HOI CHAN THtfONG CHINH HINH VIET NAM - HOI NGHj KHOA HOC TOAN QUOC LAN THtf IX
SLf DUNG CAU NOI MACH MAU TAM Tli CHE TRONG XLf TRI CAC CHAN THl/ONG CHI CO TON THl/ONG MACH M A U
Trjnh Cdng Binh*, Vu Hufu VTnh* va cs
TOM TAT
• Muc tieu nghien ciTu: LTng dung cau ndi mach mau tam (CNMMT) tU che trong xii" tri chan thUdng chi cd ton thUdng mach mau (CTCCTTMM) nham han che thap nhat thdi gian thieu mau ciia chi the do viec tdn thUdng mach mau gay ra, nhanh chdng cung cap mau cho chi the da bi thieu mau trong khoang thdi gian cd the gay hoai t i i phan chi ma mach mau tdn thUdng chi phoi, gop phan lam giam ty le cat cut chi. CNMMT dugc thiet ke de co the hut mau tir dgng mach phfa tren vung thUdng tdn va bdm cho dgng mach dUdi cho tdn thUdng.
• PhUdng phap nghien cu'u: Tien citu, thdng ke ngau nhien cac ca benh CTCCTTMM dUdc can thiep phau thuat tai BV Chd Ray t i i thang 6/2005 den thang 6/2010 cd diing CNMMT do cung mgt nhom phau thuat vien thUc hien
• Ket qua: Cd 44 ca CTCCTTMM da dUdc xit tri phau thuat cd dung CNMMT. Trong dd cd 37/44 ca dat ket qua tot va kha, chi the dUdc bao tdn, chiem 8 4 , 1 % . Cd 7/44 ca cd ket qua xau, phai cat cut chi, chiem 15,9%. Khong cd trUdng hdp nao t i i vong.
• Ket luan: Sir dung CNMMT trong xi:t tri CTCCTTMM cho thay cd hieu qua trong viec lam ngan thdi gian thieu mau chi, dac biet trong trUdng hdp benh nhan tdi tre (thdi gian vang sap het) hoac cac trUdng hdp tdn thUdng nang phirc tap doi hoi viec xir trf can nhieu thdi gian. Dieu nay gop phari quan trgng trong viec bao tdn chi the, rat nen dUdc irng dung rgng rai.
Tir khoa (keyword): Cau ndi mach mau tam (Temporary Intravascular Shunt) - TIVS, chan
thUdng chi cd kem tdn thUdng mach mau (Complex Extremity Vascular Injuries) - CEVIS
SUMMARY
APPLYING HOME-MADE TEMPORARY INTRAVASCULAR SHUNT I N MANAGEMENT OF
EXTREMITY TRAUMA WITH COMPLETE VASCULAR INJURY
Abstract: Applying home-made temporary intravascular shunt in complex extremity vascular injuries surgery could reduce the duration of distance ischemia. The shunt could quickly supply blood to distance part of the injured extremity that has been suffering from long time of ischemia or need time to repair injuries. Shunt was made by using any available tubes or catheters in the operating room. This could be sucked and pumped to push blood from the artery above the injured area to the distance.
From June 2005 to June 2010 there are 44 cases of extremity trauma with complete vascular injury has been operated by the same surgeons using temporary intravascular shunt. Of that 37 cases (84,1%) showed excellence and good result, the extremities were repaired well and kept functions post-operatively.
There were 7 cases (15,9%) that showed bad result with the outcome of amputation finally. Morbidity Is rezo.
Conclusion: Using temporary intravascular shunt is effective in an attempt to reduce ischemia duration of extremity trauma with complete vascular injury repair. It could shorten the ischemia duration of the injured extremity that has been late to come to the hospital. It also showed effectiveness in complicated injury that need long time to repair. This should be applying widely in as many medical facilities as possible.
Y HOC VIET NAM THANG 10 - SO 2/2010
I. OAT VAN DE:
- CTCKTTMM rk thudng gap trong cap cuu chin thuong chinh hinh. Nguyen nhan thudng thiy la tai nan luu thdng (TNLT), tai nan lao ddng (TNLD), te nan dam chem... dang la ndi birc xiic trong xa hdi.
