Advance Cardiovascular Life Support - Revisi Juli 2022

Advance Cardiovascular Life
Support
Nursing Division
“Advanced Innovation, Advanced You”

Materi ACLS
1. Science of Resuscitation
2. Systematic Approach
3. Airway Breathing Management (Praktik)
4. Defibrilator (Praktik)
5. ACS
6. Stroke
7. Algoritma
a. Tachicardia
b. Bradicardia
c. Cardiac Arrest
d. ROSC

Science of Resuscitation

ILMU RESUSITASI
Coronay
RJP Perfusion
Pressure
Ventilasi
ETCO2
berlebihan
Code Blue

High Quality CPR
• Push fast : Kecepatan kompresi 100 – 120 x/
menit
• Push hard : Kedalaman kompresi pada dewasa
sedikitnya 2 inchi (5 – 6 cm)
• Biarkan recoil kembali dinding dada setiap
dilakukan kompresi
• Minimal interupsi ( kurang dari 10 detik)
• Hindari hiperventilasi

Coronary Perfusion Pressure (CPP)
• CPP adalah tekanan diastolic (relaksasi) aorta
dikurangi tekanan diastolic (relaksasi) atrium
kanan. selama CPR, CPP berkorelasi dengan
aliran darah miokard dan ROSC.

Coronary Perfusion Pressure
kompresi interupsi kompresi
Nilai kecukupan CPP : ≥ 15 mmHg
Jika nilai PETCO 2 < 10mmHg Tingkatkan

Jika nilai tekanan relaksasi intra-arteri < 20 mmHg kualitas CPR

Chest compression fraction (CCF)
• Proporsi waktu selama resusitasi cardiac arrest

ketika kompresi dada dilakukan. CCF idealnya
80 – 100 %.
• CCF rendah akan menurunkan ROSC

Saat dilakukan interupsi, hindari:
• Menganalisa irama terlalu lama

• Berulang – ulang cek nadi atau cek nadi tidak
tepat
• Memberi napas pada pasien terlalu lama
• Memindahkan pasien dengan tidak tepat

Cegah Hiperventilasi
• Tidal volume yang tepat adalah 500 – 600 ml
• Ventilasi yang berlebihan dapat :
– Menyebabkan inflasi gaster
– Meningkatkan tekanan intrathorasik
– Menurunkan venous return ke jantung
– Menurunkan cardiac output
– Menurunkan harapan hidup

Manajemen Kedaruratan
• Manajemen kedaruratan yang mengancam
jiwa membutuhkan integrasi tim multidisiplin
yang dapat melibatkan Rapid Response Teams
(RRT), Tim henti jantung, dan spesialis
perawatan intensif untuk meningkatkan
tingkat kelangsungan hidup.
• Pembaruan Guidelines 2015 mencerminkan
penelitian yang menunjukkan bahwa RRT
meningkatkan hasil.

Medical Emergency Teams (MET) dan Rapid
Response Team (RRT)

Kapan mengaktifkan RRT?
• Jalan napas yang mengancam
• RR < 6x/ menit atau > 30x/ menit
• HR < 40x/ menit atau > 140x/ menit
• TD systolic , 90 mmHg
• Hipertensi simptomatik
• Penurunan kesadaran yang tidak terduga
• Agitasi yang tidak terduga
• Kejang
• Penurunan jumlah urine yang signifikan

ACLS
BLS / CPR
BLS / CPR sebagai pondasi

Systematic Review

Komponen Pendekatan Sistematik
• Pengkajian BLS
• Pengkajian Primer ( A, B, C, D dan E )
• Pengkajian Sekunder ( SAMPLE, 5 H dan 5 T )

Pendekatan
Systematik

BLS Assessment
• Cek respon
• Call for help
• Cek Nadi dan Napas
• Segera RJP
• Gunakan AED/ Defibrilator

Primary Assessment
• Airway
• Breathing: RR, Sat O2, Auskultasi
• Circulation: N, TD, EKG, IV akses,GDS, S
• Disability: GCS, Pupil, Neurologic Function
• Exposure : Trauma, Perdarahan dll

