Google Analytics Alternative

Ok

En poursuivant votre navigation sur ce site, vous acceptez l'utilisation de cookies. Ces derniers assurent le bon fonctionnement de nos services. En savoir plus.

25/10/2016

Coniotomie chirurgicale: Spécialiste ? Non, mais formé spécifiquement OUI

The success of battlefield surgical airway insertion in severely injured military patients: a UK perspective.

  

BACKGROUND:

The insertion of a surgical airway in the presence of severe airway compromise is an uncommon occurrence in everyday civilian practice. In conflict, the requirement for insertion of a surgical airway is more common. Recent military operations in Afghanistan resulted in large numbers of severely injured patients, and a significant proportion required definitive airway management through the insertion of a surgical airway.

OBJECTIVE:

To examine the procedural success and survival rate to discharge from a military hospital over an 8-year period.

METHODS:

A retrospective database and chart review was conducted, using the UK Joint Theatre Trauma Registry and the Central Health Records Library. Patients who underwent surgical airway insertion by UK medical personnel from 2006 to 2014 were included. Procedural success, demographics, Injury Severity Score, practitioner experience and patient survival data were collected. Descriptive statistics were used for data comparison, and statistical significance was defined as p<0.05.

RESULTS:

86 patients met the inclusion criterion and were included in the final analysis. The mean patient age was 25 years, (SD 5), with a median ISS of 62.5 (IQR 42). 79 (92%) of all surgical airways were successfully inserted. 7 (8%) were either inserted incorrectly or failed to perform adequately. 80 (93%) of these procedures were performed either by combat medical technicians or General Duties Medical Officers (GDMOs) at the point of wounding or Role 1. 6 (7%) were performed by the Medical Emergency Response Team. 21 (24%) patients survived to hospital discharge.

DISCUSSION:

Surgical airways can be successfully performed in the most hostile of environments with high success rates by combat medical technicians and GDMOs. These results compare favourably with US military data published from the same conflict.

 



 

| Tags : airway, coniotomie

22/09/2016

Crico: Quelques rappels qui font du bien

Evidence Is Important: Safety Considerations for Emergency Catheter Cricothyroidotomy

Marshall SD et Al. Acad Emerg Med. 2016 Sep;23(9):1074-6

 

Il existe un regain d'intérêt concernant la pratique de l'oxygénation après ponction de la membrane cricoÏdienne. De large débats portent sur la meilleure méthode à utiliser. En pratique il n'est pas inutile de rappeler quelques vérités pratiques. C'est ce que propose ce document dont la lecture est fort utile. Cliquez sur la référence pour accéder au document et ici pour accéder à des vidéos complémentaires

 

 

| Tags : coniotomie

08/07/2016

Coniotomie: Plaidoyer UK pour la chirurgie

The success of battlefield surgical airway insertion in severely injured military patients: a UK perspective

Tyle T et Al. J R Army Med Corps. 2016 Jun 6. pii: jramc-2016-000637. doi: 10.1136/jramc-2016-000637

-----------------------------------------------

Un geste peu fréquent: 86 blessés sur une période de 8 ans et pourtant un geste essentiel à maîtriser. Faire simple est mieux. Pour cela pas besoin d'être chirurgien, urgentiste ou anesthésiste-réanimateur.

-----------------------------------------------

BACKGROUND:

The insertion of a surgical airway in the presence of severe airway compromise is an uncommon occurrence in everyday civilian practice. In conflict, the requirement for insertion of a surgical airway is more common. Recent military operations in Afghanistan resulted in large numbers of severely injured patients, and a significant proportion required definitive airway management through the insertion of a surgical airway.

OBJECTIVE:

To examine the procedural success and survival rate to discharge from a military hospital over an 8-year period.

METHODS:

A retrospective database and chart review was conducted, using the UK Joint Theatre Trauma Registry and the Central Health Records Library. Patients who underwent surgical airway insertion by UK medical personnel from 2006 to 2014 were included. Procedural success, demographics, Injury Severity Score, practitioner experience and patient survival data were collected. Descriptive statistics were used for data comparison, and statistical significance was defined as p<0.05.

