The document discusses the evolving role of echocardiography in assessing and managing patients with sepsis and septic shock. It outlines how echocardiography can help evaluate cardiac function, volume status, and guide hemodynamic management. Early echocardiography in septic shock may show a hyperdynamic left ventricle with small cardiac chambers and collapsed inferior vena cava, indicating relative hypovolemia. Echocardiography provides accurate bedside information to monitor patients and improve outcomes, replacing invasive monitoring when possible. Repeated echocardiography assessments are important for dynamic management of sepsis patients.
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
Powerpoint Presentation - exported from Keynote Mac presentation. Introduction to Cardiac Point of Care U/S. Talk was meant for Emergency Medicine Residents PG1-3 level. Modest tweaks of font and spacing required prior to your own use. Associated PDF file in original Keynote format.
Ohnell described this phenomenon as the “concertina
effect,” in which the QRS complex morphologies from individual
patients with WPW pattern differ owing to variation in the degree
of ventricular excitation via the accessory pathway and AV node.
Recognizing the concertina effect in WPW pattern as normal
variation is important to prevent unnecessary diagnostic and
therapeutic interventions.
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
Right Ventricle (RV) has been treated as the neglected cardiac chamber for a long time. Advent of cardiac MRI and advancements in echocardiography have facilitated the understanding of RV structure and function and elucidated its role in management and prognosis of various cardiac ailments. Further refinement of three-dimensional (3D) and strain imaging and their application to study of right ventricular structural and functional abnormalities will be helpful in early identification of cardiac pathologies and their timely intervention.
Powerpoint Presentation - exported from Keynote Mac presentation. Introduction to Cardiac Point of Care U/S. Talk was meant for Emergency Medicine Residents PG1-3 level. Modest tweaks of font and spacing required prior to your own use. Associated PDF file in original Keynote format.
Ohnell described this phenomenon as the “concertina
effect,” in which the QRS complex morphologies from individual
patients with WPW pattern differ owing to variation in the degree
of ventricular excitation via the accessory pathway and AV node.
Recognizing the concertina effect in WPW pattern as normal
variation is important to prevent unnecessary diagnostic and
therapeutic interventions.
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
Right Ventricle (RV) has been treated as the neglected cardiac chamber for a long time. Advent of cardiac MRI and advancements in echocardiography have facilitated the understanding of RV structure and function and elucidated its role in management and prognosis of various cardiac ailments. Further refinement of three-dimensional (3D) and strain imaging and their application to study of right ventricular structural and functional abnormalities will be helpful in early identification of cardiac pathologies and their timely intervention.
Spinal stenosis is a degenrative spine disorder in which the AP and transverse diameter are decreased causing neural compression and symptoms of chronic & acute nerve compression
How to evaluate shock by echo. Echo is an essential tool in ICU and it´s the cornerstone in the management of shock nowadays, learning how to use this procedure must be mandatory
EMGuideWire's Radiology Reading Room: Stress-Induced CardiomyopathySean M. Fox
The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Stress-Induced Cardiomyopathy and is brought to you by Jenna Pallansch, MD, Claire Lawson, NP, Shelby Hixson, PA, Emily Lipsitz, PA, Ashley Moore-Gibbs, DNP, Laszlo Littmann, MD, and John Symanski, MD.
The prevalence of degenerative valvular disease is increasing in the context of an increasingly ageing population, and despite advances in medical and surgical interventions, is associated with a significantly worse outcome when compared with the general population. Data from the EuroHeart Survey (2003) suggests the commonest relates to native valve disease (predominantly aortic stenosis) however, more than one quarter of patients with valve disease have undergone a previous intervention. According to current guidelines, in general treatment for severe, symptomatic aortic stenosis is surgical aortic valve replacement, which is associated with excellent outcomes, however, despite this around 30% of such patients do not undergo surgical intervention.
The last decade has seen a significant change in the potential therapeutic options for patients with aortic valve disease due to the development of transcatheter techniques for valve implantation. Patented in 1991, the first successful human implant of a transcatheter aortic valve was undertaken in 2002, with currently >500,000 implantations having been undertaken in >70 countries worldwide. The evidence supporting transcatheter aortic valve implantation (TAVI) otherwise known as transcatheter aortic valve replacement (TAVR) came originally from the key PARTNER studies, where patients judged to have inoperable aortic stenosis who underwent TAVI having improved survival and a reduction in hospital admission at 1 year. Following the early safety and efficacy studies, and following increasing recommendations for TAVI as an option for patients at high risk in international guidelines, the use of transcatheter techniques is extending to those of lower risk.