Secondary Assessment
• S (Sign & symptoms)

• A (Allergies)
• M (Medications)
• P (Past Medical History)
• L (Last Meal Consumed)
• E (Events)

5 H dan 5 T
5H 5T
Hipovolemia Tension pneumothorax
Hipoksia Tamponade kardiak
Hydrogen ion (asidosis) Toksin
Hipo-/hyperkalemia Thrombosis pulmonari
Hipotermia Thrombosis koroner

MANAJEMEN AIRWAY BREATHING

PENDAHULUAN
Pernapasan
Gangguan Kematian Kematian
tidak Hipoksia
jalan napas jaringan biologis
adekuat

AIRWAY / JALAN
NAPAS

TATALAKSANA JALAN NAPAS
ALAT BANTU JALAN NAPAS
NPA (Nasopharyngeal Airway)
• Pada pasien yang masih
sadar
• Pengukuran dari cuping
hidung s/d ujung telinga
bagian bawah
OPA (Oropharyngeal Airway)
• Pada pasien yang tidak
sadar, ada suara napas
tambahan snoring, tidak
ada refleks muntah
• Pengukuran dari sudut
bibir s/d sudut rahang
bawah
Endotracheal Tube
Menghindari aspirasi Volume tidal yang

O2 konsentrasi diinginkan
tinggi
KEUNTUNGAN
Jalur masuk Jalan napas
beberapa obat- terpelihara
obatan
Mempermudah
“Advanced Innovation, Advanced You” Suctioning
Persiapan peralatan intubasi
S
T
A T
Note:
I
• Cara mengukur ETT C
• Pengkajian Kepatenan ETT –
Auskultasi Epigastric dan Semua
lapang paru S
Pastikan Kedudukan ETT Baik
• Dengarkan suara napas. Bila terdengar
gurgling di abdomen → cabut ETT dan pasang
kembali. Bila paru kanan saja yang terdengar
daripada paru kiri → Tarik sedikit ETT
• Lihat pengembangan dinding dada
• Lakukan pemeriksaan dengan Capnografi
Waveform (n= 35 – 45 mmHg)

Dampak Penggunaan ETT
(DOPE)
• D : Displacement (salah posisi karena masuk
ke Lambung atau terlalu dalam masuk ke paru
kanan)
• O : Obstruction (tersumbat oleh lender atau
darah)
• P : Pneumothorax
• E : Equipment Failure (kesalahan alat seperti
balon ETT bocor)

Alat bantu napas lain

Pemberian bantuan napas

2-5 liter/ menit 1-6 liter/ menit 6-8 liter/ menit
20 – 40 % 40 – 60 %
Oksigen Aliran Rendah

Konsentrasi Rendah
Oksigen Aliran Rendah
Konsentrasi Tinggi
8-12 liter/ menit 8-12 liter/ menit
Konsentrasi 60 – 80 %

25-50 liter/ menit 100%
Oksigen Aliran Tinggi Konsentrasi Tinggi

Acute Coronary Syndrome
2020 AHA Guidelines

Cause of Death in
Indonesia
1. Coronary Heart
Disease
2. Stroke

Anatomy of Coronary Artery

Patofisiologi ACS
A Unstable Plaque
B Plaque Rupture
C Unstable Angina
d Microemboli
e Occlusive Thrombus

Heart Disease

ACUTE CORONARY
SYNDROME
ALGORITHM

Symptoms Acute Coronary Syndrome

STEMI Chain of Survival
Rapid
recognition & Rapid EMS Rapid Assessment Rapid Treatment
Reaction to dispatch and EMS and Diagnosis in
STEMI Warning System Transport ED
Signs Or cath lab
Prearrival
notification to
the receiving
hospital
EMS Assessment & Care and Hospital
Preparation
1a. Monitor and
Support 4.Inform
2.Administer
Airway, Breathing, Aspirin Hospital
Circulation. Respond to STEMI
Consider Oxygen,
Nitroglycerin,
Morphine if
needed
Emergency
Department
1b.Prepare 3. 12 lead ECG 5. Fibrinolitic
Checklist
To provide CPR If ST Elevation,
& Defibrillation. notify hospital,
note time

Prehospital
Fibrinolytic
Checklist
Circulation. 2004;110:e82-e292, with permission

from Lippincott Williams & Wilkins. Copyright 2004,
American Heart Association.

