O slideshow foi denunciado.
Utilizamos seu perfil e dados de atividades no LinkedIn para personalizar e exibir anúncios mais relevantes. Altere suas preferências de anúncios quando desejar.
War – What is it Good For?Anthony HolleyIntensivistRoyal Brisbane and Women’s Hospital
Declarations No image depicts a wounded Australian. All images previously published/approved. Opinions expressed are no...
War – What is it Good For?
Probably Nothing!“A great war leaves the country with three armies - an army of cripples, anarmy of mourners, and an army ...
Moving Beyond Case Reports High volumes of trauma Extensive trauma Unique injuries Significant distances to “standard ...
Triage Napoleonic wars Baron Larrey (1766-1842) Established anambulance service and asystem of triage
“The field army has an opportunity for research thatcannot be duplicated by any other organization ...No other institution...
One month after the invasion of Iraq in2003…. US Army Surgeon General sent a team intoIraq on a fact-finding mission. “I...
Perkins et al. Research and Analytics in Combat Trauma Care. Converting Dataand Experience to Practical Guidelines. Surg C...
Deployed Combat CasualtyResearch Team Physician director Deputy director nurse 3 research nurses A senior noncommissio...
Aims1. Improve organization anddelivery of trauma care.2. Develop clinical practiceguidelines.3. Ensure continuity through...
Clinical Practice GuidelinesReviewed1 Acoustic Trauma and Hearing Loss February 16, 20102 Amputation February 16, 20103 Bl...
Does the Military Experience contributeto Civilian Medicine? Age Co-morbidities Injury mechanism Environment Limitati...
EXTREMITY INJURIES1Johnson, Burns et al. 2007; 2Gustilo and Anderson2002Injury Severity Relative to Civilian Medicine - Fr...
Civilian Medicine? New concepts in medical care introduced during warare often integrated into civilian practice. Requir...
So What Have We Learnt Over theLast Decade?
Casualties of War — Military Care for the Wounded from Iraq and AfghanistanAtul Gawande, M.D., M.P.H. N Engl J Med 2004; 3...
Potentially PreventableDeaths in Iraq and AfghanistanCNS 9% Other 4%Airway 14%Hemorrhage85%31% Compressible (prehospital t...
The Fundamentals of Casualty CareUnchanged Overthe Past 100 Years:1. Pre-hospital/point ofwounding care2. Safe evacuation ...
Why Are We Doing Better? Improved PersonalProtectiveEquipment Tactical CombatCasualty Care Fasterevacuationtimes Bette...
Improved Personal ProtectiveEquipment
Tactical Combat Casualty Care25 >75% of all combat deaths occur before thecasualty reaches a Medical TreatmentFacility T...
Previous Approach to Combat MedicTraining26 Historically modeled on civilian courses EMT, PHTLS, BTLS, ATLS Trained to ...
Phases of Care in TCCC Care Under Fire Tactical Field Care Tactical Evacuation Care
Pre-Hospital / Point of InjuryCare - MARCH Massivehaemorrhage control Airway Respiration Circulation Hypothermia
Early analysis of autopsy reportsfrom Afghanistan and Iraq: Emphasized preventable deaths due toexsanguination from extre...
Tourniquets in WWII“We believe that thestrap-and-buckletourniquet incommon use isineffective in mostinstances underfield c...
Annals of Surgery • Volume 245, Number 6, June 2007
Tourniquets Recent reviews oftourniquet use incombat Low complicationrates Positive survivalbenefit
Tourniquets 31stCSH in 2004 165 casualties with severeextremity trauma 67 with prehospitaltourniquets; 98 without Seve...
Data from 2 studies of patients presenting to acombat hospital in Iraq with tourniquets
Tourniquets
TourniquetsTourniquet vs notourniquetShock vs no shockPrehospital vs ED
Tourniquets
 Penetrating injury Police officers Terrorist attacks Wilderness accidents Industrial accidentsTourniquets
Recommendation“In rare situations tourniquet application will benecessary and lifesaving in the civilian pre-hospital sett...
Intra-osseous access Research and casestudies in the 1940sdemonstrated theusefulness of theintraosseous route forblood, f...