A lecture highlighting the role of Echocardiography as a major hemodynamic monitoring tool in the Intensive Care settings and the assessment of loading conditions.
An overview of adult respiratory distress syndrome with a focus on the updates in ventilatory management of this important syndrome in the intensive care
A lecture on the echocardiographic evaluation of hypertrophic cardiomyopathy. Starts with an overview of the topic then a systematic approach to diagnosis and then a differential diagnosis followed by take-home messages and conclusion.
A lecture discussing the role of Echocardiography in the evaluation and management of patients with different types of shock. From cardiogenic to hypovolemic to obstructive and distributive shock. A very useful guide for intensivists, cardiologists and all acute care physicians.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
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The Evolving Role of Echocardiography in Sepsis
1. The Evolving Role of
Echocardiography in Sepsis
Dr. Hatem A. Soliman, MSc, MRCP (UK)
Specialist Intensivist
Mafraq Hospital, Abu Dhabi
EACVI Club 35 Ambassador to the UAE
2. “SAY: MY LORD, INCREASE ME
IN KNOWLEDGE”
QUR’AN 20:14
“ لماِع ِدنيِز ِبَر لُقَ”و
العظيمهللا صدق
8. Why Echo ?
• US has become an invaluable tool in the
management of critically ill patients
• Sepsis and Septic Shock (SS) represent complex
situations where early hemodynamic assessment
and support are among the keys to therapeutic
success.
• Sepsis and (SS) are common causes of
cardiovascular failure in ICU and are the most
frequent causes of mortality.
9. Why Echo ?
The Heart; the main target of the Echo
examination, frequently represents itself the
core of the septic process, being either
‘‘a victim’’ (when sepsis-related myocardial
dysfunction develops) or
“a source” (in the context of endocarditis).
10. What’s the Evidence !
• TTE and TEE add new relevant information that
leads to changes in therapy in more than 50% of cases
[1,2,3], the majority of which concern volume
status and inotropy [3];
• Echo seems to be more accurate than the standardized
strategy proposed by the SSC guidelines in the detection
of the dominant features of the failing circulation
[4].
11. Cardiac dysfunction in Sepsis
• Absolute or relative reduction in central blood
volume
• Peripheral vasodilatation.
• Myocardial failure.
12. What is Ultrasound ?
• High frequency sound (pressure) waves.
• > 20.000 (2 kHz): Upper limit of human ears.
• 2-10 mHz: Medical diagnostics range.
• US waves are created by a vibrating crystal
within a ceramic probe.
• Waves travel through tissue and are partly
reflected at each tissue interface.
13. Why Ultrasound ??
• Safe (no radiation)
• Portable (bedside)
• Immediate bedside availability.
• Repeatability.
• Detailed (Focused, limited exam in ICU)
• Easy to learn and perform
• Cost saving
• Improves outcome.
14. Disadvantages of US ?
• Training curve
• Subjective (operator-dependent)
• Poor image quality.
• Reliance on technology.
• Cost
• Maintenance.
20. Echogenicity
• The more US waves reflected back, the brighter the image.
• Hyper-echoic (bright echo):
– Air
– Diaphragm
– Periostium
• Iso-echoic:
– Liver
– Kidney
– Muscle
• Hypo-echoic (dark echo):
– Fluid
– Blood
– Fat.
21. Enemies of Ultrasound
• Air (MV)
• Bone
• Foreign body
• Calcium
• Any interposed structure
• Poor positioning.
• Lack of patient co-operation
• Surgical wounds and dressings, tapes, tubing,
surgical, emphysema, obesity, and COPD
22. Indications of US
• Vascular access.
• Pleural effusion
• Intra-abdominal fluid collection
• Urinary Bladder Scan
• FAST
• Echocardiography (huge range of indications)
23. Indications of Echo
• Hemodynamic instability
– Ventricular failure
– Hypovolemia
– Pulmonary embolism
– Acute valvular dysfunction
– Cardiac tamponade
– Complications after cardiothoracic surgery
• Infective endocarditis
• Aortic dissection and rupture
• Unexplained hypoxemia
• Source of embolus
24.
25. • Identify existing cardiac dysfunction.
• Volume status (IVC and Echo)
• Cardiac Function assessment
• Identify sepsis-related cardiomyopathy (Early
avoiding extra fluids)
The role of Echo in Sepsis
26. The role of Echo in Sepsis
• Sepsis is a hyperdynamic state !!
• Exclude cardiac causes of sepsis.