RESULTS:

86 patients met the inclusion criterion and were included in the final analysis. The mean patient age was 25 years, (SD 5), with a median ISS of 62.5 (IQR 42). 79 (92%) of all surgical airways were successfully inserted. 7 (8%) were either inserted incorrectly or failed to perform adequately. 80 (93%) of these procedures were performed either by combat medical technicians or General Duties Medical Officers (GDMOs) at the point of wounding or Role 1. 6 (7%) were performed by the Medical Emergency Response Team. 21 (24%) patients survived to hospital discharge.

DISCUSSION:

Surgical airways can be successfully performed in the most hostile of environments with high success rates by combat medical technicians and GDMOs. These results compare favourably with US military data published from the same conflict.

 

| Tags : airway, coniotomie

28/06/2016

Crico: Incisez et palpez sous la peau !

Deficiencies in locating the cricothyroid membrane by palpation: We can’t and the surgeons can’t, so what now for the emergency surgical airway ?

Law JA et Al. Can J Anesth (2016) 63:791–796

"......Certaines questions concernant la localisation de la membrane cricothyroïdienne demeurent sans réponse. Nous savons désormais que la palpation externe manque de précision, indépendamment de la spécialité du médecin évaluateur. En d’autres termes, les techniques qui s’appuient sur un accès direct à la trachée via la membrane cricothyroïdienne palpée depuis l’extérieur (par ex., les techniques percutanées de Seldinger ou réalisées à l’aide d’un trocart, un accès basé sur un scalpel à l’aide d’une coupure horizontale unique) courent toutes le risque d’un mauvais positionnement. L’alternative, lorsqu’on a recours à ces techniques de cricothyrotomie (en fait, à toutes ces techniques), est de commencer par une incision verticale médiane de 3-4 cm à travers la peau et les tissus sous-cutanés situés sur l’emplacement estimé de la membrane cricothyroïdienne.5,6 La membrane cricothyroïdienne est ensuite palpée à nouveau dans la lésion, et son emplacement devrait être bien plus facile à déterminer lorsqu’il y a considérablement moins de tissu mou entre le doigt qui palpe et la membrane cricothyroïdienne. La cricothyrotomie peut ensuite se faire à l’aide de la technique choisie et en étant absolument certain de son bon positionnement......"

| Tags : airway, coniotomie

27/06/2016

Crico: Utilisez le manche du bistouri !

Crico.jpg

Surgical Procedures in Trauma Management. New York, NY: Thieme Inc; 1986:303

| Tags : airway, coniotomie

30/01/2016

Coniotomie: Modèle porcin

A porcine model for teaching surgical cricothyridootomy

Netto FA et Al. Rev Col Bras Cir. 2015 Jun;42(3):193-6

 

0100-6991-rcbc-42-03-00193-gf01.jpg

Le matériel nécessaire

0100-6991-rcbc-42-03-00193-gf02.jpg

Le montage

0100-6991-rcbc-42-03-00193-gf03.jpg

Un gant fixé derrière la peau va simuler la membrane

0100-6991-rcbc-42-03-00193-gf04.jpg

Le simulateur prêt à l'emploi.

 

| Tags : coniotomie

18/12/2015

Ejector ventilator: Quésaco ?

Ventrain: an ejector ventilator for emergency use

Hamaekers AE et Al. Br J Anaesth. 2012 Jun;108(6):1017-21

----------------------------------------

La ventilation sur cathéter de coniotomie n'est pas chose aisée du fait de l'importance des résistances à l'écoulement des gaz dans un cathéter de petit diamètre. On considère que sans dispositif d'injection de type manujet, il faut un cathéter d'au moins 4 mm pour assurer un minimum acceptable. Certains ont proposé d'avoir recours à une expiration active. Il s'agissait de dispositifs expérimentaux. Ce n'est pas le cas du Ventrain qui apparaît être un produit abouti. A suivre

---------------------------------------- 

The Use of Ventrain from Ventinova Medical BV on Vimeo.

| Tags : coniotomie

22/11/2015

Paroi postérieure: Rester à l'écart

Cricothyroidotomy catheters: an investigation of mechanisms of failure and the effect of a novel intracatheter stylet

Hebbard PD et Al. Anaesthesia. 2015 Oct 28. doi: 10.1111/anae.13269

--------------------------------------------

L'étude NAP4 a mis en avance l'importance de maîtriser les techniques d'oxygénation transtrachéale et la cricothyrotomie. Il n'est pas étonnant que, dans les démarches d'entrainement et de recherche en gestion des situations de CICO, apparaissent des interrogations sur la survenue des complications liées à ces techniques. Les atteintes de la paroi postérieures sont l'une d'entre elles. Elles s'observent aussi lors de l'emploi de simple cathéter et peuvent déboucher sur des complications grave notamment lors d'emploi de techniques de jet ventilation. C'est ce que rapporte le document proposé. D'après ce document il semble que l'on puisse réduire ce risque en orientant l'aiguille à 45° dès sa pénétration dans la lumière trachéale. 

