Bleeding

Download as docx, pdf, or txt
Download as docx, pdf, or txt
You are on page 1of 14

SHOCK

Shock is the medical condition that develops as a result of an imbalance between the delivery of
oxygen and the consumption of oxygen at the cellular level.

Perfusion is the movement of sufficient oxygenated blood to the cells. Inadequate perfusion or
hypoperfusion is the result of a problem in one of the three components of the system getting
oxygen-rich blood to cells:
• Heart: the pump of the system.
• Vessels: the pipes of the system.
• Blood: the liquid circulating in the system.

A continuous interaction between these three components maintains blood pressure, circulation,
perfusion and the delivery of oxygen to the body.
In the patrolling environment, generally:
• shock as a result of a traumatic event is most likely due to blood loss either internally or
externally;
• shock as a result of a non-traumatic event is most likely due to pump failure or compromise;
• shock as a result of sepsis is rarely seen in the field.

Signs and symptoms


Any or all of these signs and symptoms may be present. Note that many of these signs are
changes in condition, and not just single observations.
Increased pulse rate:
• The pulse rate increases in an attempt to move more oxygenated blood to the cells.
Increased respiration rate:
• It is an attempt to increase the blood oxygen levels and increase elimination of carbon
dioxide (CO2) via the lungs.
Pale, cool, clammy skin; delayed capillary refill; cool extremities:
• The body attempts to maintain blood flow to the heart, brain, lungs and kidneys by
sacrificing blood flow to the digestive organs and the extremities. This is achieved by
constricting the arterioles and redistributing blood flow. The result is pale, moist skin, cool
extremities and ultimately absent peripheral pulses.
High anxiety, restlessness and aggression:
• It is due to reduced oxygen supply to the brain. Do not mistake this behaviour for lack of
consent.
General weakness, dizziness and nausea:
• It is due to reduced oxygen supply to the brain.
Thirst:
• It is due to an attempt at restoring blood volume. This volume could also be lost through
dehydration. Drinking fluids will not restore blood volume. With the shutting down of the
digestive organs, the fluids will not be absorbed.
Decreased pulse strength:
• The volume of blood ejected by the heart becomes less. This decrease results in decreased
pulse strength. The heart may not be refilling adequately, or it may not be emptying effectively,
or there may not be enough blood to maintain the filling pressure.
Drop in blood pressure:
• It may be caused by either a combination of blood loss, loss of peripheral vasoconstriction
and/or failure of the cardiac pump.
Decreased level of consciousness:
• It is due to a decrease in blood flow and oxygen supply to the brain.

Treatment
Regardless of the cause or type of shock, the first responder treatment is the same.
• Stop external bleeding. Blood cannot be replaced in our environmental setting.
• Activate EMS and treat as a load and go.
• Administer oxygen at high flow rate.
• Keep the patient warm.
• Lay the patient down.
• Treat the patient gently.
• Give nothing by mouth.
• Closely monitor the patient. Record vital signs and history.
• Reassure the patient.

Do the following, as required:


• Assure adequate breathing, assist ventilations.
• Move patient to recovery position in case of vomiting.
• Assist patient in taking their medication.
• Control bleeding, apply traction on fractures or compression to the pelvix if a pelvic fracture
is suspected, and administer other first aid to address the cause of shock.

Make every effort to prevent the situation from deteriorating. All movement and
temperature regulation requires blood flow which is in short supply during shock. Keep the
patient quiet and ensure they are not too hot or too cold.

Types of Shock

Shock is a critical medical condition characterized by inadequate tissue perfusion, leading


to impaired oxygen and nutrient delivery to cells and organs. There are several distinct types of
shock, each with unique underlying causes and manifestations:

1. Cardiogenic Shock:
- Affected System: Heart (the pump)
- Description: Cardiogenic shock occurs when the heart fails to pump blood effectively,
leading to decreased tissue perfusion.

2. Hypovolemic Shock:
- Affected System: Circulating volume of blood
- Description: Hypovolemic shock results from a significant decrease in intravascular
volume, often due to hemorrhage, severe dehydration, or fluid loss.