Concurrent ED Assessment & Immediate
1. Check Vital Signs, evaluate O2
Treatment
saturation
2. IV access.
3. Brief targeted history,
Physical Exam 7. If O2 sat <90%
4. Fibrinolytic Checklist, Start O2 at 4L/min, titrate
check contraindications
,
5. Initial Cardiac Marker 8. Aspirin 162-325 mg, non

Level, Electrolyte, enteric coated (chew)
ED
Coagulation Studies
Assesment If not given by EMS
&
Treatment
9. Nitroglycerin
6. Portable chest Xray 1 SL nitroglycerin tablet (or spray
(<30 min). “dose”) every 3-5 minutes, may
repeat twice dose (max 3 dose)
10. Morphine IV
If discomfort not relieved by
nitroglycerin
Venodilator, use with caution

Oxygen and Medication
9. Nitroglycerin
7. Oxygen
Effectively reduces ischemic chest
Oxygen should be given if discomfort & hemodynamic effects.
patient is dyspneic, Physiologic effects → reduction in
hypoxemic, has obvious LV & right ventricular preload
sign of heart failure, through peripheral arterial &
M Morphine
arterial oxygen saturation
<90%
venodilator. Contraindication:
- Inferior wall MI and RV infarction
- Hypotension, bradycardia,
Nitrogycerin tachycardia
O - Recent
inhibitor use
phosphodiesterase
N 2
8. Aspirin
immediate & near-total
inhibition of thromboxane
10. Morphine
OXYGEN Morphin is indicated in STEMI
A2 production by inhibiting with chest discomfort
ASPIRIN
A platelet cyclooxygenase
(COX-1). Contraindication
of aspirin: history of true
unresponsive to nitrates. Action:
- CNS analgesia
- Venodilation (reduce LV
aspirin allergy and preload & oxygen
evidence of recent GI requirements)
bleeding - Reducing LV afterload

Angina – STEMI - NSTEMI

Early Reperfusion Therapy
For PCI, goal ED door-to-ballon inflation time

is 90 minutes.
If fibrinolysis is the intended reperfusion, an ED

door-to-needle time of 30 minutes is the goal that
is considered the longest time acceptable.
Patient who are ineligible for fibrinolytic therapy should be considered for
transfer to a PCI facility regardless of the delay. System should prepare for
Door-to-departure time of 30 min when transfer decision is made

Consideration for the use of PCI
PCI is treatment of choice for management of STEMI
• when it can be performed effectively with Door-to-balloon time

<90 minutes from first contact by skilled PCI facility
Primary PCI may also be offered to patients presenting to non-PCI-
capable centers
• if it can be initiated within 120 minutes from first medical
contact.
Indicated with patient with cardiogenic shock or Heart failure
complicating MI
• and if the patient is contraindicated to fibrinolytics

Acute
Coronary
Syndromes
Algorithm

ACUTE STROKE MANAGEMENT
AHA Guidelines 2020

Acute Stroke Course Outline
Stroke warning signs to

Ischemic & .
Hemorrhagic diagnosis and treatment in
Stroke hospital
Types of Stroke Stroke Chain of

Survival
12
34
Algorithm Acute Fibrinolytic Criteria
Ischemic Stroke
AHA guideline 2020
You can simply impress
your audience and add a
unique zing and appeal to
your Presentations.

Types of Stroke
ISCHEMIC HEMORAGIC
87% case of stroke is 13% of case is hemorrhagic
ischemic type, caused by an type. Occurs when blood
occlusion of an artery to a vessels in brain suddenly
region of the brain ruptures into surroundings
tissue. Fibrinolytic therapy is
contraindicated.

