01Approach to the Critical Patient/attcp46

Immediate stabilization

›Hemodynamic threat recognition

›SBP <90 mmHg defines unstable patient requiring immediate intervention

›Activate massive transfusion protocol (MTP)

›Two large-bore IV access immediately

›HR >110 bpm as additional instability marker

›Combined with hypotension indicates hemorrhagic shock

›Permissive hypotension target SBP ~90 mmHg until hemorrhage control

›Traumatic cardiac arrest with penetrating mechanism

›If CPR <15 minutes, proceed to resuscitative thoracotomy

›Bilateral finger thoracostomies in arrest to exclude tension PTX

›Airway and breathing priorities

›Tension pneumothorax recognition

›Immediate needle decompression: 2nd intercostal space midclavicular line or 4th ICS anterior axillary line

›Followed by tube thoracostomy

›Open sucking chest wound

›Three-sided occlusive dressing as temporizing measure

›Followed by tube thoracostomy at separate site

›Hemothorax causing ventilatory compromise

›Large-bore chest tube for drainage

›Monitor output for operative threshold

Decision branching

›Unstable patient pathway

›E-FAST immediately at bedside

›Positive pericardial view in cardiac box injury: emergent OR for pericardial window or thoracotomy

›Free thoracic fluid with instability: chest tube then surgical consultation

›Do not delay for CT imaging in hemodynamic instability

›Portable CXR acceptable adjunct if not delaying resuscitation

02History/hx66

Mechanism and weapon details

›Injury mechanism characterization

›Stab wound

›Blade length and estimated depth

›Number of stabs

›Body position at time of injury affecting trajectory

›Gunshot wound

›Caliber and firearm type

›Distance from shooter affects energy transfer

›Number of shots fired

›Impalement

›Object type and removal status

›Do not remove impaled objects in ED

›Wound location context

›Cardiac box wounds (sternal notch to xiphoid, between nipple lines)

›High risk for cardiac and great vessel injury

›Warrants cardiac FAST regardless of stability

›Thoracoabdominal zone (below 4th rib anteriorly, below scapular tip posteriorly)