3. Distributive Shock Types:


- Affected System: Vessels (pipes)
- Description: Distributive shock involves abnormal vasodilation and/or increased
vascular permeability, leading to inadequate tissue perfusion despite normal or increased
intravascular volume.
- Subtypes:
- Anaphylactic Shock: Caused by a severe allergic reaction.
- Vagal (formerly Psychogenic) Shock: Associated with sudden emotional or
psychological stress.
- Septic Shock: Results from a systemic response to severe infection.

4. Neurogenic / Spinal Shock:


- Affected System: Both the pump and the vessels
- Description: Neurogenic or spinal shock occurs due to disruption of sympathetic
nervous system control over vascular tone, often seen in spinal cord injury or certain
medications.
5. Obstructive Shock:
- Affected System: The pump, the vessels, and/or circulating volume
- Description: Obstructive shock arises from physical obstruction to blood flow within
the heart or great vessels, leading to impaired cardiac output.
- Examples: Cardiac tamponade, tension pneumothorax, massive pulmonary embolism.

Understanding the different types of shock is essential for healthcare professionals as it


guides appropriate management strategies and improves patient outcomes.

Cardiogenic Shock

Cardiogenic shock is a critical condition characterized by the heart's inability to perform


its pumping function effectively. This results in a reduced quantity of blood being pumped per
heartbeat, leading to inadequate perfusion of vital organs. In cardiogenic shock, the normal
dynamic of the heart is disrupted, impacting its ability to meet the body's oxygen and nutrient
demands.
Common causes of cardiogenic shock include myocardial infarction (heart attack), which
can lead to significant damage to the heart muscle and impair its contractile function.
Additionally, conditions such as the rupture of a heart valve or damage to heart muscle from
various causes can also precipitate cardiogenic shock.
In essence, cardiogenic shock poses a serious threat to overall cardiovascular function
and requires prompt medical intervention to restore adequate tissue perfusion and prevent organ
failure.

Hypovolemic Shock

Hypovolemic shock is a life-threatening condition characterized by a significant decrease


in intravascular volume, leading to impaired blood flow to vital organs. This reduction in
circulating blood volume results in inadequate oxygen and nutrient delivery to tissues
throughout the body.
Common causes of hypovolemic shock include severe bleeding from trauma,
gastrointestinal bleeding, or other sources, as well as fluid loss from conditions such as
dehydration, burns, or severe vomiting and diarrhea.
The hallmark of hypovolemic shock is a rapid heart rate, low blood pressure, and poor
tissue perfusion, which can lead to organ dysfunction and failure if left untreated. Prompt
recognition and aggressive fluid resuscitation are essential in managing hypovolemic shock to
restore intravascular volume and stabilize the patient's condition.

Bleeding (Hemorrhage) - Hypovolemia


Bleeding, also known as hemorrhage, is a critical medical condition characterized by the
loss of blood from the circulatory system. The average adult body, weighing approximately 70
kg (154 lb.), contains about five liters of blood. Any injury that disrupts the blood supply poses
a potentially dangerous situation, as the severity of bleeding correlates directly with the risk to
the individual.
Estimating the amount of blood loss is crucial in assessing the seriousness of a bleeding
injury. The condition of a person deteriorates rapidly unless bleeding is promptly arrested. It's
important to note that many small bleeds can be just as dangerous as one large bleed, as
cumulative blood loss can lead to significant hypovolemia, resulting in impaired tissue
perfusion and organ function.
In managing hemorrhage-induced hypovolemia, rapid assessment and intervention are
paramount. Prompt application of direct pressure, elevation of bleeding extremities, and, if
necessary, the use of tourniquets or hemostatic agents can help control bleeding and prevent
further blood loss. Early initiation of fluid resuscitation is crucial to restore intravascular
volume and stabilize the patient's condition.

Failure to stop bleeding may lead to the progression of profound shock and eventually lead to
death.

External Bleeding

External bleeding refers to the loss of blood from the body through visible openings in the skin,
such as wounds or lacerations. It can occur due to various causes, including trauma, injuries,
surgical procedures, or medical conditions.

External bleeding can manifest in different forms, including:

Arterial Bleeding: Arterial bleeding occurs when blood is expelled from an artery, which
carries oxygen-rich blood away from the heart and to the body's tissues. Arterial bleeding is
typically characterized by bright red, spurting blood that corresponds to the rhythmic beating of
the heart. It can be life-threatening and requires immediate medical attention.

