nitrosylation of effector proteins (8,13)
 Activates ryanodine receptors to improve myocardial contractility
 Regulates endothelial function
 Inhibits smooth muscle hyperplasia
 Regulates blood flow with changes in tissue oxygen tension matching flow to demand
 Protects myocytes by preventing oxidative damage
 Scavenges superoxide anions
 Regulates energy metabolism
 Protects cells from apoptosis
Guanylyl cyclase activation (8,17)
 Promotes venous and arterial smooth muscle relaxation decreasing preload and afterload
 Inhibits platelet aggregation by inhibiting platelet adhesion to vascular endothelium
 Has anti-inflammatory effects by preventing leukocyte adhesion to vascular endothelium
 Has antiapoptotic effects
 Has antiremodeling effects
Hemodynamic conditions (12,18,19)
 Decreased pulmonary capillary wedge pressure
 Decreased left ventricular end diastolic pressure
 Decreased pulmonary vascular resistance and right ventricular afterload
 Decreased systemic vascular resistance and left ventricular afterload
 Increased venous capacitance
 Decreased right atrial pressure
 Decreases myocardial oxygen demand
Divya Gupta, MD; Vasiliki V. Georgiopoulou, MD; Andreas P. Kalogeropoulos, MD Nitrate Therapy for Heart FailureBenefits and Strategies to Overcome Tolerance JCHF. 2013;1(3):183-191. doi:10.1016/j.jchf.2013.03.003
La somministrazione di Nitrati rimane quindi  (considerando anche i contesti in cui la NIV no è disponibile) un’utile opzione nel trattamento farmacologico dello scompenos cardiaco
1.4 Initial non-pharmacological treatment
1.4.1Do not routinely use non-invasive ventilation (continuous positive airways pressure [CPAP] or non-invasive positive pressure ventilation [NIPPV]) in people with acute heart failure and cardiogenic pulmonary oedema.
1.4.2 If a person has cardiogenic pulmonary oedema with severe dyspnoea and acidaemia consider starting non-invasive ventilation without delay at acute presentation or as an adjunct to medical therapy if the person’s condition has failed to respond
1.4.3 Consider invasive ventilation in people with acute heart failure that, despite treatment, is leading to or is complicated by:
respiratory failure or reduced consciousness or physical exhaustion
 
L’emergenza preospedaliera ha oramai adottato in modo stabile l’utilizzo della ventilazione non invasiva per il trattamento dello scompenso cardiaco. Le linee guida NICE raccomandano il suo utilizzo solo per pazienti che presentano “cardiogenic pulmonary oedema with severe dyspnoea and acidaemia“.
Mentre il criterio clinico sembra molto generico (manca infatti un riferimento ai parametri clinici per definire la dispnea grave, e mancano tutti i criteri di esclusione) risulta per la maggior parte delle nostre realtà territoriali non utilizzabile il parametro strumentale dell’acidemia.
La NIV è attualemnte uno dei cardini fondamentali della terapia non farmacologica dello scompenso cardiaco e il suo utilizzo dovrebbe essere implementato fin dalle prime fasi del soccorso.
References:
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Queste sono solo alcune alcune considerazioni.  Per approfondire l’argomento, potete comunque leggere

2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes

8 Ott

2014 AHA:ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes were published on September 23.

The new terminology, from Non STE Miocardial Infarction to Non STE Acute coronary Syndromes, establishes a  pathophysiological continuum between unstable angina and Non STE Acute coronary Syndromes, and make those two identities indistinguishable and considered together in this 2014 Guideline.

The need of High Sensitive Troponin and the importance of risk stratification are just few of the many changes made in this 2014 update

You con find this and all the newst guidelines on MEDEST Guidelines section

Sono state pubblicate il 23 di Settembre le 2014 AHA:ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes

Trovate queste e tutte le nuove linee guida su MEDEST nella sezione dedicata

Linee Guida

References:

2014 AHA:ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes

New Non-ST-Elevation ACS Guidelines: New Title, New Approach

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Vortex Approach: il manuale, i video tutorial

2 Ago

Ha suscitato molto interesse la check list per la gestione delle vie aeree Vortex.  Ed allora ecco il manuale completo ed i video tutorial. Tutto naturalmente gratuito!

Clicca sull’immagine per scaricare la versione pdf

 References:

http://www.vortexapproach.com/Vortex_Approach/Vortex.html

MEDEST you tube

 

Exertional heat stroke (EHS) Guidleines. Linee guida sulla prevenzione e cura del colpo di calore in corso di esercizio fisico.

4 Lug

While exertional heat illness (EHI) is not always a life-threatening condition, exertional heat stroke (EHS) can lead to fatality if not recognized and treated properly. As the word heat implies, these conditions most commonly occur during the hot summer months; however, EHS can happen at any time and in the absence of high environmental temperatures. Through proper education and awareness, EHS can be recognized, and treated correctly.

View the full guidelines at University of Connetticut (UCONN) website

 

 

Download all the most recent guidelines on MEDEST

Visualizza tutte le più recenti linee guida su MEDEST

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Vortex Approach: il manuale, i video tutorial

21 Giu

Ha suscitato molto interesse la check list per la gestione delle vie aeree Vortex.  Ed allora ecco il manuale completo ed i video tutorial. Tutto naturalmente gratuito!

Clicca sull’immagine per scaricare la versione pdf

 References:

http://www.vortexapproach.com/Vortex_Approach/Vortex.html

MEDEST you tube

 

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