›Risk of diaphragmatic injury and abdominal organ involvement

›Up to 20% of penetrating chest injuries have associated abdominal injuries

›Entry and exit wound identification

›Mark all wounds with radiopaque markers before imaging

›Multiple wounds complicate trajectory estimation

Symptoms and timeline

›Cardinal symptoms

›Dyspnea

›Severity and acuity of onset

›Position of comfort

03Physical Exam/exam53

Primary survey

›Vital signs assessment

›Blood pressure

›SBP <90 mmHg defines hemodynamic instability

›Serial measurement every 5 to 15 minutes in unstable patient

›Heart rate

›HR >110 bpm as instability marker

›Tachycardia masked by beta-blockers or vagal response from tamponade

›Respiratory rate and SpO2

›SpO2 trending downward despite O2 supplementation

›RR >30 per minute as severity marker

›Temperature and GCS

›Hypothermia worsens coagulopathy in trauma

›GCS <13 triggers airway reassessment

Chest and wound examination

›Wound inspection

›Number, location, and size of all wounds

›Entry vs exit characterization

›Sucking chest wound: audible airflow through wound

›Tracheal position

›Deviation toward affected side in large hemothorax

›Deviation away from affected side in tension pneumothorax

›Jugular venous distension

›JVD with hypotension and muffled heart sounds: Beck triad for tamponade

›JVD with tracheal deviation: tension pneumothorax

›Subcutaneous emphysema

›Crepitus on palpation of chest wall

›Massive subcutaneous emphysema suggests tracheobronchial injury

04Differential Diagnosis/ddx54

Life-threatening injuries

›Tension pneumothorax

›ICD-10 S27.0XXA

›Air accumulation under pressure causing mediastinal shift

›Clinical diagnosis: do not wait for CXR to treat

›Differentiating features

›Hyperresonance, absent breath sounds, tracheal deviation, JVD

›Rapid deterioration with sudden cardiovascular collapse

›Massive hemothorax

›ICD-10 S27.1XXA

›>1500 mL blood in pleural space

›Initial chest tube output >1500 mL or ongoing >200 mL/h triggers OR

›Differentiating features

›Dullness to percussion, absent breath sounds, hypotension

›Most common complication of penetrating chest trauma

›Cardiac tamponade

›ICD-10 I31.4

›Overall survival ~19% for penetrating cardiac injuries

›~40% of patients reaching trauma center survive

›Beck triad

›Hypotension, muffled heart sounds, JVD

›FAST positive pericardial view confirms diagnosis

›Aortic and great vessel injury

›ICD-10 S25.00XA

›Widened mediastinum on CXR raises concern

›CT angiography or emergent surgical exploration for diagnosis

›Air embolism

›Rare but rapidly fatal

05Laboratory Tests/lt45

Hemorrhage and resuscitation labs

›Type and crossmatch

›Immediate priority in all penetrating chest trauma

›Anticipate MTP activation

›Emergency release O-negative blood if unstable before crossmatch available

›Complete blood count

›Baseline hemoglobin and hematocrit

›Serial hemoglobin every 4 to 6 hours in admitted patients

›Platelet count for MTP threshold (target >50 x10^9/L)

›Coagulation panel

›PT/INR, PTT, fibrinogen

›Trauma-induced coagulopathy development monitoring

›Fibrinogen target >1.5 to 2.0 g/L with active hemorrhage

›Viscoelastic testing (TEG or ROTEM)

›Guides targeted transfusion in massive hemorrhage

›Additional TXA indicated if clot lysis at 30 min >10%

Perfusion and metabolic labs

›Lactate

›Marker of perfusion and shock severity

›Lactate >2 mmol/L indicates organ hypoperfusion

›Serial measurement to assess resuscitation response

›Lactate clearance target

›Goal >10% clearance per 2 hour reassessment

›Persistent elevation despite resuscitation indicates ongoing hemorrhage

›Arterial or venous blood gas

›pH and base deficit as shock markers

›Base deficit <-6 associated with significant hemorrhage

›pH <7.35 triggers damage control resuscitation approach

06Diagnostic Tests/dt70

Scoring Systems

›Trauma severity tools

›Revised Trauma Score (RTS)

›Incorporates GCS, SBP, RR

›Used for triage and outcome prediction

›Lower RTS correlates with higher mortality

›Injury Severity Score (ISS)

›AIS-based scoring of three most injured body regions

›ISS >15 defines major trauma

›ISS >25 associated with significantly increased mortality

›Abbreviated Injury Scale (AIS) for thorax

›AIS 3 to 6 range for significant thoracic injuries

›Guides ICU admission and monitoring intensity

›Cardiac tamponade estimation

›Subxiphoid FAST view

›Point-of-care tool with high sensitivity for pericardial fluid

›Cannot reliably distinguish blood from serous fluid by appearance

›Clinical context required for interpretation

›FAST may be falsely negative if cardiac injury decompresses into hemithorax

›Clinical suspicion must override negative FAST in correct context

MRI

›MRI role in penetrating chest trauma

›Generally contraindicated in acute penetrating trauma

›Metallic foreign bodies are absolute contraindication

›Time constraints in unstable patients preclude use

›Limited problem-solving indications

›Spinal cord injury evaluation when patient stabilized

›Brachial plexus injury characterization in delayed setting

›MRI angiography in specific stable cases

›Vascular injury not adequately characterized by CT

›Delayed presentation with suspected pseudoaneurysm

CT

›CT chest with IV contrast

›Primary imaging modality in hemodynamically stable patients

›NPV up to 99% for excluding surgical pathology

›Identifies vascular injuries: pseudoaneurysms, intimal flaps, contrast extravasation

›CT identifies injuries missed in 71% of patients with normal CXR

›37.5% of those CT-identified injuries required life-saving interventions

›ACR Appropriateness Criteria support CT as first-line in stable patients

›Protocol considerations

›IV contrast required for vascular and solid organ assessment

›CT chest/abdomen/pelvis with IV contrast when trajectory crosses diaphragm

›CT angiography for suspected great vessel injury

›CT contraindications in trauma

›Hemodynamically unstable patient

›Proceed directly to intervention without CT

›CT scanner is not a resuscitation environment

›Allergy to contrast media

›Premedication protocol or alternative imaging

›Renal impairment consideration with creatinine >130 umol/L

Ultrasound

›E-FAST examination

›Primary point-of-care triage tool in penetrating chest trauma

›98% sensitivity, ~100% specificity for free fluid

›More sensitive and faster than CXR for hemothorax (97.5% vs 92.5%)