 Use of intraosseousdevices in trauma istaught andadvocated in theATLS/EMST.Intra-osseous access
Damage Control Resuscitation“Damage Control Resuscitationrepresents the most important advancein trauma care for hospitali...
Damage Control Resuscitation Permissive hypotension Fluids Blood products/ratios Warming Abbreviated initial surgery
Permissive hypotension and minimalvolume resuscitationCannon W, Fraser J and Cowell E (1918). The preventive treatment ofw...
Management of critical bleeding should focuson:1. Early recognition of blood loss2. Rapid control of the source of bleedin...
Damage Control Resuscitation Acidosis- Base Deficit > - 6 Coagulopathy – INR > 1.5 Hypotension – Systolic B/P < 90 Hae...
So what product ratios shouldwe be using to optimiseResuscitation of HaemorrhagicShock?
RatiosProduct ratios
Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal LA, Schreiber MA, Gonzalez EA, Pomper GJ,Perkins JG, Spinella PC, ...
Product ratios Massive data base ~ 25 000 16% transfused 11.4% received massive transfusions 383 patients Logistic re...
Hemostatic resuscitation with plasma and platelets in trauma Pär I Johansson, Roberto S Oliveri, Sisse R OstrowskiSection ...
Pragmatic, Randomized, Optimal Plateletand Plasma Ratios (PROPPR)University of Washington Phase III trial toevaluate the d...
PROPPR Estimated Enrollment: n = 580 Study Start Date: August 2012 Estimated Study Completion Date: August 2015Primary ...
Practice PointIn patients with critical bleeding requiringmassive transfusion, suggested doses ofblood components are:1. F...
Practice PointIn patients with critical bleeding requiringmassive transfusion, insufficient evidence wasidentified to supp...
Ratios
Provision of ProductsMJA 2010; 192: 203–205Frozen blood products: clinically effective and potentially ideal for remote Au...
Cryopreserved Platelets (-80Cryopreserved Platelets (-80ooC)C)
Cryopreserved vs. Liquid Platelets(CLIP)Cryopreserved vs. Liquid PlateletsApilo t rando m ise d, co ntro lle d, blinde d c...
Adjuncts to Haemostasis Factor VIIa Topicalhaemostatics Tranexamic acid Prothrombincomplexconcentrates
Topical Haemostatics
Topical Haemostatics Topical Accelerate coagulation Junctional sites non compressible sites
In 2003, Pusateri cited criteria for the idealprehospital topical haemostatic dressing1. Ability to stop haemorrhage from ...
Haemostatic Dressings Factor concentrators e.g Zeolite “Quickclot”. Mucoadhesive agents e.g. Hemocon (Chitinbased). Pro...
Kaolin (inert mineral) Promotes clotting by two main modes ofaction:1. Activation of Factor XII (FXII) in the presenceof ...
Haemostatic Dressings
70CRASH-2trialcollaborators. TheLancet. 2010;376:23-32Effects of tranexamic acid on death,vascular occlusive events, and b...
Tranexamic AcidTranexamic Acid
Tranexamic AcidTranexamic Acid
Arch Surg. 2012;147(2):113-119. 2011Study profile illustrating the overall cohort and study groups.MATTERs
Arch Surg. 2012;147(2):113-119.2011MATTERs
From: Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) StudyArch Surg. 2012;147(2):113-...
Arch Surg. 2012;147(2):113-119.Kaplan-Meier survival curve of the overall cohort, including patients receiving tranexamic ...
From: Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) StudyArch Surg. 2012;147(2):113-...
Telemedicine Wide use oftelemedicine in Iraq andAfghanistan hindered bya lack of satellitebandwidth. Remote specialists...
Telemedicine Requires securedsystem. Email to send Images. Electronic transfer ofCT and otherradiological images toLand...
War– What is it Good For? Numbers Ideas Need Caution required indirect extrapolationto civilian practice Sadly, at ti...
Questions?
Holley: WAR - What is it good for?
Holley: WAR - What is it good for?
Holley: WAR - What is it good for?
Holley: WAR - What is it good for?
Holley: WAR - What is it good for?
Holley: WAR - What is it good for?
Holley: WAR - What is it good for?
Próximos SlideShares
Carregando em…5
×

