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ECC Final > Final > Flashcards

Final Flashcards

1
Q

Define category 1 emergency, give examples

A

Will die without immediate intervention; arrest, distressed or not breathing (open mouth in cats), pale or blue gums, severe arrhythmias, hemorrhage, etc

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2
Q

Define category 2 emergency, give examples

A

Critical, needs attention within 30 min; pale, severe fever, dystocia, LUT obstruction, severe dehydration

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3
Q

Define category 3 emergency, give examples

A

Sick, needs attention within hours; minor allergic rxn, laceration, stable fracture, V/D

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4
Q

Define category 4 emergency, give examples

A

Not true emergency, tx within 24 hours; V/D w/o dehydration, abrasions/cute, broken nail, sneezing/URT, hematuria

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5
Q

Most common cause of bradycardia

A

AV block

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6
Q

Causes of atrial standstill

A

hyperK (UO, Addisons), cardiac dz, hypothermia

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7
Q

Most common cause of weak pulses

A

Hypovolemia

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8
Q

Bounding pulses indicate what

A

Compensated hypovolemia

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9
Q

MM and CRT in: compensated hypovolemia

A

Injected,

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10
Q

MM and CRT in: hypoxia

A

cyanotic

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11
Q

MM and CRT in: anemia (normal or severe)

A

N: pale, normal CRT; severe: pale, absent

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12
Q

Pale MM with delayed CRT indicates

A

Decompensated shock (past compensation and progressing)

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13
Q

Most common type of breathing increase

A

Inspiratory

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14
Q

Localize- inspiratory effort

A

Upper airway (or abdominal distension, pleural space dz, diaphragmatic hernia)

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15
Q

Localize- expiratory effort

A

Lower airway (bronchitis, asthma)

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16
Q

PTE, pain and abdominal distension will likely cause what pattern of breathing

A

non-specific dyspnea

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17
Q

Short and shallow breathing indicates

A

Parenchymal dz or pleural space dz pr diaphragmatic hernia

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18
Q

Causes of paradoxical breathing

A

pneumothorax, pleural space dz, diaphragmatic hernia

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19
Q

Respiratory manifestations of parenchymal dz

A

mixed insp/exp dyspnea, harsh, loud sounds or crackles, short and shallow

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20
Q

Levels of consciousness

A

Coma- stupor- obtunded- dull- quiet- bright

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21
Q

Respiratory manifestations of pleural space dz or diaphragmatic hernia

A

inspiratory effort, short/shallow, quiet, +/- paradoxical

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22
Q

Respiratory manifestations of lower airway dz

A

Expiratory effort, harsh sounds/crackles, wheezing

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23
Q

Respiratory manifestations of upper airway dz

A

Inspiratory effort, stridor, referred upper airway noise on auscultation

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24
Q

MDB in triage

A

PCV/TS, glucose (esp neonates), renal, electrolytes (esp K)

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25
Q

Tx ventricular arrhythmias

A

Lidocaine (1/10th dose in cats)

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26
Q

Tx severe bradycardia

A

Atropine (fix electrolytes, warm, reverse opioids)

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27
Q

Blood typing- dogs vs cats

A

Not needed in first time dogs, mandatory in cats

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28
Q

Tx seizures

A

Diazepam IV or rectally

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29
Q

Tx ICP

A

Mannitol or hypertonic saline

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30
Q

Why do we monitor

A

ID problem for early intervention- monitoring always resulting in action

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31
Q

BP =

A

CO x VR (vascular resistance) (CO= HRxSV)

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32
Q

Limitations to CO

A

Dog >180- decreased SV maxes out CO

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33
Q

Vascular resistance formula

A

Inversely proportional to radius of tube to 4th power

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34
Q

What is the hidden killer in ECC, most patients susceptible to?

A

Thrombosis

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35
Q

Where to monitor for coagulation issues

A

Gums, pinnae, ventral abdomen

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36
Q

Common electrolyte disturbance in ECC patients

A

hypoK and hypoCa

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37
Q

Electrolyte imbalance in refeeding syndrome

A

hypoGly, hypoK, hypoP, hypoMg (all shift intracellularly when food introduced and insulin responds)

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38
Q

Dog and cats max normal HR in hospital

A

D- 120; C: 220 (should not be lower than 160 (180?)