--------------------------------------------

Emergency catheter cricothyroidotomy often fails. Case reports have concentrated on kinking and displacement of the catheter as the major causes. We investigated catheter tip penetration of the trachea. Using insertion angles of 90°, 75°, 60°, 45° and 30° we advanced 14 G intravenous catheters into fresh isolated sheep tracheas during high pressure oxygen insufflation. At all angles, the catheter tip became blocked by pushing into the mucosa with submucosal gas injection on one or more attempts. Full thickness rupture with extratracheal gas also occurred on insertions at 90° and 60°. We then tested a Luer-mounted prototype wire stylet which remains in situ during insufflation. Using the same methodology, the stylet was able to be placed and prevented blockage at all angles of insertion. Mucosal trauma and submucosal gas injection occurred on insertions at 90° and 75°. Our results should guide further stylet design.

| Tags : coniotomie

Coniotomie: D'abord chirurgicale

Evaluation of novel Surgicric cricothyroidotomy device

King W et Al. Anaesthesia. 2015 Nov 17. doi: 10.1111/anae.13275

----------------------------------

Ce travail est intéressant car il met en avant l'intérêt des techniques chirurgicales par rapport à une technique de référence qui est l'emploi du set de Melker et d'un nouveau kit: le Surgicric. Il montre également que la survenue de lésions de la paroi postérieure n'est pas une vue de l'esprit, cette complication étant la plus fréquente avec ce nouveau kit.

----------------------------------

A can't intubate, can't ventilate scenario can result in morbidity and death. Although a rare occurrence (1:50 000 general anaesthetics), it is crucial that anaesthetists maintain the skills necessary to perform cricothyroidotomy, and are well-equipped with appropriate tools. We undertook a bench study comparing a new device, Surgicric® , with two established techniques; the Melker Emergency Cricothyroidotomy, and a surgical technique. Twenty-five anaesthetists performed simulated emergency cricothyroidotomy on a porcine model, with the primary outcome measure being insertion time. Secondary outcomes included success rate, tracheal trauma and ease of use.

Surgicric.jpg

The surgical technique was fastest. The median (IQR [range]) was 81 (62-126 [37-300]) s, followed by the Melker 124 (100-217 [71-300]) s, and the Surgicric 127 (68-171 [43-300]), p = 0.003. The Surgicric device was the most traumatic, as evaluated by a blinded Ear, Nose and Throat surgeon. Subsequently, the authors contacted the device manufacturer, who has now modified the kit in the hope that its clinical application might be improved. Further studies are required to evaluate the revised model.

 

| Tags : airway, coniotomie

12/09/2015

Ouvrir un cou: Le doigt est important +++



| Tags : coniotomie

24/07/2015

Crico: Plutôt avec une canule à ballonet

The Efficacy of Spontaneous and Controlled Ventilation With Various Cricothyrotomy Devices: A Quantitative In Vitro Assessment in a Model Lung

Michalek-Sauberer M et Al. J Trauma. 2011;71: 886 – 892

-----------------------------------------------

La procédure du sauvetage au combat indique la réalisation d'une coniotomie en cas d'obstruction des voies aériennes. Le minitrach portex II doit être considéré plutôt comme un dispositif d'oxygénation. En effet il est rarissime que les obstructions soient complètes. Dans de telles conditions les fuites sont telle qu'une ventilation effective n'est pas possible sauf à utiliser un dispositif de jet ventilation de type manujet. L'article présenté exprime très bien les limites des dispositifs sans ballonet

-----------------------------------------------

Background:

Guidelines for the management of a difficult airway recommend performing a cricothyrotomy in a “can’t intubate/can’t ventilate” situation. We investigated the tidal volumes delivered by controlled and spontaneous ventilation by seven commercially available cricothyrotomy sets (cuffed: Quicktrach II, Portex Cricothyroidotomy Kit, and Melker cuffed cannula and uncuffed: Airfree, 4.0-mm ID Quicktrach, 6.0-mm inner diameter Melker, and 13-gauge Ravussin cannula) and two improvised devices (14-gauge intravenous cannula and spike and drip chamber device).