Venous Bleeding: Venous bleeding involves blood flowing from a vein, which transports
oxygen-depleted blood back to the heart. Venous bleeding is often steady and dark red in color.
While it may not be as rapid as arterial bleeding, significant venous bleeding can still lead to
hypovolemic shock if left untreated.

Capillary Bleeding: Capillary bleeding occurs from the smallest blood vessels, called
capillaries, near the skin's surface. Capillary bleeding is typically slow and oozing, and it may
appear as a reddish discharge from minor cuts or abrasions.

Special Considerations: External bleeding may also present with special considerations, such
as bleeding from specific anatomical locations (e.g., head, neck, groin), wounds with embedded
foreign objects, or bleeding disorders that affect clotting function.

The general treatment for external bleeding can be easily remembered with the acronym
RED, which stands for:

Rest: The first step in managing external bleeding is to lay the injured person down and
encourage them to rest. Resting helps reduce physical activity, which can minimize blood flow
to the injured area and promote clot formation.

Elevate: If possible, elevate the bleeding part above the level of the heart. Elevating the injured
limb helps reduce blood flow to the area by utilizing gravity to assist in drainage. This can be
particularly effective for extremity injuries, such as cuts or lacerations on the arms or legs.

Direct: Apply direct pressure to the wound using a clean cloth, bandage, or sterile dressing.
Direct pressure helps control bleeding by promoting clot formation and reducing blood flow
from the injured blood vessels. Maintain pressure continuously until bleeding stops or medical
assistance arrives.

Remembering the RED approach can help individuals respond effectively to external bleeding
emergencies by taking immediate action to control bleeding and minimize complications.

General Treatment for External Bleeding Injuries:

Quickly Check for Foreign Objects: Before applying any pressure or dressing, quickly assess
the wound for any foreign objects such as glass, debris, or penetrating objects. If present, do not
remove them; instead, stabilize the object and seek medical help.

Apply Firm, Direct Pressure: Place your protected hand (using gloves or a clean cloth if
available) directly on top of the wound and apply firm pressure. Direct pressure helps to control
bleeding by promoting clot formation and reducing blood flow from the injured blood vessels.
Maintain pressure continuously until bleeding stops or medical assistance arrives.
Apply Sterile Dressing and Bandage: With as little movement as possible to avoid
aggravating the wound, apply a sterile dressing directly over the wound. Secure the dressing in
place with a bandage, such as a cravat or other form of compression bandage. Ensure that the
bandage is snug but not too tight to impede circulation.

Treat for Shock: For severe bleeding, it's important to anticipate and treat for shock, a life-
threatening condition that can occur due to significant blood loss. Do not wait for symptoms of
shock to appear; instead, initiate appropriate treatment immediately. Lay the injured person
down, elevate their legs if possible, and cover them with a blanket to maintain body warmth.
Monitor their vital signs and provide reassurance while awaiting medical help.

Treatment for Bleeding Injuries on the Trunk:

1. Apply Sterile Dressing and Bandage


- Fasten a sterile dressing and bandage over the wound by:
- Applying a bandage around the body, if it does not interfere with breathing, ensuring it is
snug but not constricting.
- Using a triangular bandage or a chest/back bandage to secure the dressing in place. Ensure
the bandage is applied firmly but allows for adequate chest expansion during breathing.
- If applying a bandage around the body would impair breathing or circulation, tape the
dressing securely in place over the wound.

2. Transport to Medical Aid


- Evaluate the need for immediate transportation to medical aid:
- Assess the severity of bleeding. Was the bleeding significant and difficult to control?
- Look for signs of shock in the patient, such as pale skin, rapid heart rate, and altered mental
status.
- Assess breathing. Is it compromised due to the injury or bandaging?
- Consider other chest injuries that may require urgent medical attention.
- If warranted, initiate a "load and go" approach to transport the patient promptly to a medical
facility for further evaluation and treatment.

3. Maintain Direct Pressure if Bleeding Persists


- If bleeding is not adequately controlled after 10 minutes of applying the dressing and
bandage:
- Continue to maintain direct pressure with fingers or hands over the wound during
transportation to medical aid.
- Reassess and adjust the dressing if necessary to ensure it remains secure and effective in
controlling bleeding.
Treatment for Injuries to the Extremities:

1. Assess and Address Limb Injuries


- Check the injured limb for possible fractures, foreign objects, and gross contamination.
- Immobilize and stabilize any suspected fractures or dislocations using splints or improvised
materials.
- Clean the wound as required to remove debris and prevent infection.