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39
Q

When should arrhythmias be treated

A

When CS present or severe tachycardia concurrent

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40
Q

What dz states can cause decreased contracility

A

Sepsis, SIRS, heart dz

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41
Q

Tx decreased contractility

A

Positive inotropes- sepsis/SIRS: dobutamine; heart dz: pimobendan/digoxin

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42
Q

What is decreased oxygen tension in the tissues

A

Hypoxia

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43
Q

Define hypoxemia

A

Decreased partial pressure of O2 or saturation of O2 in the blood

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44
Q

Hypoxemia, hypoxia: ______ can be present without ____

A

Hypoxia, hypoxemia

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45
Q

What does using the arterial oxygen content equation demonstrate?

A

Hgb most important in oxygen delivery to tissues, dissolved O2 only a small percentage of total oxygen (ex- normal PCV 1.5% O2 is dissolved, 15% PCV- ~4% O2 is dissolved, remainder is bound to Hgb)

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46
Q

T/F inflammation indicates infection is present

A

F

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47
Q

What would indicate that a patient is developing an infection or an infection is overwhelming the patient

A

Degenerative left shift, more immature WBCs

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48
Q

What structure modulates temperature in the patient, via what signals

A

Anterior hypothalamus; monoamines and cutaneous deep receptors

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49
Q

Name the mechanisms of gaining heat

A

Increased production: catecholamines, thyroxine, shivering; decreased loss: vasoconstriction, piloerection, postural change

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50
Q

What causes fever

A

Stimulation of pyrogens (IL-1), increased hypothalamic set point

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51
Q

Describe starling forces in relation to fluid flux

A

Fluids net movement is out of the capillaries and picked up by lymphatics to prevent accumulation- when too much leaves the capillaries, causes peripheral/pulmonary edema and third spacing of fluid (pleural effusion, ascites)

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52
Q

How frequently should PCV be checked in patients receiving fluid therapy

A

daily at a minimum (more frequently if also anemic)

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53
Q

What concentration determines IV volume and why

A

Na- because water follows sodium- “total body Na determines total body hydration”

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54
Q

What are the proportions of total body water

A

60% of body weight is water, 40% intercellular, 20% extracellular (5% in vessels, 15% interstitial)

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55
Q

Na/K concentrations in and out of cell

A

Na high OUT of cell, K high IN cell

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56
Q

RER water calculation

A

70 x BW^0.75 or [(30 x kg)+70] = mL/kg/day

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57
Q

XS - S- M- L- XL fluid maintenance guidelines

A

XS (neonate) 80-100, S- 60, M (and cats) 50, L 40, XL 30 mL/kg/day

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58
Q

Dehydration v hypovolemia

A

D: interstitial and intercellular, progresses slowly, correct slowly, no bolus H: intravascular, rapid loss and rapid correction

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59
Q

Three types of fluid loss

A

Sensible- U, feces, V, exudative wounds; Insensible- sweat, saliva, panting

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60
Q

Estimate fluid dehydration deficit

A

kg x %dehy= L

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61
Q

What % dehydrated? mild skin tenting, slightly tacky to normal MM, CRT normal

A

moderate 5-7%

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62
Q

What % dehydrated? hypovolemia signs, cold extremeties, shock

A

Critical- 10% or greater

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63
Q

What % dehydrated? prolonged skin tent, dry MM, some tachycardia

A

Severe 8-10%

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64
Q

How is 5% dehydration assessed

A

Usually via Hx, no CS present on PE

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65
Q

What two conditions must be considered in correcting fluid losses and how

A

Heart disease (less need), renal compromise (more need)

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66
Q

Tachycardic, prolonged CRT, hypotensive, hypothermic, cool extremities, weak pulses- Dx, Tx

A

Hypovolemia- Rapid correction with 10-20mL/kg isotonic bolus, then goal directed therapy

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67
Q

What are the two major determinants of fluid balance

A

Alb and Na

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68
Q

Tonicity refers to

A

Effective osmolality of a solution compared to plasma

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69
Q

Why is a weak base sometimes added to crystalloid fluids

A

Excess Cl in fluids binds to HCl and creates acid, so bicarb added to create appropriate pH

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70
Q

Crystalloid fluids- what compartments, what speed

A

All compartments at different rates

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71
Q

What makes a fluid balanced, give some examples

A

If it resembles the proportion of plasma (extracellular fluid); normosolR, plasmalyte 148, LRS

