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Critical Care > Exam 4 > Flashcards

Exam 4 Flashcards

1
Q

what is an open fracture?

A

occurs when the skull is punctured causing the dura to be punctured exposing the brain

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2
Q

what is a primary TBI?

A

damage that occurs at the time of injury due to stress on the brain

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3
Q

is a open fracture primary or secondary?

A

primary

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4
Q

what is a linear fracture?

A

a crack to the skull that does not move bone

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5
Q

is a linear fracture primary or secondary?

A

primary

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6
Q

what is a depressed fracture?

A

a portion of the skull is caved inward towards the brain

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7
Q

what is a comminuted fracture?

A

fractured in one spot with many pieces

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8
Q

what is a basilar fracture?

A

fracture at the floor of the skull

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9
Q

what causes basilar fracture?

A

MVA, assault,

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10
Q

what will a basilar fracture patient present like?

A

Bleeding from ears/nose, CSF from nose, Racoon eyes, mastoid bruising

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11
Q

what is battles sign?

A

bruising at the mastoid

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12
Q

what type of fracture will have a positive battles sign?

A

basilar fracture

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13
Q

what is the halo test?

A

a test that looks for csf being present in blood from some ones nose

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14
Q

what fracture do you do the halo test on?

A

basilar

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15
Q

how can you test if what is coming from someones nose is CSF?

A

do a blood sugar the fluid if it has a glucose content its csf and the halo test

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16
Q

what is a closed brain injury?

A

occurs when skull integrity is good but damage has occurred to the brain

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17
Q

what is a concussion?

A

a closed brain injury that causes tissue to be stunned

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18
Q

what is a contusion?

A

a closed brain injury that causes damage to the brain

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19
Q

does a concussion or contusion cause brain damage?

A

contusion

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20
Q

what does the contusion do to the brain?

A

causes bruising in a area

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21
Q

what is a diffused axonal injury?

A

damage to the axons in the white matter
and tearing of vessels

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22
Q

what is the severity of a diffused axonal injury?

A

extreme deficits

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23
Q

what is a secondary brain injury?

A

something that occurs after a injury

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24
Q

what are examples of secondary brain injury?

A

hemorrhage, epidural, subdural, intracerebral, brain herniation

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25
Q

what is a epidural hemorrhage?

A

ARTERIAL bleeding between the inner skull and the dural space

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26
Q

is an epidural bleed slow or fast?

A

fast bleed

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27
Q

what can trick you about an epidural bleed?

A

they will brief loss of LOC, get better, and then rapidly deteriorate

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28
Q

what is a subdural bleed?

A

Venous bleed beneath the dura and above the arachnoid…..blood touching the brain

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29
Q

is a subdural bleed slow or fast?

A

slow

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30
Q

what is a intracerebral bleed?

A

arterial and venous bleeding into the subcortical white matter inside the brain

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31
Q

what is brain herniation?

A

continued edema in the brain causes the brain tissue to be squeezed into structres

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32
Q

what type of bleed is usually not caught right away?

A

subdural because it is a slower bleed

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33
Q

what are symptoms of brain herniation?

A

rapid decrease in neuro status, rapid decline in LOC, pupils will change into many different things

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34
Q

how is a brain herniation fixed?

A

****cranioplasty to remove part of the skull

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35
Q

what should be done with the patient prior to surgery?

A

CT scan

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36
Q

what is done in the OR to help with increased ICP?

A

drains

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37
Q

how do you treat tbi patients?

A

like SCI

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38
Q

what precautions are TBI patients on?

A

spinal precautions and seizure precautions

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39
Q

whats included in spinal precautions?

A

lay flat, spinal board, log roll, c collar

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40
Q

what acronym should you keep in mind with TBI?

A

ABC

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41
Q

what questions should you ask yourself when thinking airway on TBI?

A

can they breath on their own, clear secretions, maintain spo2, is their pattern normal

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42
Q

what may be done prophylactically to TBI patietns?

A

intubation

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43
Q

what are the early neuro changes for TBI?

A

change in LOC, restless, irritable, coordination changes, different strength in extremities

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44
Q

what might a TBI patient be doing with their hands?

A

posturing

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45
Q

what are the two kinds of posturing?

A

Decorticate and decerebrate

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46
Q

what does decerebrate posturing look like?

A

arms at side and wrists extension

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47
Q

what does Decorticate posturing look like?