Methods:

A LS800 model lung, set at different values for compliance and resistance and modified with different upper airway diameter, was ventilated via the respective cricothyrotomy device mechanically and using a selfinflating bag. With the 13-gauge Ravussin cannula and the 14-gauge intravenous cannula, a Manujet injector was used for jet ventilation. Spontaneous ventilation was simulated with a Michigan 560i lung.

Results:

During controlled or manual ventilation, all cuffed cricothyrotomy devices yielded adequate tidal volumes. Uncuffed devices provided tidal volumes 300 mL only with an upper airway diameter of 3 mm. With a Manujet injector, adequate tidal volumes required an upper airway diameter between 3 mm and 5 mm. A spike and drip chamber device does not provide suitable emergency airway access. Spontaneous ventilation at adequate inspiratory pressure levels required a device inner diameter of at least 4 mm.

 

 

ConioVentilationVariousDevices.jpgConclusion:

As expected, cuffed cricothyrotomy devices yield the best results during controlled, manual, and spontaneous ventilation. With uncuffed cricothyrotomy devices, ventilation becomes ineffective when the upper airway obstruction allows for an upper airway diameter 3 mm.

 

| Tags : coniotomie, airway

03/07/2015

Coniotomie: improviser ?

coniotomie.jpg

| Tags : coniotomie

22/06/2015

Coniotomie: Pas si simple à enseigner

 Cricothyroidotomy Bottom–Up Training Review: Battlefield Lessons Learned

Benett BL et Al. Military Medicine, 176, 11:1311, 2011 

Challenges with surgical cricothyroidotomy on the battlefi eld can be attributed to limited frequency of use, procedure unfamiliarity, and limited knowledge base of anatomical landmarks of which is further heighten in the tactical environment. The objective was to identify ways to enhance the cricothyroidotomy training to minimize potential preventable procedural errors. A training review was conducted to determine the gaps in the cricothyroidotomy training in a 4-day Tactical Combat Casualty Care course at the Naval Medical Center Portsmouth. An ad hoc Working Group team identified five specific gap areas in the cricothyroidotomy training: 1) limited gross airway anatomy review; 2) lack of “hands-on” human laryngeal anatomy; 3) nonstandardized step-by-step surgical incision skill procedure; 4) inferior standards for anatomically correct cricothyroid mannequins; 5) lack of standardized refresher training frequency. Specific training enhancements are recommended across each day in the classroom, simulation laboratory, and field exercise. 

| Tags : coniotomie, airway

20/06/2015

Coniotomie sur le terrain: La vraie vie

An analysis of battlefield cricothyrotomy in Iraq and Afghanistan

J Spec Oper Med. 2012 Spring;12(1):17-23

-----------------------------------------------------------

Pouvoir oxygéner est fondamental. Mais il existe de très nombreuses situations où l'oxygénation par masque ou ballon n'est pas possible ou insuffisante. Il faut alors contrôler les voies aériennes, en particulier la la réalisation d'une coniotomie (1). Ce travail est un des rares actuellement publiés qui fasse le point sur la réalisation de ce geste en conditions de combat (2,3,). Il met en avant la réalité de sa réalisation y compris par les medic, qui ont cependant un taux d'échec double de celui des médecins. Il suggère également tout l'intérêt des ateliers de formation et de séjours au bloc opératoire pour améliorer cet état de fait.

-----------------------------------------------------------

OBJECTIVES:

Historical review of modern military conflicts suggests that airway compromise accounts for 1,2% of total combat fatalities. This study examines the specific intervention of pre-hospital cricothyrotomy (PC) in the military setting using the largest studies of civilian medics performing PC as historical controls. The goal of this paper is to help define optimal airway management strategies, tools and techniques for use in the military pre-hospital setting.