- De lai hau qua nang ne nhu giam thieu chuc nang chi, doan cut chi, ddi khi tir vong neu viec dieu
- Can cd mdt quy trinh didu tri hieu qua loai tdn thuang CTCCTTMM, trong dd vai trd sir dung CNMMT la rkt can thiit.
I I . DOI Tl/QNG - PHl/QNG PHAP NGHIEN CLTU:
• Doi tu-gng nghien cihi:
- Chi thieu mau hoan toan, cdn kha nang sdng tdi tre (sap bet thdi gian vang 6 - 8h).
- Chi thieu mau hoan toan, cdn kha
nang sdng vdi thuoTig tdn phuc tap cSn nhilu tinh trang thieu mau chi nhanh hay cham, thdi gian xu ly. nang hay nhe. Mach mau bi tdn thuang
• PhuoTig phap nghien cihi: thudng d nhiing vimg di sat vdi xuong hoac - TiSn cuu 44 ca CTCCTTMM dugc nSm kep trong gifta cac khdi ca ldn hay day ung dung CNMMT trong qua trinh xir tri tir chang vdi xuong. ddng mach dui thudng bi thang 6-2005 din thang 06-2010 tai khoa , tdn thuong d viing dng diii sau khi chui qua tdn thuong mach mau phoi hgp vdi gly xuong hay trat khdp, vi hg thudng la ngudi dau tien kham benh nhan. Chin doan tdn thuang mach, ngoai cac diu hieu lam sang, sieu am Doppler, thi viec chup ddng mach van la tieu chuan vang de phat hien thuang tdn, dac biet trong nhirng ca khd nhu vi tri tdn thuang khdng rd rang, kha nang cd nhilu vi tri bi tdn thuong. Tuy nhien viec chup ddng mach khdng dugc lam qua cham phau thuat mdt khi tdn thuong mach da rd, cd thi dilu tri chan doan bing mo tham sat khi nghi ngd cd tdn thuong mach mau.
- Cd 5 loai tdn thuong mach mau: 1- Tao cac mang ndi mac. 2- Raeh ndi mac tao tu mau dudi ndi mac. 3- Raeh thanh mach. 4- Dut rdi mach mau. 5- Thdng ddng tinh mach.
Tuy loai tdn thuong mach tren vdi ca cbl chan thuong dung dap hay cit ggn se dua din
chan thuong chinh hinh BV Chg Riy.
I I I . TONG QUAN TAI LIEU:
- Tdn thuong mach mau trong gay xuong hay trat khdp chi, cd thi gay hau qua nang nl nlu viec xir tri khdng diing hoac
dng can co khep de tao ddng mach khoeo, nd song hanh vdi tinh mach diii chay cheo qua mat sau gdi, quyen chat liy nhau trong khe cac can viing khoeo. vi ly do nay ma khi chin thuong viing gdi nhu gay lien ldi clu dui, mam chay hoac trat khdp gdi ra sau dl dua cham tre, biln chiimg cua tdn thuang nay <5en nguy co tdn thuong mach khoeo, su mit thudng la nhilm trimg, tic mach gay hoai tii ^"^ thdng mau dot ngdt viing nay vdi cac chi din din cit cut, ddi khi la tir vong. Tdn nhanh ben it phin mlm thudng khdng bii dip thuang mach mau chi cd khi la hau qua cua
vet thuong dam xuyen bdi siing va dao hay TNLT, TNLD... tdn thuang cdn cd thi do sai sdt cua thiy thudc trong qua trinh chin doan dilu tri, hay van chuyen benh nhan.
Dilu quan trgng: ngudi phlu thuat vien chin thuong phai dugc dao tao de danh gia dugc
dugc, dac biet trong chan thuong dung dap nang cang din den nguy hilm.
- Cd su khac biet dang kl vl tuin hoan bang he giua chi tren va chi dudi, chi tren phong phii hon nen it din tdi cit cut ban. Cd rit it ddng mach d chi thi khdng thi thit dugc, tuy nhien khi cd them tdn thuong phin
HOI CHAN THtfONG CHINH HINH VIET NAM - HOI NGHI KHOA HOC TOAN QUOC LAN THtf IX
mem nhilu thi nguy co thieu mau cang tang len. Quan diem hien nay la nen cd gang phuc hoi mach mau bi tdn thuong vdi ndi true tiep (< 2cm), ghep mach tu than hoac nhan tao, trong chin thuang dung dap cd tdn thuong mach mau vdi phuc hdi bang ghep mach tu than la tdt nhat.