Stroke Chain Of Survival
Rapid EMS Rapid

Rapid Rapid EMS
system diagnosis
Recognition & Dispatch
transport and
Reaction to
and treatment
stroke warning
prearrival in hospital
signs
notification
to hospital

The 8 D’s of Stroke Care
➢DETECTION: Rapid recognition of stroke symptoms
➢DISPATCH: Early Activation and Dispatch of EMS
➢DELIVERY: Rapid EMS Identification, management,
and transport
➢DOOR: Appropriate triage to stroke center
➢DATA: Rapid Triage, evaluation, and management
within the ED
➢DECISION: Stroke expertise and therapy selection
➢DRUG/DEVICE: Fibrinolytic or endovascular therapy
➢DISPOSITION: Rapid admission to the stroke unit or
critical care unit

ADULT
SUSPECTED
STROKE
ALGORITHM

Critical EMS Assessments & Actions
Identify Signs Define and Recognize the Signs of Stroke
Support ABCs Support Airway, Breathing, Circulation
Provide supplementary Oxygen to hypoxemic (<94% O2 saturation)
Perform Stroke Rapid out-of-hospital stroke assessment
Assessment (Cincinnati Pre Hospital Stroke Scale)
Establish Time Determine when the patient was last known to be normal (time
zero)
If patient wakes from sleep with symptoms of stroke, time zero is
last time patient was seen to be normal
Triage to stroke center Transport patient rapidly and consider triage to a stroke center.
Support cardiopulmonary function during transport
If possible bring witness or family to confirm time of onset
Alert hospital Provider prearrival notification to receiving hospital
Check glucose During transport, check blood glucose if protocol or medical control
allows
Cincinnati Pre-hospital Stroke Scale

Immediate General Assessment and Stabilization at ED
Step Actions
Assess ABCs Assess ABCs and evaluate baseline vital signs
Provide Oxygen Provide supplementary Oxygen to hypoxemic (Oxyhemoglobin

saturation <94%) stroke patient or patient with unknown oxygen
saturation
Establish IV access Establish IV access and obtain blood samples for baseline blood count,
and obtain blood coagulation studies, blood glucose.
samples Do not let this delay obtaining CT scan of brain
Check glucose Promptly treat hypoglycemia
Perform neurologic Perform neurologic screening assessment

assessment Use NIH Stroke Scale or similar too
Activate the stroke Activate stroke team or arrange consultation with a stroke expert based
team on predetermined protocol
Order CT Brain Scan Order emergent CT scan of brain, have it read promptly by a qualified
physician
Obtain 12-lead ECG 12-lead ECG may identify a recent or ongoing AMI or arrhythmias (eg
AF) as cause embolic stroke. Recommendation → cardiac monitor
during first 24 hours of evaluation
The National Institutes of
Health Stroke Scale

CT Scan: Hemorrhage or No Hemorrhage
The CT scan should be completed within 25 minutes of the
patients arrival in the ED and should be read within 45
minutes from ED arrival: “Time is Brain”
Yes, Hemorrhage is Present

Patient is not candidate for fibrinolytic
therapy. Consult to neurologist or
neurosurgeon. Consider transfer to
appropriate care
No, Hemorrhage is not present

CT Scan show no evidence of hemorrhage
or no sign of other abnormality, patient
may be a candidate for fibrinolytic
therapy
If hemorrhage is not present, but
Decision Point patient is not candidate for
fibrinolytics
Consider giving aspirin.
Copyright © 2020 by Summit Healthcare Pte Ltd
Fibrinolytic Therapy

Adult
Suspected
Stroke
Algorithm

ALGORITMA ACLS
• Cardiac Arrest
• Bradicardia
• Tachicardia
• ROSC

HENTI JANTUNG
(Cardiac Arrest)