4

Compartilhar

Baixar para ler offline

Holley: WAR - What is it good for?

Baixar para ler offline

Anthony Holley brings a military perspective to advances made in trauma management on and off the battlefield.

Audiolivros relacionados

Gratuito durante 30 dias do Scribd

Ver tudo

Holley: WAR - What is it good for?

  1. 1. War – What is it Good For?Anthony HolleyIntensivistRoyal Brisbane and Women’s Hospital
  2. 2. Declarations No image depicts a wounded Australian. All images previously published/approved. Opinions expressed are not those of the ADF No conflict/financial advantage.
  3. 3. War – What is it Good For?
  4. 4. Probably Nothing!“A great war leaves the country with three armies - an army of cripples, anarmy of mourners, and an army of thieves” German proverb“He who would become a surgeon should join the army and follow it.”Hippocrates
  5. 5. Moving Beyond Case Reports High volumes of trauma Extensive trauma Unique injuries Significant distances to “standard facilities”
  6. 6. Triage Napoleonic wars Baron Larrey (1766-1842) Established anambulance service and asystem of triage
  7. 7. “The field army has an opportunity for research thatcannot be duplicated by any other organization ...No other institution has an opportunity orresponsibility in the field of trauma comparable tothat of the Army Medical Service”.Battle Casualties in Korea, Studies of the SurgicalResearch Team, 1955, p. 16.
  8. 8. One month after the invasion of Iraq in2003…. US Army Surgeon General sent a team intoIraq on a fact-finding mission. “Ide ntify what was wro ng and fix it. ”
  9. 9. Perkins et al. Research and Analytics in Combat Trauma Care. Converting Dataand Experience to Practical Guidelines. Surg Clin N Am 92 (2012) 1041–1054
  10. 10. Deployed Combat CasualtyResearch Team Physician director Deputy director nurse 3 research nurses A senior noncommissioned officer.
  11. 11. Aims1. Improve organization anddelivery of trauma care.2. Develop clinical practiceguidelines.3. Ensure continuity throughchain of evacuation.4. Conferences.5. Evaluate new equipment.6. Populate trauma registry.7. Facilitate formal research.Joint Theater Trauma System (JTTS)and Joint Theater Trauma Registry (JTTR)
  12. 12. Clinical Practice GuidelinesReviewed1 Acoustic Trauma and Hearing Loss February 16, 20102 Amputation February 16, 20103 Blunt Abdominal Trauma June 30, 20094 Burn Care December20, 20095 Catastrophic Care February 16, 20106 Cervical Spine Evaluation June 30, 20107 Compartment Syndrome (CS) and the Role of Fasciotomy in Extremity WarWounds April 30, 20098 Damage Control Resuscitation at Level IIb/III Treatment Facilities February 13, 20099 Emergent Resuscitative Thoracotomy May 6, 200910 Fresh Whole Blood (FWB) Transfusion January 12, 200911 Frozen and Deglycerolized Red Blood Cells (RBCs) June 30, 201012 Hypothermia Prevention, Monitoring, and Management June 30, 201013 Infection Control February 16, 201014 Inhalation Injury and Toxic Industrial Chemical Exposure November7, 200815 Initial Care of Ocularand Adnexal Injuries February 16, 201016 IntratheaterTransferand Transport of Level IIand IIICritical Care Trauma Patients November19, 200817 Management of Patients with Severe Head Trauma November23, 201018 Management of Patients with Severe Head Trauma June 30, 201019 Management of WarWounds February 16, 201020 Nutrition February 16, 201021 Pelvic Fracture Care June 30, 201022 Post-Splenectomy Vaccination June 30, 201023 Prevention of Deep Venous Thrombosis (DVT) November21, 200824 Spine Injury Surgical Management and Transport July 9, 201025 Trauma Airway Management June 30, 201026 Urologic Trauma Management June 30, 201027 Use of Electronic Clinical Documentation in the CENTCOMAOR June 30, 201028 Use of Trauma Flow Sheets December1, 200829 VentilatorAssociated Pneumonia - February 16, 201030 VascularInjury November7, 2008Source: http://www.usaisr.amedd.army.mil/cpgs.html