- Trong CTCCTTMM, van de phuc hdi luu thong mau la quan trgng nhat, nen viec sir dung CNMMT de nudi dudng chi trong nhieu trudng hgp that su can thiet, quyet dinh su thanh bai ciia dieu tri nhu chan thuong tdi tre hay qua trinh xir tri phiic tap, mat nhieu thdi gian. Eger va CS lan dau tien bao cao viec sir dung CNMMT trong xir tri CTCCTTMM vao nam 1971 tai BV Quan Dgi My, trai qua hon 30 nam nit kinh nghiem va phat trien viec iing dung CNMMT da cd nhieu budc tien vugt bac dat dugc ket qua my man. Carrel la ngudi dau tien dung CNMMT nghien ciiu tren ddng vat, tiep dd nam 1915 Tuffer trong the chien thii I da dung dng bac trang parafin lam CNMMT trong xir tri CTCCTTMM ciia thuong binh, sau dd dimg dng thuy tinh, rdi dng nhua
H I : CNMM tam - BVCR
¥^
trang Silicon. CNMMT dugc ghi nhan su dung nhilu tai hai cugc the chien, tuy nhien khdng dugc tdng kit va bao cao. Ngay nay nhiing CNMMT chuyen dung Pruit-Inahara hoac bat cii loai dng nao cd sin tai phdng m6 cd kich cd tuong duong, vdi tinh chat mlm, dau thon lang khdng gay tdn thuang ndi mac mach mau dugc ung dung nham nhanh chong cung cap mau cho phan chi bi tdn thuong giam thieu thdi gian thieu mau chi.
- Cd dinh ngoai bat ddng xuong gay la phii hgp cho viec bit ddng chi trong loai t6n thuong nay, bdi tinh chit thuong tdn: chi thilu mau nudi, vet thuang dl hd, vlt thuang nhiem ban nang... cd thi phai phdi hgp them vdi nep bdt (khdng dugc bd bdt trdn) dl bit ddng khdp noi mach mau bi ton thuong^'".
'X*
1^
~5i
H 2 : CNi\fHf tftm Pruit- Inahara va tdc gia Pruit
Y HOC VlgT NAM THANG 10 - SO 2/2010
H 4: Ton thuang mgch khoeo • • IV. PHU'ONG PHAP NGHIEN CU'U:
3 budc
Sau khi chan doan dugc cd tdn thuong mach mau trong chan thuong chi gay thieu mau hoan toan, cdn kha nang sdng tdi tre (6- 8h). Hay vdi tinh chat tdn thuang phirc tap can nhieu thdi gian xir ly.
a J Buac 1: phdu thudt chdn thuang (PTCT):
- Md can mac cac khoang chi phia dudi thuong tdn, danh gia kha nang sdng ciia co vdi 5 dau hieu (5C: Color-Mau sac, Cold- Lanh, Consistency-Mat do, Contractibility- Co CO, Capacity of bleeding-Mau chay). Neu CO cdn sac dd, am, mat do chac, cd phan xa CO CO va khi cat cd mau chay la tinh trang co con kha nang sdng. '
H.5: CNMM tgm tru&c kh i xu- tri - Tien hanh dat cau ndi mach mau tam tu che sau khi xir ly 2 dau ddng mach bi tdn thuong: cat bd phan dap nat, lay mau cue, chdng ddng... Cau ndi tam ciia chiing tdi dugc lam vdi 2 phan dng Feeding hoac dng hiit khi quan (vdi nhieu loai kich cd phii hgp vdi kich thudc cua mach mau tir sd 6 den 12), ndi ket vdi 1 chac 3 va dugc gan 1 bom tiem. Cau ndi cd kha nang hut mau tir phan tren bom xudng phan dudi hoac de ddng chay tu do va de dang kiem soat dugc viec luu thdng mau.
- Xdi rira, cat lge vet thuong va cd dinh xuong gay dugc tien hanh sau khi dat cau ndi, vdi cd dinh ngoai hoac trong. CNMMT dugc duy tri trong sudt qua trinh xir ly tren.