HENTI JANTUNG (CARDIAC ARREST)
VF / VT
tanpa nadi Asistol / PEA

Henti jantung/ Cardiac Arrest

Henti jantung/ Cardiac Arrest
• Shockable
• Non – Shockabel

Tatalaksana irama
shockable
• Defibrilasi
– Monofasik → 360 Joule
– Bifasik → 200 Joule
• RJP
– Kompresi → 30x
– Ventilasi → 2x
• Obat-obatan
– Epinefrin → 1 mg (setiap 3-5 menit)
– Amiodaron → 300 mg & 150 mg

Algoritma
Cardiac Arrest
Shockable

Tatalaksana irama
non-shockable
• Pada Asistole pastikan True Asistole
• RJP
– Kompresi → 30x
– Ventilasi → 2x
• Obat-obatan
– Epinefrin → 1 mg (setiap 3-5 menit)
• Mencari penyebab reversible
– 5H dan 5 T

ALGORITMA
Cardiac Arrest
nonShockabel

Bradikardia

Bradikardia
• Bradikardi
merupakan suatu
kondisi pasien dengan
frekuensi denyut
jantung <50x/menit
• Kategori Bradikardia:
– Stabil
– Tidak Stabil

Jenis Bradikardi
Sinus Bradikardi
AV Blok Derajat Satu
AV Blok Derajat Dua Tipe I (wenckebach/Mobitz I)
AV blok Derajat Dua Tipe II (Mobitz II)
AV Blok Derajat Tiga

SINUS
BRADIKARDIA
AV Blok
Derajat 1
AV Blok
Derajat II
AV Blok
Derajat III
Stabil vs tidak stabil
Hipotensi
Penurunan kesadaran
Tanda-tanda syok
Nyeri dada iskemik
Gejala gagal jantung akut

Tatalaksana Bradikardi Tidak Stabil
• Atropin: dosis pertama 1 mg bolus, ulang
setiap 3 – 5 menit (dosis maksimal → 3 mg)
• TCP pada kecepatan sekitar 60/menit
• Dopamin (infusion) 5-20 mcg/kg per menit
• Epinefrin (infusion) 2 – 10 mcg per menit

ALGORITMA
BRADIKARDIA

Takikardia

Takikardia
• Takikardi merupakan suatu
kondisi pasien dengan
frekuensi denyut jantung >
100x/menit
• Kategori takikardia:
– Stabil
– Tidak Stabil
• Tatalaksana pada takikardia
dibedakan berdasarkan
kompleks QRS pada monitor
maupun EKG 12 Lead
Jenis Takikardia
• QRS Sempit :
–Teratur : AF (Atrial Fibrilasi)
–Tidak Teratur : SVT (Supra Ventrikular
Tachicardia)
• QRS Lebar :
–Teratur : VT dengan Nadi
–Tidak Teratur : VF → Cardiac Carrest

SINUS TAKIKARIDA
FIBRILASI ATRIUM ATRIAL FLUTTER
VT MONOMORFIK TORSADE DE POINTES
Supraventricular Tachicardia
Tatalaksana
• Manuver vagal
• Adenosin 6mg dan 12mg (bolus cepat) + flush NS
cepat
• Kardioversi tersinkronisasi
– Sempit regular → 50 – 100 Joule
– Sempit ireguler → 120 – 200 Joule (200 Joule
untuk alat defibrilasi monofasik)
– Lebar regular → 100 Joule
– Lebar ireguler → Dosis defibrilasi : 200 Joule

ALGORITMA
Takikardia

Stabil vs tidak stabil
Hipotensi
Penurunan kesadaran
Tanda-tanda syok
Nyeri dada iskemik
Gejala gagal jantung akut

Tachicardia
Stabil QRS
Sempit
“Advanced Innovation , Advanced You”

Tachicardia
Stabil QRS
Lebar

Tachicardia
Tidak Stabil

Cardiac
Arrest in
Pregnancy
In-Hospital

MANAJEMEN PASKA HENTI
JANTUNG
(ROSC)