›Four views in extended FAST

›Subxiphoid cardiac view for hemopericardium

›Right upper quadrant for hepatorenal space fluid

›Left upper quadrant for splenorenal space fluid

›Suprapubic view for pelvic free fluid

›Lung sliding assessment

›Absent lung sliding with A-lines indicates pneumothorax

›Present sliding effectively excludes PTX at that probe site

›Limitations

›FAST may be falsely negative if cardiac injury decompresses into hemithorax

›Operator-dependent accuracy

›Subcutaneous emphysema degrades image quality

›Extended chest ultrasound

›Hemothorax detection

›Anechoic or complex fluid in pleural space

›More sensitive than supine CXR for hemothorax detection

›Lung point sign for pneumothorax

›Confirms pneumothorax at site of transition from sliding to absent

›Helpful for sizing occult pneumothorax

07Disposition/dispo50

Operative and ICU admission

›Immediate operative intervention criteria

›Hemodynamic instability with active intrathoracic hemorrhage

›Not responding to resuscitation and chest tube drainage

›Emergent thoracotomy or pericardial window

›Chest tube output thresholds

›Initial output >1500 mL: immediate operative exploration

›Ongoing output >200 mL/h for 2 to 4 consecutive hours: operative

›Cardiac tamponade with hemodynamic instability

›Positive FAST with Beck triad in cardiac box injury: emergent OR

›Large persistent air leak suggesting tracheobronchial injury

›Bronchoscopy followed by surgical repair

›ICU admission criteria

›Intubated or requiring ventilatory support

›Post-resuscitative thoracotomy

›Respiratory failure from pulmonary contusion or PTX

›Hemodynamic instability requiring vasopressors

›Norepinephrine as vasopressor of choice in neurogenic shock

›Chest tube with ongoing significant drainage

›Monitoring for operative threshold

›Cardiac box or mediastinal trajectory injuries

›Monitoring for delayed cardiac or vascular complications

›Significant parenchymal injury on CT

Ward admission and observation

›Ward admission indications

›Chest tube in place with minimal drainage

›Monitoring for re-expansion and output stabilization

›Daily CXR to confirm lung expansion

08Treatment/t81

Immediate hemorrhage control

›Damage control resuscitation

›Balanced blood product transfusion

›1:1:1 ratio pRBCs:FFP:platelets as MTP standard

›Avoid crystalloid-dominant resuscitation

›Permissive hypotension: target SBP ~90 mmHg until hemorrhage controlled

›Tranexamic acid (TXA)

›1 g IV bolus over 10 minutes

›Followed by 1 g IV over 8 hours

›Must be given within 3 hours of injury (ideally <90 minutes)

›Greatest mortality benefit when given earliest (CRASH-2 data)

›Conditionally recommended by EAST, NAEMSP/ACEP/ACS-COT

›Additional dose if TEG/ROTEM shows clot lysis at 30 min >10%

›Direct pressure for external hemorrhage

›Tourniquet for extremity hemorrhage contributing to shock

Chest decompression procedures

›Tension pneumothorax decompression

›Needle decompression

›2nd ICS midclavicular line or 4th ICS anterior axillary line

›14-gauge or 3.25 cm needle in adults

›Failure rate with 2nd ICS midclavicular up to 38% in obese patients

›Finger thoracostomy preferred in cardiac arrest

›4th or 5th ICS anterior axillary line

›Immediate bilateral finger thoracostomies in traumatic cardiac arrest

›Chest tube thoracostomy

›Pneumothorax drainage

›Small-bore 8.5 to 24 Fr or pigtail catheter acceptable

›Larger bore for expected blood or viscous fluid

›Hemothorax drainage

›14 Fr pigtail catheter equivalent to 28 to 32 Fr large-bore tube for uncomplicated HTX

›Large-bore 28 to 40 Fr traditionally used for massive HTX

›Placement at 4th to 6th ICS anterior to mid-axillary line

›Tube thoracostomy technique adjunct

›Irrigation with warm sterile saline at time of placement decreases secondary interventions