A

arms on chest and wrist in flexiom

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48
Q

what is glasgow scale?

A

Extent of neuro activity

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49
Q

what are the diagnostics for TBI?

A

full rainbow and CT/MRI

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50
Q

what are the interventions for TBI?

A

could be trached, could be intubated, seizure precautions, neuro checks q 2, reorient, restraints, repeat ct/mri

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51
Q

what should be used sparingly with TBI?

A

sedation

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52
Q

why is sedation used cautiously in TBI patients?

A

it can mask neuro changes

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53
Q

what meds are TBI patients on?

A

Dexamethasone, Fentanyl, and pheytoin

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54
Q

what does dexamethasone do for TBI?

A

alleviates edema and decreases ICP

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55
Q

what should you watch for when giving dexamethasone?

A

hypoglycemia, hyperglycemia,

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56
Q

why is fentanyl given to TBI?

A

pain

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57
Q

is fent iv push or continous?

A

both

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58
Q

why is phenytoin given to TBI?

A

anticonvulsant to prevent seizures

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59
Q

is phenytoin iv push or continous?

A

both

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60
Q

what should you always do when giving phenytoin?

A

run the drug through a filter, check ALT/AST, and check serum levels in blood

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61
Q

why should phenytoin be run through a filter?

A

it crystalizes

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62
Q

what is a good phenytoin serum level?

A

10-20

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63
Q

what is the monroe kellie hypothesis?

A

brain, blood, and CSF are in a constant equilibrium where if one increases the others decrease

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64
Q

what are early signs of increased ICP?

A

decline in LOC, restless, irritable, confusion, headache, unilateral weakness, pupil changes

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65
Q

what are late signs of increased ICP?

A

severe headache, LOC change, coma, erratic resp rate/cheyenne stokes, irregular pulse, hyperthermia, projectile vomitting, loss of corneal reflex, loss of gag reflex, posturing, seiaures, flaccidity, unreactive pupils, cushings triad

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66
Q

what reflex changes can increase ICP lead to?

A

loss of corneal, cough, and gag

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67
Q

what is the corneal reflex?

A

when you touch their eye they move their head

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68
Q

what are signs of cushings triad?

A

hypertension with a widened pulse pressure, bradycardia, bradypnea

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69
Q

what is a widened pule pressure?

A

a pulse pressure greater than 40

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70
Q

how is pulse pressure calculated?

A

SBP - DBP

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71
Q

in someone with increased ICP what are you monitoring?

A

5 lead, pulse ox, ICP, CO2

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72
Q

what is used to monitor ICP?

A

bolt or EVD

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73
Q

what type of ICP device is a surgical procedure?

A

EVD

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74
Q

why is edema in the skull bad?

A

leads to ischemia of the brain

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75
Q

why is CO2 monitored in increased ICP?

A

because CO2 has a direct effect on pressure in the skull

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76
Q

what does high CO2 do to the brain?

A

increases pressure

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77
Q

what does low CO2 do to the brain?

A

decreases venous outlfow increasing the pressure

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78
Q

what are the diagnostics done for increased ICP?

A

CT and MRI

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79
Q

what are the procedures done for increased ICP?

A

Craniotomy, burr holes, cranioplasty, and drains

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80
Q

what is a craniotomy?

A

cut into skull suck out blood and put the flap back

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81
Q

what are burr holes?

A

hole is made for needle to suck out contents

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82
Q

what is a cranioplasty?

A

cut into the skull and remove a portion

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83
Q

what are the interventions for increased ICP?

A

keep CPP greater than 70, HOB at 30 degrees or more, keep head midline, help with temp control, low stim enviroment, paralyzing to lower ICP

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84
Q

what should be avoided in increased ICP patients?

A

low HOB, dont cluster care, avoid hip flexion, suctioning for more than 10 seconds

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85
Q

why should you avoid hip flexion in increased ICP?

A

it reduce venous outflow

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86
Q

how is CPP calculated?

A

MAP-ICP

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87
Q

what does CPP tell us?

A

cerebral perfusion pressure tells you xxx

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88
Q

what meds are given for increased ICP?

A

mannitol, succinylcholine, and vecuronium

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89
Q

why is mannitol given for increased ICP?

A

reduces icp by directly targeting the brain

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90
Q

is mannitol k sparring or wasting?

A

wasting

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91
Q

what other med maybe given with mannitol?