  13. 13. Does the Military Experience contributeto Civilian Medicine? Age Co-morbidities Injury mechanism Environment Limitations Expectations Levels of evidence
  14. 14. EXTREMITY INJURIES1Johnson, Burns et al. 2007; 2Gustilo and Anderson2002Injury Severity Relative to Civilian Medicine - Fractures
  15. 15. Civilian Medicine? New concepts in medical care introduced during warare often integrated into civilian practice. Require validation through quality prospectiveresearch.
  16. 16. So What Have We Learnt Over theLast Decade?
  17. 17. Casualties of War — Military Care for the Wounded from Iraq and AfghanistanAtul Gawande, M.D., M.P.H. N Engl J Med 2004; 351:2471-2475
  18. 18. Potentially PreventableDeaths in Iraq and AfghanistanCNS 9% Other 4%Airway 14%Hemorrhage85%31% Compressible (prehospital target)69% Non-Compressible (FST/CSH target)(Kelly J., J Trauma 64:S21, 2008)n= 232
  19. 19. The Fundamentals of Casualty CareUnchanged Overthe Past 100 Years:1. Pre-hospital/point ofwounding care2. Safe evacuation fromfront-line combat3. Rapid control ofhaemorrhage4. Prevention ofcontamination/infectious sources.
  20. 20. Why Are We Doing Better? Improved PersonalProtectiveEquipment Tactical CombatCasualty Care Fasterevacuationtimes BettertrainedmedicsHolcomb et al J Trauma 2006
  21. 21. Improved Personal ProtectiveEquipment
  22. 22. Tactical Combat Casualty Care25 >75% of all combat deaths occur before thecasualty reaches a Medical TreatmentFacility The fate of the injured often lies in thehands of the one who provides the first careto the casualty.
  23. 23. Previous Approach to Combat MedicTraining26 Historically modeled on civilian courses EMT, PHTLS, BTLS, ATLS Trained to standard of care in civilian settings No consideration for tactical elements
  24. 24. Phases of Care in TCCC Care Under Fire Tactical Field Care Tactical Evacuation Care
  25. 25. Pre-Hospital / Point of InjuryCare - MARCH Massivehaemorrhage control Airway Respiration Circulation Hypothermia
  26. 26. Early analysis of autopsy reportsfrom Afghanistan and Iraq: Emphasized preventable deaths due toexsanguination from extremity trauma. Key focus of intervention.
  27. 27. Tourniquets in WWII“We believe that thestrap-and-buckletourniquet incommon use isineffective in mostinstances underfield conditions…itrarely controlsbleeding no matterhow tightly applied.”
  28. 28. Annals of Surgery • Volume 245, Number 6, June 2007
  29. 29. Tourniquets Recent reviews oftourniquet use incombat Low complicationrates Positive survivalbenefit
  30. 30. Tourniquets 31stCSH in 2004 165 casualties with severeextremity trauma 67 with prehospitaltourniquets; 98 without Seven deaths Four of the seven deathswere potentially preventablehad an adequate prehospitaltourniquet been placedBeekley et al Journal of Trauma 2008
  31. 31. Data from 2 studies of patients presenting to acombat hospital in Iraq with tourniquets
  32. 32. Tourniquets
  33. 33. TourniquetsTourniquet vs notourniquetShock vs no shockPrehospital vs ED
  34. 34. Tourniquets
  35. 35.  Penetrating injury Police officers Terrorist attacks Wilderness accidents Industrial accidentsTourniquets
  36. 36. Recommendation“In rare situations tourniquet application will benecessary and lifesaving in the civilian pre-hospital setting. Tourniquets are no longeronly considered as a ‘‘last resort’’ device.Practitioners should familiarise themselveswith this simple piece of equipment and beprepared to use it in appropriate cases withoutan irrational fear of complications”.
  37. 37. Intra-osseous access Research and casestudies in the 1940sdemonstrated theusefulness of theintraosseous route forblood, fluids, andmedications. An intraosseous devicesused during World War II.Dublick MA, Holcomb JB. A review of intraosseous vascular access: current statusand military application. Mil Med. 2000; 165:552-559
  38. 38.  Use of intraosseousdevices in trauma istaught andadvocated in theATLS/EMST.Intra-osseous access