›Hemothorax drainage threshold: >300 to 500 mL

›Open/sucking chest wound management

›Three-sided occlusive dressing as temporizing measure

›Allows air escape but prevents air entry

›Chest tube at separate site to definitive management

›Commercial chest seals preferred over improvised dressings

›Vented seal recommended over non-vented to prevent tension

Resuscitative thoracotomy

›Indications

›SBP <60 mmHg not responding to resuscitation

›Or traumatic cardiac arrest with penetrating mechanism

›CPR duration <15 minutes for penetrating trauma

›Survival outcomes

›~35% survival for penetrating cardiac wounds with tamponade

›~15% overall survival for penetrating chest trauma requiring RT

›Blunt trauma RT: <2% survival, much less favourable

›Technique steps

›Left anterolateral thoracotomy

›4th or 5th ICS with rib spreader

›Extend to clamshell if right-sided injury

›Pericardiotomy anterior to phrenic nerve

›Evacuate hemopericardium

›Cardiac repair with finger, stapler, or suture

›Open cardiac massage

›Two-handed compression technique

›Aortic cross-clamping at descending aorta to redistribute circulation

Antibiotic prophylaxis

›Indications for antibiotics

›Penetrating chest injuries requiring chest tube placement

›Prophylactic antibiotics reduce empyema risk

›Pre-procedural dose preferred

›All operative penetrating chest trauma cases

›Perioperative prophylaxis per surgical protocol

›Antibiotic selection

›Cefazolin 2 g IV for prophylaxis

›3 g IV if weight >120 kg

›Re-dose every 4 hours during long operations

›Clindamycin or vancomycin if penicillin allergy

›Vancomycin 15 mg/kg IV

›Duration: single dose or 24 hours maximum for prophylaxis

Pain management

›Multimodal analgesia

›IV opioid titration

›Morphine 2 to 4 mg IV every 4 hours PRN

›Fentanyl 25 to 50 mcg IV titrated for severe pain

›Avoid oversedation in spontaneously breathing patients

›Non-opioid adjuncts

›Ketorolac 15 to 30 mg IV if no contraindication

›Acetaminophen 1 g IV every 6 hours

›Regional analgesia for chest tube pain

›Intercostal nerve block with bupivacaine 0.25%

›Serratus plane block or thoracic epidural in selected patients

09Special Populations/sp77

Pregnancy

›Physiologic considerations

›Elevated diaphragm from gravid uterus shifts chest tube placement landmarks

›Adjust ICS selection based on fundal height

›Confirm position with bedside ultrasound

›Increased blood volume (40 to 50% above baseline) may mask hemorrhage

›Patient may not appear hypotensive until 30 to 35% blood loss

›Fetal distress may precede maternal instability

›Aortocaval compression in supine position

›15 degree left lateral tilt during resuscitation when possible

›Manual uterine displacement if log-roll contraindicated

›Imaging approach

›CXR with abdominal shielding when clinically indicated

›Radiation risk to fetus is low and should not delay necessary imaging

›CT chest when clinical benefit outweighs minimal radiation risk

›E-FAST is first-line and has no radiation exposure

›Assess for fetal cardiac activity and placental abruption

›TXA in pregnancy

›TXA is used in obstetric hemorrhage; reasonable to administer in life-threatening trauma

›No established contraindication in pregnancy for trauma indication

›Risk-benefit favours administration when indicated

›Fetal monitoring

›Obstetric consultation for viable gestation (>24 weeks)

›Continuous electronic fetal monitoring after maternal stabilization

›Emergency caesarean section if fetal distress and viable fetus

Geriatric

›Physiologic differences

›Reduced physiologic reserve

›Tachycardia may be absent on beta-blockers despite significant hemorrhage

›Normal BP may mask significant relative hypotension if baseline hypertensive

›Reduced chest wall compliance

›Greater energy transmission from lower-energy mechanisms

›Rib fractures more likely, increasing pneumothorax risk

›Cardiac and pulmonary reserve reduced

›Impaired compensation for hypoxemia

›Lower threshold for respiratory failure

›Medication considerations

›Anticoagulant use common

›Warfarin reversal: 4-factor PCC (Kcentra) 25 to 50 units/kg IV plus vitamin K 10 mg IV

›DOAC reversal: dabigatran with idarucizumab, factor Xa inhibitors with andexanet alfa