Manajemen Paska Henti Jantung
• Tujuan: mengurangi kematian dini karena
hemodinamik yang tidak stabil
• Aspek yang perlu diperhatikan :
– Patensi jalan napas
– Optimalisasi hemodinamik
– Reperfusi koroner jika ada indikasi
– Kesadaran pasien
– Targeted Temperature Management / TTM
Target Pada Pasien Paska Henti
Jantung
• Jalan napas paten
• Saturasi oksigen 92 – 98 %
• Tekanan Darah sistolik ≥90 mmHg
• EKG 12 Lead → STEMI / AMI (-)
• Suhu tubuh pasien 32-36˚C setidaknya 24 jam pertama
paska henti jantung
• Penanganan 5H & 5T

Patensi jalan
napas
• Manuver Head tilt -
Chin lift
• Gurgling →
Suctioning
• Snoring → OPA
• Intubasi Endotrakea

Tekanan darah pada pasien paska henti
jantung
• Cairan kristaloid RL atau Normal Saline 1-2 liter

• Epinefrin intravena 0.1-0.5 mcg/ kgBB/ menit
• Dopamin intravena 5-10 mcg/ kgBB/ menit
• Norepinefrin intravena 0.1-0.5 mcg/ kgBB/ menit

EKG 12 LEAD
Curiga STEMI / AMI → Tindakan reperfusi

Targeted
Temperature
Management (TTM)
Membuat suhu tubuh
pasien 32-36˚C setidaknya
24 jam pertama paska
henti jantung

5H & 5T
5H
– Hipovolemia
– Hipoksia
– Hipo/Hiperkalemia
– Hidrogen ion (Asidosis)
– Hipotermia
5T
– Tamponade jantung
– Tension pneumothorax
– Trombosis koroner
– Trombosis pulmoner
– Toksin
Algoritma
Paska Henti
Jantung

Neuroprognostication

Reference
1. American Heart Association (2020). Advanced Cardiovascular Life
Support Provider Manual. USA: First American Heart Association
Printing. P59-91. ISBN 978-1-61669-400-5
2. Acute Coronary Syndrome. JAMA. 2015;314(18):1990.
doi:10.1001/jama.2015.12743.
3. Circulation. 2004;110:e82-e292, with permission from Lippincott
Williams & Wilkins. Copyright 2004, American Heart Association.
4. Cincinnati Pre-hospital Stroke Scale. The Nurse Zone. Retrieved July14,
2020. [http://thenurseszone.com/cincinnati-pre-hospital-stroke-
scale/]
5. The NIH Stroke Scale. Stroke Sciences. Retrieved July 14, 2020.
[https://strokesciences.com/the-national-institutes-of-health-stroke-
scale-nihss/]


Advance Cardiovascular Life Support - Revisi Juli 2022

Diunggah oleh

Informasi Dokumen

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Advance Cardiovascular Life Support - Revisi Juli 2022

Diunggah oleh

Hak Cipta:

Format Tersedia

Advance Cardiovascular Life

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

kompresi interupsi kompresi

Nilai kecukupan CPP : ≥ 15 mmHg

Jika nilai PETCO 2 < 10mmHg Tingkatkan

“Advanced Innovation, Advanced You”

• Proporsi waktu selama resusitasi cardiac arrest

“Advanced Innovation, Advanced You”

• Menganalisa irama terlalu lama

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

BLS / CPR sebagai pondasi

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

• S (Sign & symptoms)

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

Menghindari aspirasi Volume tidal yang

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

Oksigen Aliran Rendah

8-12 liter/ menit 8-12 liter/ menit

“Advanced Innovation, Advanced You”

Oksigen Aliran Tinggi Konsentrasi Tinggi

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

Circulation. 2004;110:e82-e292, with permission

“Advanced Innovation, Advanced You”

5. Initial Cardiac Marker 8. Aspirin 162-325 mg, non

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

For PCI, goal ED door-to-ballon inflation time

If fibrinolysis is the intended reperfusion, an ED

“Advanced Innovation, Advanced You”

PCI is treatment of choice for management of STEMI

• when it can be performed effectively with Door-to-balloon time

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

“Advanced Innovation, Advanced You”

Stroke warning signs to