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72
Q

What type of solutions should be avoided in end stage liver disease and why

A

Lactate buffered solutions because lactate is metabolized in the liver

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73
Q

Name two “unbalanced” fluids

A

0.9% saline, 5% dextrose in water (D5W)

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74
Q

What happens when water is bolused IV

A

RBC will swell and lyse due to zero tonicity causing rapid intracellular shift

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75
Q

Name three maintenance fluids

A

NormosolM, 0.45% saline, plasmalyte 56

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76
Q

When are maintenance fluids used

A

When patient is euvolemic but not eating/drinking, never as a bolus- rarely used in vet med

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77
Q

What are the characteristics of maintenance fluids

A

Lower in NaCl (Na 50-70), higher in K (10-20) (because regular losses (from kidney) low in NaCl, higher in K), usually hypotonic

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78
Q

What are the characteristics of replacement fluids

A

Similar to ECF- so High in NaCl (130-154), lower in K (0-5), tend to be isotonic- these are resuscitation fluids

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79
Q

Describe the movement of replacement fluids

A

Meant to go to interstitial space

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80
Q

Name three replacement fluids

A

0.9% saline, NormosolR, plasmalyte A or 148, LRS

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81
Q

What are hypertonic fluids used for (function and indications)

A

Rapid intravascular volume expansion (hemorrhage), reduction of ICP in head trauma- DO NOT USE FOR RESUSCITATION

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82
Q

Describe the effects of hypertonic fluids

A

Short acting (15-20min) rapid pull of fluids from interstitial space into intravascular space causing 3-3.5x volume expansion per unit administered

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83
Q

How are hypertonic fluids administered

A

In short, 5-15 min boluses (may be repeated once) followed by isotonic/maintenance fluids to avoid electrolyte abnormalities and dehydration

84
Q

Name three hypertonic fluids

A

3% or 7.5% saline, 20% mannitol

85
Q

What are the other benefits of hypertonic saline

A

Decreased cerebral edema, increased cardiac contractility, possible anti-inflammatory effects

86
Q

What are the disadvantages of hypertonic saline

A

hypernatremia, rapid admin (>1mL/kg/min) can cause bradycardia, hypotension, bronchoconstriction

87
Q

Indications for mannitol

A

Head trauma, acute glaucoma

88
Q

Mannitol- adv and disadv

A

Adv: dec cerebral edema and blood viscosity, free radical scavenger; DisAd: can exacerbate edema, hemorrhage (esp in brain)

89
Q

1 tsp = __mL, 1 c= ____ mL

A

5, 236

90
Q

What is the most important part of a fluid plan

A

Reassessment during treatment

91
Q

What are colloids

A

Fluids with large insoluble molecules that wont cross membranes easily and hold water in vascular space for longer than crystalloids

92
Q

What is the V of D of iso and hypertonic cystalloids

A

Initally to plasma then rapidly equillibrate (go more to intravasc (20%) and interstitial bc Na pumped out of cell)

93
Q

What is the V of D of crystalloids

A

meant to have 100% V of D in intravascular space to maintain volume, but in vivo this is not fully the case

94
Q

What value of the Starling Equation explains why very hypoproteinemic patients get limn edema but not pulmonary

A

Reflection coefficient- because this is the degree too which a membrane prevents transfer of colloid molecules-

95
Q

How can colloid therapy be monitored

A

COP measured by colloid osmometer, measures the change in pressure; refractometer does not change above 4.5

96
Q

How well does USG measure colloid administration

A

USG overestimated compared to urine osmolality with HES after 2-3 hours, usually correlate

97
Q

What are the most important drugs in a crash cart

A

Atropine and epinephrine

98
Q

What does the 10 second CPR assessment check for

A

Responsiveness, breathing/agonal breaths, pulses/heartsounds

99
Q

What is the most important part of CPR

A

Compressions

100
Q

What is the aim of CPR

A

Perfuse the brain and heart with oxygenated blood

101
Q

What is the formula for cerebral perfusion pressure

A

MAP- ICP

102
Q

What is the formula for coronary perfusion pressure

A

Aortic diastolic pressure - right atrial diastolic pressure

103
Q

CPR breaths rate, depth, pressure

A

10-12 bpm, enough to make chest wall rise, no more than 20mmHg ((avoid pneumothorax)