A

furosemide

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92
Q

is mannitol continuous or bolused?

A

bolused

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93
Q

what should always be done when giving mannitol?

A

filter on IV line

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94
Q

what should be hooked up before giving mannitol?

A

ICP monitoring and filter

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95
Q

what happens to mannitol if it sits too long at room temp?

A

crystalize

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96
Q

what paralytics are given to reduce ICP?

A

succinylcholine and vecuronium

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97
Q

what are side effects of paralytics?

A

apnea

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98
Q

what paralytic is IV push only?

A

suc

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99
Q

what paralytic is IV drip?

A

vec

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100
Q

what paralytic can raise K level?

A

succinylcholine

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101
Q

what is a complete SCI?

A

spinal cord damage enough to eliminate function below injury

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102
Q

what is incomplete SCI?

A

injury allowing some function below injury

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103
Q

what is a hyperflexion SCI?

A

sudden forward acceleration

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104
Q

what is hyperextension SCI?

A

sudden acceleration and deccelerationw

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105
Q

what is an example of hyperflexion sci?

A

head on collision or diving

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106
Q

what is an example of hyperextension SCI?

A

rear ended

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107
Q

what is axial loading sci?

A

vertical compression of vertebae

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108
Q

what are some examples of axial loading SCI?

A

diving, falling on butt, landing on feet

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109
Q

what is a rotational SCI?

A

turning head beyond ROM

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110
Q

what is penetrating sci?

A

damage to spine due to knife, gun shot etc

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111
Q

what are secondary sci?

A

hemorrhage, ischemia, shock, edema

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112
Q

why are you worried about ABC with SCI?

A

high risk of resp complications in cervical sci because of damage to the phrenic nerve

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113
Q

what does the phrenic nerve control?

A

diaphragm and accessory muscles

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114
Q

how often do you assess resp function in sci?

A

q2

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115
Q

what might be done to SCI injury to help with oxygenation?

A

intubated/trach

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116
Q

what is also calculated on SCI?

A

glasgow scale

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117
Q

how can you assess hemodynamics in SCI?

A

art line

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118
Q

what is common in sci in relation to waste?

A

illeus and neurogenic bladder

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119
Q

what is neurogenic bladder?

A

they dont empty all of the way

120
Q

what are diagnostics for sci?

A

ct, mri, x ray

121
Q

what do you want MAP to be in SCI patient?

A

90 or more

122
Q

what prophylaxis are SCI patietns on?

A

DVT/ clot

123
Q

what are the intervention for DVT porphylaxis?

A

TED, SCD, ROM, heparin,warfarin, enoxaparin, IVC

124
Q

what patients cant get blood thinning medications?

A

hemmorhage

125
Q

what is an IVC

A

filter that goes into inferior vena cava that catches clots

126
Q

what are sci patients at risk for resp wise?

A

mucus plugs, pneumonia, atelactasis

127
Q

what can be done to help sci patients with resp comp?

A

incentive spirometry, suction, quad cough

128
Q

what kind of rolling for sci patients?

A

log

129
Q

what devices help keep spine neutral?

A

c collar, halo, and tlso

130
Q

whats better c collar or halo?

A

halo

131
Q

is a halo removable?

A

no

132
Q

why cant the halo be removed?

A

its screwed into the skull

133
Q

what if halo comes undone?

A

hold head in neutral, yell for help, keep them still

134
Q

what meds do sci patients take?

A

methlyprednisone and baclofen

135
Q

what should be avoided if taking methylprednisone?

A

grapfruit

136
Q

what should be checked in patients taking methyl prednisone

A

hypo/hyperglycemia

137
Q

what are then complications of sci?

A

spinal shock, neurogenic shock, autonomic dyseflexia

138
Q

what does the sympathetic control?

A

fight or flith

139
Q

what does parasympathetic do?

A

calm down

140
Q

what happens during spinal shock?

A

temporary complete loss of function below the injury

141
Q

symptoms of spinal shock?

A

hypotension, bradycardia, flaccid,

142
Q

what are the interventions for spinal shock?

A

maintain airway, mobilize spine, fluids, control body temp

143
Q

how long does it take to recover from spinal shock?

A

48 hours

144
Q

what is neurogenic shock?

A

imbalance of sympathetic and parasympathetic

145
Q

what is too high in neurogenic shock?