2. Apply Dressing and Bandage


- Apply a sterile dressing directly over the wound to absorb blood and provide protection.
- Secure the dressing in place with a cravat or other form of bandage, ensuring it is snug but
not too tight to impede circulation.

3. Maintain Pressure
- Tie the knot of the bandage directly over the wound site to maintain constant pressure and
promote clot formation.

4. Elevate the Injury


- Elevate the injured limb above the level of the heart, if possible, to reduce swelling and
minimize bleeding.

5. Check Circulation and Sensation


- Before and after bandaging, assess distal circulation and sensation in the injured limb. Look
for signs of impaired blood flow, such as pallor, coolness, numbness, or tingling.
- If circulation or sensation is compromised, adjust the bandage or remove it if necessary to
restore blood flow.

6. Transport to Medical Aid


- After initial treatment, transport the injured individual to a medical facility for further
evaluation and treatment.
- If there are signs of poor perfusion (e.g., pale or mottled skin, weak pulse, numbness), or if
the limb is severely injured or unstable, activate emergency medical services (EMS) and treat as
a "load and go" scenario to ensure prompt medical intervention.

Internal Bleeding

Internal bleeding refers to the loss of blood into compartments within the body, rather than
external bleeding that occurs outside the body. It can occur in various compartments depending
on the affected organs or structures. Unlike external bleeding, signs and symptoms of internal
bleeding may not always be evident, making it challenging to diagnose without medical
intervention.

Symptoms of internal bleeding can vary depending on the location and severity of the bleed. In
cases of abdominal bleeding, free blood in the abdominal cavity can irritate nerves, resulting in
pain, guarding (tensing of muscles to protect the area), and rigidity of the abdominal wall.
Additionally, internal bleeding may lead to referred pain, where the perception of pain occurs in
locations remote from the site of injury. For example:

Left shoulder tip pain may indicate possible rupture of the spleen.
Right shoulder tip pain may suggest injury to the liver or gall bladder.
Shoulder tip pain in the presence of abdominal bleeding is known as Kehr's Sign.

Evident Signs and Symptoms of Internal Bleeding

Internal bleeding can present with various signs and symptoms depending on the location and
severity of the bleed. Recognizing these signs is crucial for timely diagnosis and appropriate
medical intervention. Here are some evident signs and symptoms associated with internal
bleeding:

1. Bright Red, Frothy Blood Coughed Up


- If the patient coughs up bright red, frothy blood, the source of bleeding can be in the trachea
or the lungs. This could indicate conditions such as pulmonary embolism, pulmonary edema, or
severe lung injury.

2. Vomiting Blood (Hematemesis)


- Blood vomited by the patient often has the appearance of coffee grounds. This suggests
bleeding from the esophagus or the stomach. Possible causes include peptic ulcers, esophageal
varices, or gastritis.

3. Blood in Feces (Melena)


- Blood mixed with feces that appears black and tarry is known as melena. This indicates
bleeding from the stomach or the upper part of the small intestine. Common causes include
gastrointestinal ulcers, gastritis, or gastrointestinal bleeding disorders.

4. Red Blood in Feces


- If the patient passes red blood in the feces, the source of bleeding can be the lower
gastrointestinal tract, including the intestine, colon, rectum, or anus. This may indicate
conditions such as hemorrhoids, diverticulosis, inflammatory bowel disease, or colorectal
cancer.
5. Smoky or Red Appearance of Urine
- Smoky or red-colored urine suggests bleeding from the kidneys, ureter, or bladder. This
could be due to conditions such as kidney stones, urinary tract infections, or bladder cancer.
Pain over the kidney area may also be present.

It's important to note that injuries to the bowels (small or large), stomach, or bladder may often
result in free air in the abdomen rather than internal bleeding. This can be detected through
medical imaging tests such as X-rays or CT scans.

Non-Evident Signs and Symptoms of Internal Bleeding

Internal bleeding resulting from trauma, particularly crushing injuries or blows to the abdominal
region, can be insidious and challenging to detect. Here are some non-evident signs and
symptoms associated with internal bleeding:

1. Bleeding into Tissues Associated with Fractures


- Internal bleeding may occur within tissues surrounding fractures, especially in cases of
severe trauma. This bleeding may not be readily apparent externally but can contribute to
swelling and pain at the injury site.