›Avoid overly aggressive fluid resuscitation

›Higher risk of heart failure and pulmonary edema

›Analgesic dose reduction

›Morphine and fentanyl at lower initial doses

›Increased sensitivity to opioids and sedatives

›Disposition bias toward admission

›Lower threshold for chest tube even for small hemothorax

›Reduced ability to compensate for ongoing blood loss

›Aggressive pain management to prevent splinting

›Atelectasis and pneumonia risk from splinting higher in elderly

›Incentive spirometry and early mobilization emphasized

Pediatrics

›Anatomic and physiologic differences

›More compliant chest wall

›Energy transmitted to intrathoracic structures without rib fracture

›Rib fractures in children suggest high-energy mechanism

›Higher oxygen consumption per kg

›Hypoxemia develops more rapidly than in adults

›Escalate oxygen support quickly if SpO2 declining

›Smaller blood volume

›70 to 80 mL/kg total blood volume

›Loss of 30 mL/kg represents >40% blood volume loss

›Weight-based resuscitation

›MTP activation at 40 mL/kg blood product requirement

›1:1:1 ratio pRBCs:FFP:platelets maintained

›Blood products in 10 mL/kg boluses titrated to response

›TXA in pediatric trauma

›15 mg/kg IV bolus (max 1 g) then 2 mg/kg/h for 8 hours

›Limited pediatric data; extrapolated from adult evidence

›Chest tube sizing by weight

›<10 kg: 10 to 14 Fr

›10 to 20 kg: 16 to 20 Fr

›>20 kg: 20 to 28 Fr

›Child protection considerations

›Self-inflicted or assault mechanism requires child protection evaluation

›Mandatory reporting obligation

›Social work and child protection service involvement

›Non-accidental trauma must be considered

›Inconsistent history with injury pattern

›Skeletal survey and further evaluation as indicated

10Background/b74

Epidemiology

›Incidence and demographics

›Penetrating trauma accounts for 10 to 15% of all trauma admissions in North America

›Higher proportion in urban trauma centres

›Young males represent highest incidence demographic

›Stab wounds vs GSWs

›Stab wounds more common but lower mortality than GSWs

›GSWs carry higher kinetic energy and unpredictable trajectories

›Mortality rates

›Overall penetrating chest trauma mortality 5 to 15% at trauma centres

›Penetrating cardiac injuries: overall survival ~19%

›~40% of penetrating cardiac injury patients reaching a trauma centre survive

›Injury patterns

›Pneumothorax and hemothorax most common injuries

›Risk up to 50% for significant chest trauma

›Hemopneumothorax in majority of GSW cases

›Cardiac injuries less common but highly lethal

›Right ventricle most commonly injured (anterior position)

›Left ventricular injuries carry higher mortality

›Associated abdominal injuries in up to 20% of cases

›Diaphragmatic injury often missed on initial evaluation

Pathophysiology

›Injury mechanisms by weapon type

›Stab wounds

›Laceration along blade path with predictable anatomic trajectory

›Lower energy, less collateral tissue damage

›Depth and angle determine structures at risk

›Gunshot wounds

›Cavitation effect creates injury zone beyond bullet track

›High-velocity rounds cause greater tissue disruption

›Fragmentation from hollow-point or expanding rounds

›Cardiopulmonary consequences

›Hemothorax physiology

›Blood accumulation compresses lung and impairs ventilation

›Mediastinal shift from large hemothorax reduces venous return

›Retained hemothorax leads to fibrothorax and trapped lung if not evacuated

›Pneumothorax physiology

›Simple PTX: air accumulation without pressure

›Tension PTX: one-way valve mechanism, progressive pressure, cardiovascular collapse

›Open PTX: equilibration with atmospheric pressure impairs ventilation

›Cardiac tamponade physiology

›Pericardial pressure accumulation impairs diastolic filling

›Beck triad develops as pressure rises

›Compensatory tachycardia and vasoconstriction initially maintain BP

›Hemorrhagic shock phases

›Class I: <15% blood volume loss, compensated

›Class II: 15 to 30% loss, tachycardia, narrowed pulse pressure

›Class III: 30 to 40% loss, hypotension, altered mental status

›Class IV: >40% loss, life-threatening, requires immediate intervention

Therapeutic Considerations

›Damage control resuscitation principles

›Avoid crystalloid excess

›Dilutional coagulopathy risk with saline-dominant resuscitation

›Abdominal compartment syndrome risk

›Hypotensive resuscitation in actively bleeding patient

›Target SBP ~90 mmHg until surgical hemorrhage control

›Not applicable after hemorrhage control achieved

›Calcium replacement during massive transfusion

›Citrate in blood products chelates ionized calcium

›Ionized calcium <1.1 mmol/L triggers replacement

›TXA evidence base

›CRASH-2 trial: TXA reduced all-cause mortality (RR 0.91) and hemorrhagic death

›Benefit only when given within 3 hours of injury

›Harm signal if given after 3 hours

›NAEMSP/ACEP/ACS-COT joint position: conditional recommendation for TXA in trauma hemorrhage