A

parasympathetic

146
Q

what can cause neurogenic shock?

A

issue below the injury like urinary retention or constipation

147
Q

what are symptoms of neurogenic shock?

A

hypotension, bradycardia, periphreal vasodilation, decreased LOC, and decreased UOP

148
Q

what might neurogenic shock patients need?

A

pressors

149
Q

what can neurogenic shock lead to?

A

organ failure

150
Q

how can you tell the difference between spinal shock and neurogenic shock?

A

spinal shock has flaccidity is that it?????

151
Q

what type of injury increases your risk of neurogenic shock?

A

injury above t6

152
Q

what is anutonimc dyseflexia?

A

sympathetic is too high

153
Q

symptoms of autonomic dyseflexia?

A

headache, hypertension, bradycardia, N/v, stuffy, flushing/sweating above injury, pale/goosbumps below the injury

154
Q

what non med interventions for autonomic dyserflexia?

A

sit up, loose clothing, check catheter for obstruction, check for retention, check for impactment, adjust temp

155
Q

what meds are given to autonomic dyserflexia patiens?

A

nifedipine

156
Q

what are the types of burns?

A

dry heat, moist heat, contact, electrical, and chemical

157
Q

what is dry heat?

A

open flame

158
Q

what are open flame burns at risk for ?

A

inhalation injury

159
Q

what is a moist hear burn?

A

steam or hot water

160
Q

what is contact burn?

A

hot metal, grease, tar

161
Q

what is also know as a grand masquerader ?

A

electrical burn

162
Q

why are elctrical burns so bad?

A

it burns outside and inside the body

163
Q

what is considered a superficial burn?

A

first degree

164
Q

what causes first degree burns?

A

sunburn, flame, scald

165
Q

what layers are involved in first degree?

A

epidermis

166
Q

symptoms of first degree burn?

A

tingling, pink, red, hyperthesia, itching, peeling/desquamation, possible blisters

167
Q

what happens if you rub first degree burns?

A

the epidermis wont rub off

168
Q

what meds might help first degree burns?

A

Ibuprofen and cooling lotions

169
Q

what is the other term for second degree burns?

A

partial thickness

170
Q

what are some causes of second degree burns?

A

scalds, flames, contact

171
Q

what layers are burned in second degree?

A

epidermis and part of the dermis

172
Q

what are the symptoms of second degree burn?

A

pain, hyperthesia, sensitive to air

173
Q

what does the burn look like in second degree burns?

A

blistered, red, weeping, edema, mottled

174
Q

how long do second degree burns take to heal?

A

10-21 days

175
Q

is there scarring in first degree burns?

A

no

176
Q

what does the wound look like after its healed in a second degree burn?

A

scarring and pigment change

177
Q

what is another name for a third degree burn?

A

full thickness burn

178
Q

what are causes of a third degree burn

A

flame, prolonged hot lot liquids, eletrical burn, chemical

179
Q

what skin layers are involved in a third degree burn?

A

epidermis, dermins, and some sub cu tissue….no muscle and bone?????

180
Q

what are symptoms of third degree burn?

A

insensate, shock, myoglobinuria, contact points

181
Q

what is insensate?

A

occurs when nerves are burned so there is no pain

182
Q

what is myoglobin uria?

A

red urine due to break down of myoglobin from muscle damage

183
Q

what are contact points?

A

entrance and exit wound from electrical burns

184
Q

what does the wound look like in third degree burns?

A

pale, white, red, brown, black/charred, leathery, dry, edema

185
Q

what is another term for black/charred skin?

A

eschar

186
Q

what is another name for fourth degree burns?

A

full thickness

187
Q

what tissue involment in fourth degree burns?

A

all skin layers, tissue , muscle, bone

188
Q

what causes fourth degree burns?

A

prolonged exposure to hot surfaces, high voltages, chemicals

189
Q

when do burns cause coagulated vessels?

A

third degree onward

190
Q

what are symptoms of fourth degree burns?

A

shock, myoglobinuria, no edema, no pain,

191
Q

what does the wound look like in fourth degree?

A

charred

192
Q

what is the only treatment option for fourth degree?

A

amputation

193
Q

does second degree burn require graft?

A

it could

194
Q

does third degree require graft?

A

yes

195
Q

what is a circumferential burn?

A

a burn that goes around an entire area

196
Q

what are cirucmferential burns of the abdomen and chest at risk for?