H 6: Gdy dui - ton thuang dong mgch dui dung CNMM tgm nuoi chi
H 7: CNMM tgm nuoi chi trong xir tri gdy mdm chay - ton thuang dong mgch khoeo
HOI CHAN THtfONG CHJNH HINH VIET NAM - HOI NGHj KHOA HOC TOAN QUOC LAN THtf IX
h./ Buac 2: phdu thudt mgch mdu (PTMM) (phuc hoi luu thong mdu): viec phuc h6i luu thdng mau dugc tien hanh ngay sau khi hoan tat viec cat lge va cd dinh chi.
vdi 2 phuong thiic: ndi tan-tan hoac ghep mach tu than . dugc thuc hien bdi cac nha phlu thuat chuyen ve mach mau.
c./ Buoc 3: phdu thudt chdn thuang (PTCT): tiln hanh elt lge lai vlt thuong, phuc hdi clu true phan mem nhu than kinh, gan, CO...Tilp do che phu xuong mach mau va din luu triet dl vet thuang. vet thuong ludn dugc de hd de tranh gay chen ep anh hudng tdi viec nudi dudng chi.
V. SO LIEU VA KET QUA:
a./ so lieu:
- Nguyen nhan: TNLT 29/44 ca (65,9%).
TNLD 8/44 ca (18,18 %). Dam chem 7/44 ca (15,9%).
- Vi tri: chi tren 10/44 ca (22,72 %).
vimg gdi 25/44 ca (56,81 %). chi dudi khac 9/44 ca (20,45 %)^chi dudi 34/44 ca (77,27 %).
- Thdi gian: trudc md: sdm nhat 215' (phiit), tri nhit 1800', trung binh 600'. trong md: nhanh nhat 120', lau nhat 360', trung binh 215'.
- Phuc hdi mach mau: ndi tan-tan 18/44 ca (40,9 %), ghep mach tu than 26/44 ca (59,09 %).
- Bat ddng chi: cd dinh ngoai 25/44 ca (56,81 %), CO djnh trong 19/44 ca (43,18 %).
b.l kit qud: tdt (chi sdng hoan toan 26/44 ca (59,09 %). kha (mit mdt vai nhdm co) 11/44 ca (25%). xlu (doan cut chi) 7/44 ca (15,9%)^ bao tdn dugc chi 37/44 ca (84,09%).
VI. BAN LUAN:
/./ Nguyin nhdn: TNLT 29/44 ca (65,9%) chilm gin 2/3 sd ca CTCCTTMM,
dang la ndi biic xiic trong xa hdi, gay tdn hai nhieu cho siic khoe cung nhu chi phi ton kem. TNLD va te nan dam chem la hai nguyen nhan tilp theo, cin gidng chudng canh bao cho cac nha quan ly lao ddng va xa hdi.
2./ Chdn dodn: cin sdm nhan biet dugc CTCCTTMM, dac biet luu y viing gli voi tdn thuong ddng mach khoeo, miic do nang, phirc tap ciia vlt thuang de cd thai do xu tri diing va kip thdi.
3./ Th&i gian:
- Trudc md: (Bao gdm 1 - Thdi gian hr liic bi tai nan tdi khi nhap cap cuu, 2 - Thdi gian trong cap ciiu, 3 - Thdi gian tir liic dugc chi dinh phau thuat tdi khi dugc chuyen toi phdng md va 4 - Thdi gian chd dgi tai phong md den khi dugc md). Sdm nhat 215', lau nhat 1800', trung binh 760' {tgi cdp cm BVCR trung binh 160'- cua nhom chimg toi), Tac gia Srius Sadapoms - Thai Lan: sdm nhit 120', lau nhit 450', trung binh 410' ->
Cho thay rat can su quan tam dung muc loai tdn thuong nay trong he thdng cap eim y te, dac biet nai ed chuyen khoa chan thuang chinl; liinh. Nhdm chiing: 32 ca khdng sir dung cau ndi tam tai BVCR thdi gian tmng binh trudc md 870' (trong cap cuu BVCR:
270').
- Trong md: nhanh nhat 120', dai nhat 360', trung binh 215' tai BVCR, tac gia Srius Sadapoms: 225', 360', 285', thdi gian chuin bi dat cau ndi 30', thdi gian luu giii cau noi tam 60 - 180' ^ tuong duong nhau. Nhom 32 ca khdng su dung cau ndi tam tai BVCR thdi gian trung binh trong md 236'.