METHODS:

This retrospective chart review examined all patients presenting to combat support hospitals following prehospital cricothyrotomy during combat operations in Iraq and Afghanistan during a 22-month period. A PC was determined successful if it was documented as functional on arrival to the hospital. All PC complications that were documented in the patient's record were also noted in the review.

RESULTS:

Two thirds of the patients died. The most common injuries were caused by explosions, followed by gunshot wounds (GSW) and blunt trauma. Eighty-two percent of the casualties had injures to face, neck or head. Those injured by gunshot wounds to the head or thorax all died. The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Pre-hospital cricothyrotomy was documented as successful in 68% of the cases while 26% of the PCs failed to cannulate the trachea. In 6% of cases the patient was pronounced dead on arrival without documentation of PC function. The majority of PCs (62%) were performed by combat medics at the point of injury. Physicians and physician assistants (PA) were more successful performing PC than medics with a 15% versus a 33% failure rate. Complications were not significantly different than those found in civilian PC studies, including incorrect anatomic placement, excessive bleeding, air leak and right main stem placement.

CONCLUSIONS:

The majority of patients who underwent PC died (66%). The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Military medics have a 33% failure rate when performing this procedure compared to 15% for physicians and physician assistants. Minor complications occurred in 21% of cases. The survival rate and complication rates are similar to previous civilian studies of medics performing PC. However the failure rate for military medics is three to five times higher than comparable civilian studies. Further study is required to define the optimal equipment, technique, and training required for combat medics to master this infrequently performed but lifesaving procedure.

07/05/2015

CICO: Stratégies et équipement

Equipment and strategies for emergency tracheal access in the adult patient

Hamaekers A; et All. Anaesthesia, 2011, 66 (Suppl. 2), pages 65–80

-----------------------------------------------------------------------

Un document qui passe en revue les équipements à mettre en oeuvre lors de sutuation de CICO (Can't intubate can't oxygneate)

-----------------------------------------------------------------------

The inability to maintain oxygenation by non-invasive means is one of the most pressing emergencies in anaesthesia and emergency care. To prevent hypoxic brain damage and death in a ‘cannot intubate, cannot oxygenate’ situation, emergency percutaneous airway access must be performed immediately. Even though this emergency is rare, every anaesthetist should be capable of performing an emergency percutaneous airway as the situation may arise unexpectedly. Clear knowledge of the anatomy and the insertion technique, and repeated skill training are essential to ensure completion of this procedure rapidly and successfully. Various techniques have been described for emergency oxygenation and several commercial emergency cricothyroidotomy sets are available. There is, however, no consensus on the best technique or device. As each has its limitations, it is recommended that all anaesthetists are skilled in more than one technique of emergency percutaneous airway. Avoiding delay in initiating rescue techniques is at least as important as choice of device in determining outcome

04/04/2015

Simulateur de tâche: Modifié pour + de réalisme!

Rescuing the obese or burned airway: are conventional training manikins adequate? A simulation study

 Howes TE. et Al. Br J Anaesth. 2015 Jan;114(1):136-42

-------------------------------------------------

L'emploi de simulateurs de taches se heurte au problème du réalisme de ces derniers. Cette équipe propose de modifier les simulateurs industriels pour plus de réalité.

-------------------------------------------------

Background. Percutaneous tracheal access is required in more than 40% of major airway emergencies, and rates of failure are high among anaesthetists. Supraglottic airway management is more likely to fail in patients with obesity or neck pathology. Commercially available manikins may aid training. In this study, we modified a standard ‘front of neck’ manikin and evaluated anaesthetists’ performance of percutaneous tracheal access.

Methods. Two cricothyroidotomy training manikins were modified using sections of belly pork to simulate a morbidly obese patient and an obese patient with neck burns.

 

F2.medium.gif

 

An unmodified manikin was used to simulate a slim patient. Twenty consultant anaesthetists were asked to manage a ‘can’t intubate, can’t ventilate’ scenario involving each of the three manikins. Outcome measures were success using their chosen technique and time to first effective breath.

Results. Success rates using first-choice equipment were: ‘slim’ manikin 100%, ‘morbidly obese’ manikin 60%, and ‘burned obese’ manikin 77%. All attempts on the ‘slim’ manikin succeeded within 240 s, the majority within 120 s. In attempts on the ‘morbidly obese’ manikin, 60% succeeded within 240 s and 20% required more than 720 s. All attempts on the ‘burned obese’ manikin succeeded within 180 s.