A

resp issues due to the chest not being able to fully expand

197
Q

what is an escharotomy?

A

a cut to the skin to allow for expansion

198
Q

what is a fasciotomy?

A

a cut that is deeper than a escharotomy to allow for even more expansion

199
Q

what should be kept in mind with electrical burns?

A

there is an entrance and exit but tissue internal can still be destroyed

200
Q

what is considered a major burn?

A

more than 20% of the body or burn to the eyes, ears, face, hands, feet, genitals, or perenium

201
Q

at what point do you go to burn center?

A

if you have more than 20% burn, third degree, electrical or inhalation

202
Q

what systemic changes are there for major burns?

A

vascular changes, fluid and electrolytes shift, cv changes, pulmonary changes, renal, Gi,

203
Q

what vascular changes occur during major burn?

A

clots, necrosis, and bad perfusion

204
Q

what fluid/electrolyte changes occur from major burn?

A

Fluid shifts causing hypovolemia, hyperkalemia, hyponatremia, metabolic acidosis??

205
Q

what cv changes occur during major burn?

A

hyperkalemia, tachycardia, decreased cardiac output low bP???

206
Q

what pulmonary changes occur during a major burn?

A

pulmonary edema, swelling of airway, carbon monoxide poising, inability to breath deeply if circumfrential burn

207
Q

what renal changes occurs during a major burn?

A

the kidneys dont have good blood flow due to hypovolemia/low cardiac output, pre renal failure due to the excessive amount of cellular debris

208
Q

what gi changes occur during major burns?

A

ulcers, impaired motility, and bowel obstruction

209
Q

what immunoloical changes occur during major burns?

A

infection/sepsis risk

210
Q

what thermoregulation problems occur with burns?

A

hypothermia or hyperthermia without infection

211
Q

what kind of shock do burn patients go in?

A

hypovolemic or septic

212
Q

whats the range for ICP?

A

10-15

213
Q

what are priorites during a emergent/resuscitative burn?

A

secure airway, support perfusion, stop burning, remove clothes/jewlery, prevent infection, maintain body temp, fluid resuscitation, and pain management

214
Q

when will patient be intubated for burns?

A

if they are having trouble breathing, airway burns, cant keep spo2 high

215
Q

if airway burn is not present what will they do for oxygenation?

A

100% oxygen on a non rebreather

216
Q

what are signs of airway burns?

A

burnt facia/eyebrow hair, sut in mouth, cough, dry nagging cough, drooling

217
Q

what should be inserted into burn patients?

A

NG, foley, and possible ET for intubation

218
Q

what kind of IVs should you have for fluid resuscitation?

A

2 or more 16-18 gauge

219
Q

besides IV what other line may burn patients have?

A

central line

220
Q

how often should you check output?

A

hourly

221
Q

what characteristics do you look for in urine output?

A

color, volume, odor

222
Q

what are signs of fluid overload?

A

JVD, crackles, weight gain, SOB, High blood pressure ??????

223
Q

what else besides urine would increase output in burn patients?

A

chest tube, blood, vomit, diarrhea

224
Q

what is parklands formula?

A

kg x 4ml x % of body burned = fluid for 24 hours

225
Q

what fluid is used during fluid resuscitatiuon?

A

lactated ringers

226
Q

what is an expected weight gain in the first 72 hours?

A

15-20 %

227
Q

how much fluid is given in the first 8 hours?

A

50%

228
Q

how much fluid is given over the next 16 hours?

A

50%

229
Q

what urine output indicates adequate fluid replacement in electrical burns?

A

electrical burns 75-100ml per hour

230
Q

what urine output indicates adequate fluid replacemnt in burns?

A

0.5 -1 ml per kg/hour

231
Q

what HR indicates adequate fluid replacement in burns?

A

less than 120

232
Q

what BP indicates adequate fluid replacement?

A

greater than 100 systolic

233
Q

what cvp indicates adequate fluid replacement?

A

2-6

234
Q

what is used to measure cvp?

A

swan or equation

235
Q

where does cvp get measured?

A

in the pulmonary artery

236
Q

what is typically given for pain in burns?

A

morphine

237
Q

what does morphine due to bodily function?

A

reduces resp functino and decreases motility

238
Q

what non pharm interventions for burn patients in emergent phase?

A

relaxing, breathing, guided imagery

239
Q

what should be avoided in emergent burn phase?