104
Q

Type of CPR- up to 15kg patient

A

Direct

105
Q

Direct CPR- describe method, function

A

compression directly over heart, compression of heart chambers and artificial systole

106
Q

Type of CPR for large dogs

A

Thoracic pump mechanism

107
Q

Thoracic pump CPR- method, function

A

Compressions at deepest part of chest, complete relaxation between each- increase pressure in chest to force blood away from heart, relaxation allows blood to flow back towards thanks to one way valves

108
Q

CPR compression rate

A

>100bpm (100-120, faster not better)

109
Q

Open chest CPR- method, approach

A

Technique to maximize flow via direct cardiac massage- cut right side between 5th and 6th rib space

110
Q

Open chest CPR indications

A

Pneumothorax, pleural effusion, pericardial effusion, chest trauma, DOA, too large for external

111
Q

When to stop CPR

A

return of pulse, spontaneous apex beat, sudden increase in CO2 output

112
Q

Capnograph- what does 0-5 mean

A

Initial reading in arrested patient, 0 means ineffective chest compression

113
Q

Capnograph- what reading indicates ROSC

A

Return of spontaneous circulation- 50-60, built up is leaving

114
Q

What two ECG readings are indications for defibrillation

A

Ventricular fibrillation and pulseless ventricular fibrillation

115
Q
A

Pulseless ventricular fibrillation

116
Q
A

Ventricular fibrillation

117
Q
A

Pulseless electrical activity- can look REGULAR, but has NO pulse!

118
Q
A

Asystole

119
Q

What is the most common EKG rhythm in vet med

A

Asystole

120
Q

Which drugs cause constriction and increase arterial pressure

A

Vasopressors- epinephrine, vasopressin

121
Q

Epinephrine administration

A

0.01 mg/kg @ 1mg/mL q 3-5 min during CPR- IV or endotracheally(double dose with saline flush and a large breath)

122
Q

What can be used as a rescue medication if epinephrine fails during CPR, what other indications does it have

A

Vasopressin; helpful in severe acidosis or prolonged arrest

123
Q

What is the effect of atropine, when should it be given

A

Reduce parasympathetic tone, first choice in bradycardia (and vagally mediated arrest)

124
Q

Function of anti-arrhythmics besides arrhythmia correction; name two

A

Improve arterial BP; amiodorone, lidocaine

125
Q

What contraindications are there for lidocaine

A

Cats and fibrillation (defibrillate first or it will reduce efficacy)

126
Q

Amiodorone- indications, cautions

A

In V-fib after 2 unsuccessful defibrillations, possible anaphylaxis risk

127
Q

What drug should only be used in severe pre-existing metabolic acidosis and hyperK arrests which arent responding to fluid therapy

A

Sodium bicarbonate- use with blood gas analysis

128
Q

When should Calcium gluconate be used

A

HyperK cause of death or pre-existing hypoCa (like in eclampsia)- CONTRAINDICATED IN ALL OTHERS

129
Q

What is the reversal for opioids

A

Naloxone

130
Q

What is the reversal for benzos

A

Flumazenil

131
Q

What is the reversal for alpha2agonists like xylazine and metomidine

A

atipamezole or yohimbine

132
Q

What should be tried if defib is not successful

A

Amiodarone

133
Q

What is the defib dose

A

2-4J/kg (4-6 in monophasic); increase by 50% on second try

134
Q

Describe the flow of defib

A

shock- 2 min CPR - check ECG- increase dose 50%

135
Q

What should be used if possible in open chest defib

A

Saline soaked gauze between heart and paddles

136
Q

What is a possible effect of excess fluid therapy, explain

A

Overload goes to RA, increasing coronary pressure and reducing cardiac perfusion

137
Q

What are some concerns for colloid therapy

A

Kidney damage and coagulopathy

138
Q

What is a common post-resuscitation complication and how should it be treated

A

Myocardial dysfunction- pressors like dopamine or dobutamine (careful in cats); norepi can be added to dopamine

139
Q

When to stop CPR

A

Assess q 3-5 min, avg stopping time 15-20 min, max 20-30 without improvement signs

140
Q

What are the muscles of inspiration

A

Diaphragm, external intercostals, (in effort: scalene, nasal alae, and sternomastoids)

141
Q

Muscles of expiration

A

Normal breathing elasticity of lung and chest wall recoil, but in effort- abdominal wall contraction increases intra-abd pressure to push diaphragm cranially