• Guiding hemodynamic management.
• DD of shock
• Comprehensive hemodynamic monitoring
(repeat echo)
27. Echo at early Septic Shock
• Small LV
• Small RV
• LV and RV hyperkinesia
• Small IVC
• IVC respiratory collapse (spontaneous ventilation)
• None of the above (but rather a variable degree of
LV or RV
• dysfunction) in the setting of relevant pre-existing
cardiac disease
32. Cardiac Output assessment by Echo
LV outflow tract (LVOT) and aortic valve as the
conduit is probably the most reliable and most
commonly used, with an excellent agreement
with Thermo-dilution in most situations.
33. Anatomy of IVC
• The IVC returns blood from the
body to the right atrium
• Formed by the convergence
of the illiac veins
• Retroperitoneal
• Right of the aorta
• Normal size 1.5-2.5 cm
• During expiration,
• In a spontaneously breathing patient,
• Just distal the hepatic vein
• Varies with respiration
48. (False) Collapse of IVC
• Diaphragmatic breathing (Kimura 2011) “Important in the
ICU”
• Raised intra-abdominal pressure (in animal studies: Takata
1990)
• Even pressure from the probe! (anecdotally)
IVC Pearls
65. Who is eligible?
• Everyone who is interested in cardiovascular
imaging. The cut-off age for
• participation is currently 35 years of age but
from January 2016 eligibility criteria will
• be altered. So stay tuned!
66. • Doctors (cardiologists, intensivists, anaesthetists,
cardiothoracic surgeons, internal medicine
physicians)
• Medical students
• Technicians/sonographers / allied health
professionals (incl. nurses)
Who is eligible?
67. Benefits
• Become a full member of the (EACVI), leading
European Cardiovascular Imaging network.
• Get involved in Several Echo workshops, endorsed by
the EACVI.
• Register for free to all EACVI webinars and their
recordings if you missed the live sessions
• Apply for EACVI Training and Research Grants
• Participate to projects / registries
70. • We call for a mandatory training of all
intensivists and ED physicians on US and Echo
basics.
• Learning focused, limited bedside Echo is a life
saver and a game changer tool.
• Hyper-dynamic LV doesn’t mean normal global
function.
• It is mostly accompanied by small collapsed
chambers and IVC.
Take-Home Message
71. • Hyperdynamic LV also is highly specific for
sepsis (94%).
• Bedside Echo currently replaces mandatory
CVP measurement.
• Dynamic frequent re-assessment is the key to
management with Echo.
Take-Home Message
75. References
1. Manasia AR, Nagaraj HM, Kodali RB, Croft LB, Oropello JM, Kohli-Seth R, Leibowitz AB, DelGiudice R, Hufanda JF,
Benjamin E, Goldman ME (2005) Feasibility and potential clinical utility of goal-directed transthoracic
echocardiography performed by noncardiologist intensivists using a small hand-carried device (SonoHeart) in critically
2. Hu¨ttemann E, Schlenz C, Kara F (2004) The use and safety of TEE in the general ICU—a minireview. Acta
Aanaesthesiol Scand 48:827–836
3. Orme RM, Oram MP, McKinstry CE (2009) Impact of echocardiography on patient management in the intensive care
unit: an audit of district general hospital practice. Br J Anaesth 102:340–344
4. Bouferrachea K, Caille V, Chimot L, Castro S, Charron C, Page B, Vieillard-Baron A (2010) Monitorage
he´modynamique dans le sepsis: confrontation des recommandations de la Surviving Sepsis Campaign a`
l’e´chocardiographie. Re´animation 19S:S32–S33 (Abst)
5. Cloreavy FB, Donovan K, Lee KY, et al. Transesophageal echocardiography in critically ill patients. Crit Care Med 2002;
30:989–996
6. Benjamin E, Griffin K, Leibowitz AB, et al. Goal-directed transesophageal echocardiography performed by intensivists
to assess left ventricular function: comparison with pulmonary artery catheterization. J Cardiothorac Vasc Anesth
1998; 12:10–15
7. Spevack DM, Spevack DM, Tunick PA, et al. Hand carried echocardiography in the critical care setting.
Echocardiography 2003; 20:455–461
76. “AND WHOEVER SAVES A LIFE, IT
IS CONSIDERED AS IF
HE SAVED AN ENTIRE WORLD”
QUR’AN 5:32
“ َيْحَأاَمَّنَأَكَف اَاهَيْحَأ ْنَمَوايعِمََ ََاََّّالا ”
العظيمهللا صدق