Conclusions. Significantly greater technical difficulty was experienced with our ‘morbidly obese’ manikin compared with the unmodified manikin. Failure rates and times to completion were considerably more consistent with real-life reports. Modifying a standard manikin to simulate an obese patient is likely to better prepare anaesthetists for this challenging situation. Development of a commercial manikin with such properties would be of value

| Tags : coniotomie

Crico: S'entraîner sur un modèle animal est pertinent ?

 Comparison of manikin versus porcine models in cricothyrotomy procedure training

Cho J et Coll. Emerg Med J 2008;25:732-734

--------------------------------------------------------------------------

Le choix du simulateur de tache utilisé  pour l'enseignement de la coniotomie reste une vrai question. Modèle humain, animal ou artificiel. Cet article met en avant l'intérêt du modèle animal qui offrirait plus de réalité anatomique. Néanmoins il faut lire ce document avec un peu de recul car la coniotomie est un geste peu fréquemment réalisé, et probablement que la notion de réalisme porte plutôt sur les aspects anatomiques de la région cervicale que sur le réalisme de pratique de geste sur la région cervicale. Encore faut-il pouvoir dans la vrai vie pouvoir disposer d'une filière d'approvisionnement qui souvent se résume au boucher du quartier. 

--------------------------------------------------------------------------

Objective: To compare the usefulness for training of a porcine model (larynx, trachea, and pig skin) and a manikin model using a Portex cricothyrotomy kit (PCK). 

Methods: In a prospective randomised crossover trial, participants in the airway workshop performed crico-thyrotomy using a PCK on the porcine and manikin models (Tracheostomy Trainer and Case). The porcine model was made with larynxes and trachea from freshly slaughtered pigs and covered with a piece of thinned pigskin stapled to a wooden board.

CricoPig.jpg

Participants were asked to assess the following: reality of skin turgor; difficulty with skin penetration, landmark recognition and procedure; reality of the model; and preference for each model using a visual analogue scale (VAS) of 0–10 cm. The VAS scores for each model were compared. 

Results: 49 participants were included in the study. Mean (SD) VAS scores for the reality of skin turgor, degree of difficulty with skin penetration and landmark recognition were higher with the porcine model than with the manikin model (7.0 (2.1) vs 4.7 (2.0), 6.4 (2.4) vs 3.6 (2.2), 5.1 (2.2) vs 4.2 (2.5), respectively). There was no difference between the models in the difficulty of the procedure (5.0 (2.4) vs 4.7 (3.2)). The porcine model had a higher VAS score for overall reality and preference of the model (7.1 (2.0) vs 4.8 (2.3) and 7.1 (2.0) vs 4.8 (2.2), respectively).

CricoPig2.jpg

 Conclusion: The porcine model is a more useful training tool than the manikin model for cricothyrotomy with PCK because of its reality and similarity to human anatomy. 

| Tags : coniotomie

Crico: Pour en savoir plus en 5 min ?

Large-bore cricothyroidotomy devices

Patel B. et Al. Contin Educ Anaesth Crit Care Pain(2008) (5): 157-160

 

L'article proposé fait une revue simple des divers équipements permettant la réalisation d'une coniotomie. Il apporte par ailleurs quelques compléments d'informations sur les facteurs de réussite de cette pratique dont l'éventualité d'occurrence est faible mais à laquelle il faut se préparer.

| Tags : coniotomie

Simulateur de crico: Encore le modèle porcin

A home-made animal model in comparison with a standard manikin for teaching percutaneous dilatational tracheostomy

Interact Cardiovasc Thorac Surg. 2015 Feb;20(2):248-53

F1.medium.gif

 

13/03/2015

Simulation, simple est possible: La coniotomie

Il existe de nombreux simulateurs de coniotomie commerciaux. Ils sont onéreux tant à l'achat que dans leur entretien. Faire simple et peu onéreux est possible.

Premier exemple:

CriCTrainer6.jpg

Clic sur l'image pour accéder à la notice de montage 

Second exemple: 

CriCTrainer_E.jpg

Clic sur l'image pour accéder à la notice de montage

 

Troisième exemple

s12245-014-0046-z-3.jpg

Clic sur l'image pour accéder à la source

| Tags : coniotomie