142
Q

Define labored breathing

A

Engaging accessory inspiratory or expiratory muscles

143
Q

Orthopnea

A

positional increases in difficulty- elbows abducted, head/neck extended

144
Q

Ddx upper airway dz

A

LarPar, tracheal collapse, FB, cat polyps, BOAS

145
Q

Ddz lower airway dz

A

asthma, chronic bronchitis, coughing/whezes

146
Q

Tx for primary cardiac dz of respiratory parenchyma

A

Furosemide! (congenital, MVD, DCM, HCM, RA enlargement)

147
Q

Tx non-cardiac respiratory parenchyma dz

A

Bronchodilators (Hx of V, anesthesia, coughing)

148
Q

How can cardiac and non-cardiac respiratory parenchymal dz be differentiated

A

Rads-

Cardiac- LA backpack, PA/V enlargement, lung patterns

149
Q

What are the three most important things in respiratory distress

A

Hands off- oxygen- sedate when needed

150
Q

Indications and Rx for sedated airway exam

A

Upper airway: stridor, obstruction, BOAS; sedate to effect with propofol (dont knock out), avoid acepromazine and opiates (decrease laryngeal and cough fxn)

151
Q

Sedated airway exam: what to check

A

Larynx for arytenoid fxn; tissues surrounding for saccules, elongation; oral masses; inflammation of proximal trachea

152
Q

Upper airway dz- exam ddx

A

SCC (cat larynx), LarPar polyneuropathy (L side), lymphoma (looks like edema, not mass)

153
Q

What Rx can be given to increase breathing and show arytenoid movement

A

Doxapram

154
Q

Thoracocentesis- approach

A

8th or 9th intercostal space, avoid caudal edge of ribs for vessels and nerves; Fluid- bottom third; Air- top third- 16g catheter through nick in skin from scalpel

Can also do over the wire or surgical approach

155
Q

Nasal oxygen- tube type, drugs needed, approach

A

Measure from end of nose to medial canthus8-14 Fr, wider tube causes less pressure/irritation; tetracine local drops in nostril; ventromedial approach

156
Q

Technique: temporary tracheostomy

A

Inscise skin and SQ longitudinally in the midline (patient must be straight), separate strap muscles, go 2-3 rings below larynx, incise horizontally less than 1/3 circumferance, use stay sutures labeled up and down to open hole later when changing tube

157
Q

Stages of labor: 1

A

12-24 h, restlessness, queens dig/bitches quiet, temp drop to 98F

158
Q

Stages of labor: 2

A

6-12h, temp normal, see uterine contraction, fetal expulsion

159
Q

Stages of labor: 3

A

Immediately after stage 2- placental expulsion

160
Q

Signs of dystocia

A

Stage 2 > 12h, Weak contractions for 2-3 h, strong contractions with no expulsion in 1h, >3 hours between deliveries, temp drop and no birth in 24-36h, fetal HR <160

161
Q

Fetal causes of dystocia (5)

A

Monster, oversize, singleon, improper presentation, death

162
Q

Maternal causes of dystocia (5)

A

Uterine inertia, abdominal hernias, pelvic stenoses, uterine/vaginal trauma, hydrops

163
Q

Primary uterine intertia

A

contractions never were going to happen, oxytocin wont help

164
Q

Secondary uterine intertia

A

so exhausted uterus gives up

165
Q

Why does singleton cause dystocia

A

Not enough to send hormonal signals to start uterine inertia or sustain

166
Q

Breeds susceptible to fetal oversize and singleton

A

persian, himalayans, bulldogs

167
Q

Describe hydrops

A

Golden retriever with cankles/edematous vulva, excess fluid in amniotic sac occluding CaVC- caudal and ventral edema

168
Q

Causes of uterine inertia

A

Hormonal- abnormalities of cascade (est, progest, relax, prolactin, PGs)

Metabolic- hypoGly, hypoCa

Myometrial- single pup, age, overstretch

Anatomic- cervix/vagina/vulva- immaturity, under-dilated, dz, abnormal, etc

Psychologic

169
Q

Dx dystocia

A

Fetal HR <160 is best (also PE, rads, U/S, acid/base, etc)

170
Q

Rx for metabolic uterine inertia

A

Oxytocin

171
Q

When can medical tx be used to dystocia

A

Only when not obstructed, healthy, failure to progress, contractions present, no oversize