2. Intra-Abdominal Bleeding from Solid Organs


- Bleeding from organs such as the liver, spleen, or pancreas typically occurs into the
abdominal cavity rather than externally. This type of internal bleeding can be significant and
life-threatening, leading to abdominal distention and discomfort.

3. Delayed Symptoms from Spleen Injury


- The spleen, when injured, may bleed into its capsule, forming a hematoma. Initially,
symptoms may be minimal, but rupture of the spleen capsule can lead to delayed and severe
symptoms such as abdominal pain, lightheadedness, and signs of shock.

4. Bleeding from Kidney Injury


- Bleeding resulting from kidney injury may not present with typical abdominal compartment
signs and symptoms. Instead, patients may experience flank pain, hematuria (blood in the
urine), or generalized weakness.

5. Presence of Hematomas and Ecchymosis


- The presence of hematomas (localized swelling filled with blood) or ecchymosis (bruising)
on the skin can be indicative of significant internal hemorrhage. These external signs may direct
healthcare providers to suspect underlying internal bleeding, especially following trauma.

Signs and Symptoms of Internal Abdominal Bleeding


Internal abdominal bleeding can manifest with various signs and symptoms, which may indicate
a medical emergency. Here are some common indicators to watch for:

1. Tenderness
- Increasing sensitivity to touch or pressure over the abdomen. Patients may report discomfort
or pain when pressure is applied to the affected area.

2. Rigidity
- The abdomen may feel rigid or tense, resembling a wooden or boardlike texture upon
palpation. This rigidity can indicate internal bleeding and is often associated with intra-
abdominal inflammation or irritation.

3. Guarding
- Guarding refers to the involuntary tightening of the abdominal muscles in response to pain
or discomfort. Patients may instinctively tense their muscles to protect the injured or sensitive
area.

Treatment for Internal Bleeding

When signs and symptoms of internal bleeding become evident, prompt action is crucial to
optimize patient outcomes. Here's what to do as a first aid provider:

1. Activate EMS and Treat as a Load and Go


- Immediately activate emergency medical services (EMS) by calling for assistance. Internal
bleeding can rapidly deteriorate into a life-threatening situation, requiring urgent medical
intervention. Treat the situation as a "load and go" scenario, prioritizing rapid transport to a
medical facility for definitive care.

2. Treat for Shock (Proactively)


- Initiate treatment for shock without waiting for it to fully manifest. Internal bleeding can
lead to hypovolemic shock, a potentially deadly condition resulting from significant blood loss.
Lay the patient flat on their back and elevate their legs slightly (no more than 30 cm) to improve
blood flow to vital organs and minimize shock symptoms.

3. Positioning and Precautions


- Transport the patient flat on their back, maintaining spinal alignment, unless there's a risk of
vomiting. In such cases, place the patient in a semi-prone position to facilitate drainage and
prevent aspiration of vomitus.
- Elevate the legs slightly to further aid in venous return and reduce shock symptoms.
- Do not give the patient anything by mouth, as oral intake may worsen internal bleeding or
increase the risk of aspiration if the patient is unconscious or vomiting.

Distributive Shock

Distributive shock is a term used to describe a type of shock characterized by abnormalities in


peripheral vascular resistance. Under normal conditions, blood vessels maintain mild
vasoconstriction to regulate blood pressure and ensure adequate perfusion to organs. However,
in distributive shock, there is inappropriate vasodilation despite signals from the body to
constrict blood vessels. This leads to the same volume of blood being distributed in a larger
vascular space, resulting in decreased blood pressure and impaired perfusion to organs and
peripheral tissues.

The underlying causes of distributive shock may vary and can include conditions such as:

1. Septic Shock Caused by a severe systemic infection leading to widespread inflammation and
vasodilation.

2. Anaphylactic Shock Triggered by an exaggerated immune response to an allergen, resulting


in systemic vasodilation and increased vascular permeability.

3. Neurogenic Shock Occurs due to dysfunction of the autonomic nervous system, leading to
widespread vasodilation following spinal cord injury or neurological disorders.

4. Drug-induced Shock Certain medications or toxins can cause vasodilation, leading to


distributive shock.