  39. 39. Damage Control Resuscitation“Damage Control Resuscitationrepresents the most important advancein trauma care for hospitalized civilianand military casualties from this war.”Cordts, Brosch and Holcomb, J Trauma, 2008
  40. 40. Damage Control Resuscitation Permissive hypotension Fluids Blood products/ratios Warming Abbreviated initial surgery
  41. 41. Permissive hypotension and minimalvolume resuscitationCannon W, Fraser J and Cowell E (1918). The preventive treatment ofwound shock. Journal of the American Medical Association 70:618–621.
  42. 42. Management of critical bleeding should focuson:1. Early recognition of blood loss2. Rapid control of the source of bleeding3. Restoration of circulating blood volume.
  43. 43. Damage Control Resuscitation Acidosis- Base Deficit > - 6 Coagulopathy – INR > 1.5 Hypotension – Systolic B/P < 90 Haemoglobin - < 11 Temperature - < 36 oC Pattern recognition Weak or absent radial pulse Abnormal mental status Severe Traumatic Injury
  44. 44. So what product ratios shouldwe be using to optimiseResuscitation of HaemorrhagicShock?
  45. 45. RatiosProduct ratios
  46. 46. Holcomb JB, Wade CE, Michalek JE, Chisholm GB, Zarzabal LA, Schreiber MA, Gonzalez EA, Pomper GJ,Perkins JG, Spinella PC, Williams KL, Park MS. Increased plasma and platelet to red blood cell ratios improvesoutcome in 466 massively transfused civilian trauma patients. Ann Surg 2008; 248:447-458.
  47. 47. Product ratios Massive data base ~ 25 000 16% transfused 11.4% received massive transfusions 383 patients Logistic regression identified the ratio of FFP to PRBC use asan independent predictor of survival. Higher the ratio of FFP:PRBC the greater the probability ofsurvival. The optimal ratio in this analysis was an FFP:PRBC ratio of1:3 or less.Teixeira PG, Inaba K, Shulman I, Salim A, Demetriades D, Brown C, Browder T, Green D, Rhee P.Impact of plasma transfusion in massively transfusedtrauma patients. J Trauma 2009; 66:693-697.
  48. 48. Hemostatic resuscitation with plasma and platelets in trauma Pär I Johansson, Roberto S Oliveri, Sisse R OstrowskiSection for Transfusion Medicine, Capital Region Blood Bank, Department of Clinical Immunology, Rigshospitalet, University ofCopenhagen, Denmark
  49. 49. Pragmatic, Randomized, Optimal Plateletand Plasma Ratios (PROPPR)University of Washington Phase III trial toevaluate the difference in 24-hour and 30-daymortality among subjects predicted to receivemassive transfusion.
  50. 50. PROPPR Estimated Enrollment: n = 580 Study Start Date: August 2012 Estimated Study Completion Date: August 2015Primary Outcome Measures: 24-hour mortality 30-day mortality Coagulation and inflammatory phenotypes at emergency department admission and over time.Secondary Outcome Measures: Hospital fee Ventilator free and ICU free days Time to haemostasis, major surgical procedures, incidence of transfusion related serious adverseevents. Functional status at time of hospital discharge, initial hospital discharge status
  51. 51. Practice PointIn patients with critical bleeding requiringmassive transfusion, suggested doses ofblood components are:1. FFP: 15 mL/kg2. platelets: 1 adult therapeutic dose3. cryoprecipitate: 3–4 g.
  52. 52. Practice PointIn patients with critical bleeding requiringmassive transfusion, insufficient evidence wasidentified to support or refute the use ofspecific ratios of RBCs to blood components.
  53. 53. Ratios
  54. 54. Provision of ProductsMJA 2010; 192: 203–205Frozen blood products: clinically effective and potentially ideal for remote AustraliaHolley et al.. Anaesth Intensive care. 2013 Jan;41(1):10-9.
  55. 55. Cryopreserved Platelets (-80Cryopreserved Platelets (-80ooC)C)
  56. 56. Cryopreserved vs. Liquid Platelets(CLIP)Cryopreserved vs. Liquid PlateletsApilo t rando m ise d, co ntro lle d, blinde d clinicaltrialo fcryo pre se rve d plate le ts vs. co nve ntio nalliq uid-sto re dplate le ts fo r the m anag e m e nt o f po st-surg icalble e ding• 90 cardiac surgical patients in 3 hospitals (TPCH, RPAH, Austin)• Supported by ANZCA ($94K) and ARCBS ($50K) grants• Will facilitate NH&MRC project grant application in 2014.