›Greatest benefit with early administration

›Chest tube management principles

›Small-bore pigtail catheters equivalent to large-bore for uncomplicated hemothorax

›Multicenter RCT (Kulvatunyou 2021): 14 Fr P-Cat vs 28 to 32 Fr tube equivalent efficacy

›Better patient comfort and fewer complications with smaller bore

›Irrigation of hemothorax at time of tube placement

›Warm sterile saline irrigation reduces retained hemothorax

›Decreases need for secondary VATS or thrombolytics

›Chest tube removal criteria

›Output <200 mL/day

›No air leak

›Lung fully expanded on CXR

11Patient Discharge Instructions/pdi42

copy discharge instructions

›Penetrating chest trauma discharge instructions

›Activity restrictions

›No strenuous activity for 2 to 4 weeks depending on injury

›No lifting >5 kg until cleared by trauma surgery

›Breathing exercises

›Incentive spirometry 10 deep breaths every 1 to 2 hours while awake

›Deep breathing and coughing exercises to prevent pneumonia

›Wound care

›Keep wound clean and dry

›Dressing changes as instructed; watch for redness, swelling, or discharge

›Medications

›Take prescribed pain medication as directed

›Avoid ibuprofen or aspirin unless specifically prescribed (bleeding risk)

›Warning signs to return to emergency immediately

›Worsening shortness of breath or difficulty breathing at rest

›Especially if sudden onset suggests delayed pneumothorax

›Chest pain that is new or worsening

›Coughing up blood (hemoptysis)

›Fever above 38.5 C

›May indicate developing empyema or wound infection

›Wound site drainage, increasing redness or swelling

›Lightheadedness, dizziness, or feeling faint

›May indicate delayed hemorrhage

›Confusion or decreased level of consciousness

›Blue lips or fingertips (cyanosis)

›Follow-up instructions

›Trauma surgery clinic within 1 to 2 weeks

12References/r44

Guidelines and key sources

›Primary guidelines

›WSES-AAST Thoracic Trauma Guidelines (Coccolini et al., World Journal of Emergency Surgery 2025)

›Comprehensive thoracic trauma management evidence synthesis

›ACR Appropriateness Criteria: Penetrating Torso Trauma (Lee et al., JACR 2024)

›Imaging pathway recommendations for penetrating trauma

›ACS Best Practices Guidelines in Imaging (Tominaga et al., American College of Surgeons 2018)

›Trauma imaging protocols and clinical decision support

›AAST/ACS Damage Control Resuscitation Protocol (LaGrone et al., J Trauma 2024)

›1:1:1 transfusion strategy and MTP framework

Landmark trials and studies

›TXA evidence

›CRASH-2 Trial (Roberts I, Lancet 2010)

›TXA reduces all-cause mortality and hemorrhagic death within 3 hours

›Harm signal for administration after 3 hours of injury

›NAEMSP/ACEP/ACS-COT Joint Position Statement on TXA (Barrett et al., J Trauma 2025)

›Conditional recommendation for TXA in trauma hemorrhage

›Osawa et al., British Journal of Surgery 2025

›Optimal timing analysis from CRASH-2 and CRASH-3 data

›Chest tube evidence

›Kulvatunyou et al., J Trauma 2021

›Multicenter RCT: 14 Fr pigtail equivalent to 28 to 32 Fr for traumatic hemothorax

›Lyons et al., J Trauma 2024

›Systematic review and meta-analysis: small vs large-bore thoracostomy for traumatic hemothorax

›Blank and de Moya, J Trauma 2025

›Current review on traumatic pneumothorax and hemothorax management

›Resuscitative thoracotomy evidence

›Perkins et al., JAMA Surgery 2025

Evidence & Review

Evidence & Review