A

ointments

240
Q

what shot should burn patients get?

A

tetanus

241
Q

what are signs that someone is coping with burns?

A

dressing changes and looks at themselves

242
Q

what are the percentages for the rule of 9s

A

head is 9%, arms are 9%, abdomen is 18%, back is 18%, legs are 18%, privates 1%

243
Q

when does the acute/intermediate phase start?

A

after 24 hours

244
Q

when does the diuretic phase start?

A

after 36-48 hours

245
Q

what are lab values in the first phase of a burn?

A

hyponatremia and hyperkalemia ????

246
Q

what are the lab values before the diuretic phase?

A

hyponatremia and hypokalemia???

247
Q

what are the lab values after the diuretic phase?

A

xx

248
Q

what should be assessed in relation to CV in the intermediate phase?

A

???

249
Q

what should be assessed in relation to resp in the intermediate phase?

A

watch for pneumonia and infection

250
Q

what should be assessed in relation to immune in the intermediate phase?

A

infection this is the most common time to get a infectino

251
Q

what should be assessed in relation to muscle in the intermediate phase?

A

rom

252
Q

what should be assessed in relation to neuro endocrine in the intermediate phase?

A

daily weights, caloric intake, loosing weight

253
Q

when will feedings be considered in burn patients in the intermediate/acute phase?

A

if they lost more than 10% of initial body weight

254
Q

when does fluid shift back into the normal spaces?

A

after 36-48 hours

255
Q

what should be assessed during burn wound care?

A

color, drainage, odor, sloughing,

256
Q

what should be given before wound care?

A

morphine and hydromorphone??

257
Q

how to prevent infection during wound change?

A

aseptic technique, silver nitrate for regular burn, and mefnide acetate, monitor for s/s of infection

258
Q

what do you need to know for mefnide acetate

A

only for electrical burns, penetrates eschar, painful, give pain meds

259
Q

what does silver nitrate do to K and Na

A

> >

260
Q

what do you need to know silver nitrate?

A

monitor wbc, k, na???????

261
Q

what burns require silver nitrate?

A

xxx

262
Q

what burns need telemetry?

A

electricity

263
Q

what is the equation for ICP

A

Map - ICP

264
Q

how many cal do burn patients need ?

A

5k or more

265
Q

what nutrient needs to be high in burns?

A

high protein

266
Q

what happens if burn patient doesnt eat?

A

tpn or tube feedings

267
Q

what factors affect severity of burn?

A

skin, patient, agent, depth, diabetes, HF

268
Q

what does a low cvp indicate?

A

dehydration

269
Q

what does a high cvp indicated?

A

fluid overload

270
Q

why would emergent burns patients need pantoprazole?

A

risk of stress ulcers

271
Q

can burn patients eat during emergent phase?

A

no

272
Q

what happens if brain herniation goes untreated?

A

resp arrest or cardiac arrest

273
Q

what is eye opening response rate ?

A

1-4

274
Q

what is a 1 eye response?

A

never open eyes

275
Q

what is a 2 eye response

A

only open to pain

276
Q

what is a 3 eye response?

A

open to voice

277
Q

what is a 4 eye response?

A

spontaneous…keeps eyes open

278
Q

what is verbal response rate by?

A

1-5

279
Q

what is a 1 verbal response?

A

never say anything

280
Q

what is a 2 verbal response?

A

only sounds no words

281
Q

what is a 3 verbal response?

A

inappropriate wordswha

282
Q

what is a 4 verbal response?

A

confused

283
Q
A
283
Q

what is a 5 verbal response?

A

oriented

284
Q

what is best motor response rated?

A

1-6

285
Q

what do you do when testing motor response?

A

pressure or pain

286
Q

what does a 1 motor response mean?

A

no reaction

287
Q

what does a 2 motor response mean?

A

extension or decerebrate

288
Q

what does a 3 motor response mean?

A

flexion or decorabate

289
Q

what does a 4 motor response mean?

A

withdraw hand from stimuli

290
Q

what does 5 motor response mean?

A

localizes pain…..opposite hand to move the painful side away

290
Q

what does 6 on motor response mean?

A

obeys command

291
Q

what is the lowest glasgow scale mean?

A

coma

292
Q

what is the lower glasgow scale score?

A

3

293
Q

what is the highest glasgows scale?

A

15

Critical Care (6 decks)

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