  57. 57. Adjuncts to Haemostasis Factor VIIa Topicalhaemostatics Tranexamic acid Prothrombincomplexconcentrates
  58. 58. Topical Haemostatics
  59. 59. Topical Haemostatics Topical Accelerate coagulation Junctional sites non compressible sites
  60. 60. In 2003, Pusateri cited criteria for the idealprehospital topical haemostatic dressing1. Ability to stop haemorrhage from actively bleedinglarge arteries and veins within 2 min.2. Delivered through a pool of blood.3. Ready to use requiring no on scene mixing orpreparation4. Simple to apply by casualty, non-medical firstresponder or medical staff.5. Lightweight and durable.6. Minimum 2 year shelf-life and wide temperaturestorage capability (ideally 10–55 8C).7. Risk free – no injury or viral disease transmissionrisk8. Inexpensive.
  61. 61. Haemostatic Dressings Factor concentrators e.g Zeolite “Quickclot”. Mucoadhesive agents e.g. Hemocon (Chitinbased). Procoagulant supplementors e.g. KaolinQuickclot combat gauze.
  62. 62. Kaolin (inert mineral) Promotes clotting by two main modes ofaction:1. Activation of Factor XII (FXII) in the presenceof kallikrein and high molecular weightkininogen. Activated FXII initiates the intrinsicclotting pathway via the activation of FactorXI. 2. Activation of platelet-associated FXI (a distinctand separate molecule from plasma FXI). 
  63. 63. Haemostatic Dressings
  64. 64. 70CRASH-2trialcollaborators. TheLancet. 2010;376:23-32Effects of tranexamic acid on death,vascular occlusive events, and bloodtransfusion in trauma patients withsignificant haemorrhage (CRASH-2): arandomised, placebo-controlled trialTranexamic acid
  65. 65. Tranexamic AcidTranexamic Acid
  66. 66. Tranexamic AcidTranexamic Acid
  67. 67. Arch Surg. 2012;147(2):113-119. 2011Study profile illustrating the overall cohort and study groups.MATTERs
  68. 68. Arch Surg. 2012;147(2):113-119.2011MATTERs
  69. 69. From: Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) StudyArch Surg. 2012;147(2):113-119.Percentage of patients with hypocoagulopathy on admission to the emergency department (ED) and then the intensive care unit(ICU) following the initial operation. Coagulation data were available for 462 patients in the overall cohort and 155 patients in thegroups that received massive transfusion. TXA indicates tranexamic acid. * P < .05.MATTERs
  70. 70. Arch Surg. 2012;147(2):113-119.Kaplan-Meier survival curve of the overall cohort, including patients receiving tranexamic acid (TXA) vs no TXA. P = .006, Mantel-Cox log-rank test.MATTERs
  71. 71. From: Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) StudyArch Surg. 2012;147(2):113-119.Kaplan-Meier survival curve of the massive transfusion group receiving tranexamic acid (TXA) or no TXA. P = .004, Mantel-Coxlog-rank test.MATTERs
  72. 72. Telemedicine Wide use oftelemedicine in Iraq andAfghanistan hindered bya lack of satellitebandwidth. Remote specialists > 40000 consultsLam DM, Poropatich RK Telemedicine deployments within NATO militaryforces: a data analysis of current and projected capabilities. Telemed J EHealth. 2008 Nov;14(9):946-51
  73. 73. Telemedicine Requires securedsystem. Email to send Images. Electronic transfer ofCT and otherradiological images toLandstuhl RegionalMedical Centre.
  74. 74. War– What is it Good For? Numbers Ideas Need Caution required indirect extrapolationto civilian practice Sadly, at timescivilian practice allto similar to war
  75. 75. Questions?
  • AlaaMuhsin1

    Jan. 27, 2018
  • ssuser2d0a831

    Aug. 22, 2015
  • rjjaramillo

    Aug. 5, 2015
  • peterfoster5855

    Jun. 21, 2015

Anthony Holley brings a military perspective to advances made in trauma management on and off the battlefield.

Vistos

Vistos totais

4.787

No Slideshare

0

De incorporações

0

Número de incorporações

2.377

Ações

Baixados

31

Compartilhados

0

Comentários

0

Curtir

4

×