^ 4./ Cdc bu&c thuc hiin: quy trinh xu tri CTCCTTMM qua 3 budc: PTCT - PTMM - PTCT vdi su phdi hgp ciia 2 chuyen khoa ngoai: chin thuong chinh hinh va ngoai long nguc mach mau dk phat huy the manh cua
Y HOC VIET NAM THANG 10 - SO 2/2010
mdi chuyen khoa. Su phdi hgp chat che va ddng bd dl dat dugc kit qua tdt.
5./ Cdu ndi mgch mdu tgm: Tir thang 6- 2005 tdi nay, nhdm chiing tdi ung dung CNMMT tu cbl trong qua trinh xir tri loai ton thuong nay, qua 4 thi he cau ndi: the he 1 - mgt doan dng (nhugc diem: dau dng cat ra dl gay tdn thuong ndi mac mach mau), the he 2 - hai dng (nhugc diem: cau ndi qua dai giam tdc do ddng chay), the he 3 - hai doan ong (khd kiem soat ddng chay), the he 4 - hien nay: hai doan dng ket ndi vdi 1 chac 3 gan ket vdi 1 bom tiem cd kha nang hiit mau phia tren bom xudng phia dudi hoac de tu chay, de kiem soat luu thdng mau. CNMMT chuyen dung cua Pruit - Inahara hien tai BVCR chua cd, gia 60 USD va ciia chiing tdi:21.000VND.
6./Phuc hdi mgch mdu: 18/44 ca (40,9
%) ndi tan-tan tai BVCR cho thay chua phu hgp vdi loai ton thuong CTCCTTMM ma nguyen nhan vdi co che chan thuang da sd la dung dap nang. tac gia Srius Sadapoms 6/7 ca ghep mach tu than. Nhdm 32 ca khdng sir dung cau ndi tam 24/32 ca ndi tan - tan (75%) m».:(-^.;' ' .:
7./Kit qud:
- Nam 1949 Miler va CS thir nghiem d chd cho thiy: 90%) chi sdng khi thieu mau <
6h, 50% sdng tir 12 - 18h, va 20%) sdng tir 24 - 3 Oh. Tdt nhit thdi gian trudc 6 - 8h thieu mau : •
- Su dung CNMM tam trong xir tri CTCCTTMM cho thiy cai thien viec nudi dudng chi chin thuong, qua danh gia tinh trang co trudc khi dat cau ndi vdi trudc khi phuc hdi luu thdng mach mau. Trudc day, khi chua su dung CNMMT tinh trang co liic diu cdn tdt, sau khi cit lge, cd dinh xuong gly, phuc hdi mach mau, kiem tra lai, nhieu khi CO da chit. Trong nhiing trudng hgp thit
bai vdi sd lieu cua chimg tdi, nguyen nhan do tic mach, nhiem triing lam hoai tir chi, d nhirng ca vdi tinh chat dap nat nang, cd nhieu vi tri thuong tdn d mdt va d cac trudng hgp phuc hdi mach mau bang ndi tan-tan.
- Nhom benh khong sie dung CNMM tgm: tai BVCR qua sd lieu tir 6/2008 den 6/2009 vdi 32/152 trudng hgp tdn thuong mach cd chi dinh dat cau ndi tam: Vi tri: chi tren: 8 ca (25,6%), vimg gdi: 15 ca (48%), chi dudi khac: 9 ca (26,4%). Thai gian:
Trudc cap ciiu BVCR: Trung binh 870', trong d p ciiu BVCR: 270', mo: 236'. Phuc hoi mgch mdu: Ndi tan - tan 24/32 ca (75%).
Kit qud: 11 ca elt cut (34,4%.). Denis 19%
cat cut khi chan thuong gdi cd tdn thuang mach khoeo, Kendall : 6,7%) cat cut khi thieu mau < 6h va 33% cat cut khi > 6h, Hoover:
75% cat cut khi chan thuong gdi cd tdn thuong mach khoeo. Green va Allen 86% cat cut sau 8h, Caudle & Stem : 78%) cat cut gay hd do 3c chi dudi do dap nat nang. Debatkey va Simeon (1946) trong the chien thii II tdng ket 35,8%) cat cut trong tdng sd 2471 ca tdi trudc 12h.