172
Q

First Rx, medical dystocia tx

A

Calcium- 10% CaGluconate to increase strength of contractions

173
Q

Secondary Rx for medical dystocia tx

A

Oxytocin- to increase freq of contractions

174
Q

Indications for Sx tx of dystocia

A

obstruction, stressed/dead, oversize, sick mom, failed medical tx

175
Q

Sx tx of dystocia, Rx used

A

Balanced electrolytes throughout all, pre-oxygenate ebfore anesthesia, propofol induction, iso maintenance, lidocaine block

176
Q

Sx approach- C-section

A

Ventral midline incision, extrude uterus, the three options:

take out, put back in

Take out, OHE

En Bloc- OHE then remove fetus (MUST BE FAST)

177
Q

Dystocia surgical emergencies

A

uterine torsion, uterine rupture

178
Q

Neonate resuscitation

A

Remove fetal membranes, suction mouth/nose, clamp umb 1/4” from body (suture, betadine, dry), DV with head extended, stimulation of respiration, thermal support with 60% humidity

If none after 35-40 sec, GV26 acupuncture point at nasal filtrum and doxapram sublingual

179
Q

Indications for maternal Abx after birth

A

Rupture, torsion, fetal fluid contamination of abdomen

180
Q

Cause of pregnancy toxemia, CS

A

Nutritional related ketosis and negative energy balance late in prenancy from lack of carbs; weakness, lethargy, seizures, hyporexia

181
Q

Dx pregnancy toxemia

A

ketosis with glucosuria

182
Q

1-4 weeks after whelping, face rubbing, anorexia, hyperthermia, tremor, seizure

A

Eclampsia

183
Q

Dx eclampsia

A

iCa- <1.4 mmol>L

or

tCa <6.5 dog or <6 cat

184
Q

Tx eclampsia

A

CaGluconate IV over 10-15 min,

185
Q

When does pyometra occur

A

During diestrus due to high progesterone in middle to older aged

186
Q

Tx pyometra

A

Dont let the sun set- IV fluids, OHE, IV Abx

187
Q

What causes vaginal hyperplasia

A

Estrogen influence

188
Q

Tx vaginal hyperplasia

A

lubricate and protect if no necrosis, wait til follicular phase pases and will resolve; Sx if mucosal damage or too large

189
Q

Mastitis- causes, dx, tx

A

e. coli or staph; milk cytology/culture, cidal abx, lance/drain

190
Q

Causes of testicular abscess

A

trauma, brucellosis

191
Q

Paraphimosis

A

Penis stuck out, not erect

192
Q

Priapism

A

Erect penis stuck out

193
Q

Tx paraphimosis or priapism

A

sedation/anesthesia, no drugs with peripheral vasodilation, lubrication or hypertonic soak

194
Q

Top causes of blocked cat

A

uroliths and FIC (cells/mucus/cystal plugs)

195
Q

What kills blocked cat

A

HyperK, hypovolemia, metabolic acidosis

196
Q

Tx blocked cat- stable

A

Bolus LRS or 0.9 saline, sedation, catheter

197
Q

Dx, tx sick blocked cat

A

K >8, sine wave or absent P wave on ECG; Fluid resuscitation to tx hyperkalemia before unblocking,

198
Q

Lowering K in blocked cat

A

Ca gluconate- changes threshold to restore gradient

Insulin/NaBicarb/terbutaline to send K intracellularly

199
Q

Sedation options for blocked cat (without ET, with ET, sick

A

without ET- ket, midazolam, buprenorphine

With ET- propofol

Sick: sacro-coccygeal blck or buprenorphine

200
Q

Unblocking procedure

A

Open ended tom cat catheter, extrude penis then pull prepuce over catheter to straighten S shape, flush while passing if resistance, gently twist while applying gentle pressure to bladder, empty bladder, replace with red rubber tube, suture to skin

201
Q

Post-unblock tx

A

Buprenorphine q6-8, monitor urine output q1-2, copious fluids to deal with possible post-obstructive diuresis- WATCH OUT FOR HYPOKalemia

202
Q

Causes of post-obstructive diuresis

A

medullary washout, osmotic diuresis, pressure necrosis, ADH resistance

203
Q

When is blocked cat surgical

A

Repeats, stones, cant unblock

204
Q

Why not PU right away?

A
205
Q
A

ECC Final (2 decks)

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