Distributive shock is characterized by decreased systemic vascular resistance, low blood


pressure, and inadequate tissue perfusion. Prompt recognition and treatment are essential to
restore vascular tone, stabilize blood pressure, and improve organ perfusion.

Vasovagal Syncope (Fainting)

Vasovagal syncope, also known as vasovagal fainting, is a common cause of fainting episodes
triggered by various physical or emotional stressors. It occurs due to a sudden dilation of
peripheral blood vessels, leading to a drop in blood pressure and temporary deprivation of
oxygen to the brain, resulting in loss of consciousness.

Mechanism:
- Stressful stimuli, such as pain, fear, anxiety, or standing for long periods, can stimulate the
vagus nerve, which regulates heart rate and blood vessel dilation.
- Activation of the vagus nerve leads to excessive dilation of peripheral blood vessels and a
decrease in heart rate, resulting in reduced blood flow to the brain.
- The insufficient blood supply to the brain causes temporary loss of consciousness, resulting in
fainting.

Characteristics:
- Vasovagal syncope typically presents with prodromal symptoms such as lightheadedness,
nausea, sweating, and feeling warm or clammy.
- Loss of consciousness is brief and self-limiting, usually lasting only a few seconds to minutes.
- Patients often recover spontaneously when lying down horizontally, as normal blood flow to
the brain is restored.

Management:
1. Ensure Patient Safety: Check for any injuries resulting from the fainting episode. Provide a
safe environment and prevent further harm.

2. Positioning: Lay the patient flat on their back with their legs elevated slightly, which helps
improve blood flow to the brain and facilitates recovery.

3. Monitor Vital Signs: Assess the patient's vital signs, including heart rate and blood pressure,
to ensure stability and rule out any underlying medical conditions.

4. Reassurance: Offer reassurance to the patient and provide emotional support. Explain the
benign nature of vasovagal syncope and the expected resolution of symptoms.

5. Preventive Measures: Encourage the patient to avoid triggers known to precipitate vasovagal
episodes, such as prolonged standing, dehydration, or extreme emotional stress.

6. Medical Evaluation: Consider referral to a healthcare provider for further evaluation,


especially if the fainting episodes are recurrent or associated with concerning symptoms.

By understanding the mechanisms and management of vasovagal syncope, healthcare providers


can effectively recognize and address fainting episodes, ensuring patient safety and well-being.

Obstructive Shock

Obstructive shock occurs due to the obstruction of blood flow outside of the heart. Various
conditions can lead to this type of shock, each affecting blood flow in different ways:

1. Tension Pneumothorax:
- Tension pneumothorax occurs when air accumulates in the pleural space, leading to
increased pressure within the chest cavity. This increased pressure compresses the blood
vessels, impeding blood return to the heart and reducing cardiac output. The collapsed lung
further exacerbates the obstruction of blood flow, leading to decreased oxygenation and
perfusion.

2. Cardiac Tamponade:
- Cardiac tamponade occurs when fluid (usually blood) accumulates in the pericardial sac
surrounding the heart, exerting pressure on the heart chambers and restricting their ability to fill
with blood. This impairs cardiac function and reduces cardiac output, leading to decreased
tissue perfusion and shock. Cardiac tamponade is commonly associated with penetrating chest
injuries.

3. Blockage of Blood Vessels:


- Blood vessel blockage can occur due to various factors:
- Pulmonary embolism: A blood clot travels to the lungs, obstructing blood flow in the
pulmonary arteries and impairing oxygenation.
- Fat embolism: Fat particles from long bone fractures or orthopedic procedures enter the
bloodstream, leading to blockage of blood vessels and tissue injury.
- Air embolism: Compressed air bubbles enter the bloodstream, obstructing blood flow and
causing tissue ischemia. This is commonly associated with scuba diving accidents or medical
procedures.

4. Aortic Stenosis:
- Aortic stenosis refers to the narrowing of the aortic valve, obstructing the outflow of blood
from the heart to the systemic circulation. This obstruction increases the workload of the heart
and reduces cardiac output, leading to decreased tissue perfusion and shock.

Obstructive shock requires prompt recognition and management to relieve the obstruction and
restore normal blood flow. Treatment may involve interventions such as chest decompression
for tension pneumothorax, pericardiocentesis for cardiac tamponade, thrombolytic therapy or
embolectomy for embolic events, and valve replacement or repair for aortic stenosis.

You might also like