- Nhom benh sie dung CNMM tgm:
Hughes (1954): Trong chien tranh Trieu Tien 89% CTCCTTMM dugc ciiu sdng khi su dung CNMM tam. Rich (1971) : Trong chiln tranh Viet Nam 86,5%) giii dugc chi trong tdng sd hon 1000 ca. Baros : Trong chien tranh Bac Ailand 5% phai cat chi. Chamber
& CS (2005) tai chiln trudng Iraq tir 01/9/2004 din 31/8/2005 cd 30/126 ca CTCCTTMM dugc img dimg CNMM tam phai cat cut 2 ca (0,6%)). Husain A, and khaudaparka J va CS: BV KEM, (Bombay - India) tir 1/1988 din 10/1990: 5 ca tdn thuang ddng mach khoeo dugc sir dung CNMM tam dat kit qua tdt, khdng biln chiing, dung dng hiit ndi khi quan lam
HOI CHAN THtfONG CHJNH HJNH VIET NAM - HOI NGHj KHOA HOC TOAN QUOC LAN THtf IX
CNMM tam. Sriussadapoms va CS: 7/7 ca tot (100%). Subramanian, Anuradha MD, Christopher MD va CS: Tdng kit 10 nam dilu tri TTMM tir 01/1997 din 01/2007 tai BV Grandy Memory (My) vdi 786 ca TTMM cd 67 ca dugc dat CNMM tam (72:
ddng mach, 29: tinh mach), chii ylu la loai tdn thuong Gustilo IIIC va diit lia. Kit qua 5% tic mach lai, cit cut 18%, 8 ca (12%) tir vong (do da thuang), 73% bao tdn dugc chi va benh nhan. Nguyen Trudng Giang & CS (2009 - QYV 103)16/16 bao tdn dugc chi khi sir dung CNMM tam. Chiing tdi : 37/44 (84,09%) bao tdn dugc chi.
V I I . KET LUAN:
- CNMM tam thuc su giir vai trd quan trgng dl bao ton dugc chi trong qua trinh xir tri da sd cac trudng hgp CTCCTTMM, nen rit cin dugc phd bien va nhan rdng cho cac ddng nghiep ap dung tai cac trung tam phau thuat cap ciiu chan thuong.
- CNMM tam cd the dugc sir dung khi van chuyin benh nhan CTCCTTMM tir tuyen dudi len tuyen tren nham giam thieu thdi gian thieu mau chi.
- Can sdm nhan biet dugc thuong tdn CTCCTTMM dl cd thai do xii tri diing va kip thdi, can su phdi hgp chat che giiia hai chuyen khoa PTCT - PTMM qua 3 budc xir tri.
TAI LIEU THAM KHAO
1. Christian, CA: General Principles Of Fracture Treatment. Cambell's Operative Orthopedics. 1998. vol 111: 1193-2041
2. Colton, 'CL: The History Of Fracture Treatment. Skeletal Trauma, 1992, vol 1: 3- 30
3. Husain AK, and Khandeparker J;
Temporary Intravascular Shunt for peripheral vascular Trauma. 25 April 2009; Juomal of Posgraduate Medicine, vol 38
4. Kirti.D. Moholka and Bruce H.Ziran:
Vascular Injuries. Local Complications.
Rockwood And Green's Fractures In Aduh 2006. vol 1:564-598
5. Nguyen Trirtrng Giang: Nghien ciru sir dung CNMM tam trong dieu trj ton thuotig mach mau chi the. Tap chi Y -Dugc hpe Quan sir, sd 41/2009. Tr : 185 - 191.
6. Nguyen Khanh Du*: Dieu trj vet thuang va di chiing vet thucmg mach mau ldn ngoai bien. Bai giang dieu trj benh hgc ngoai khoa tap 1, xuit ban 1986, trang 95-108.
7. Robert C. Shenk and Daniel E. Washer:
Dislocation And Fracture -Dislocation Of The Knee. Rockwood And Green's Fractures In Aduh 2006. vol 11: 2041-2072
8. Scottw. Alpert MD: Knee Dislocations, Fracture And Dislocations: 1994: 115 - 117 9. Sriussadapoms : Chulalonkom University - Bangkok Thailand Trauma. 2002 jun; 52(6):
1129-33.
10. Subrananian, Anuradha MD, Christopher MD: Adecad's Experience with Temporary Intravascular Shunt at a Civilian Level 1 Trauma Center. The Joumal of Trauma;
Injury, Infection and Cristical Care. August 2008 - Volume 65 - Issue 2 - PP 316-326
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