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Aunque pueda contener afirmaciones, datos o apuntes procedentes de instituciones o profesionales sanitarios, la información contenida en el blog EMS Solutions International está editada y elaborada por profesionales de la salud. Recomendamos al lector que cualquier duda relacionada con la salud sea consultada con un profesional del ámbito sanitario. by Dr. Ramon REYES, MD

viernes, 7 de septiembre de 2018

8 pitfalls to avoid in hemorrhage control by Dr. Peter Pons, FACEP

8 pitfalls to avoid in hemorrhage control by Dr. Peter Pons, ACEP



TCCC Tactical Combat Casualty Care Handbook


BCon  Saber un poco mas sobre control de sangrados 


Tactical Medics vs Rescue Task Force





8 trampas a evitar en el controlhemorragias 

Guia de Soporte en Incidentes con Amenaza para Primer Interviniente Policial by Juan Jose Pajuelo Castro  emssolutionsint.blogspot.com/2018/07/guia-de-soporte-en-incidentes-con.html

TACTICAL COMBAT CASUALTY CARE Handbook version 5 May 2017 emssolutionsint.blogspot.com/2017/07/tactical-combat-casualty-care-handbook.html

Updated TCCC Guidelines (31 JAN 2017) "Actualizacion 2017 de las Guias" Tactical Combat Casualty Care emssolutionsint.blogspot.com/2012/07/presentacion-del-programa-phtls-tccc.html

TCCC TACTICAL COMBAT CASUALTY CARE Quick Reference Guide First Edition 2017 FREE PDF  emssolutionsint.blogspot.com/2018/07/tccc-tactical-combat-casualty-care.html

Updated TCCC Guidelines (31 JAN 2017) "Actualizacion 2017 de las Guias" Tactical Combat Casualty Care emssolutionsint.blogspot.com.es/2012/07/presentacion-del-programa-phtls-tccc.html

MANUAL DE SOPORTE VITAL AVANZADO EN COMBATE Ministerio de Defensa España 2014   http://emssolutionsint.blogspot.com.es/2016/02/manual-de-soporte-vital-avanzado-en.html


Guías para el Manejo de Heridos en Incidentes Intencionados con Múltiples Víctimas y Tiradores Activo "MACTAC" emssolutionsint.blogspot.com/2016/12/guias-para-el-manejo-de-heridos-en.html

Manejo de Heridos en Incidentes Intencionados Múltiples Víctimas y Tiradores Activos 09/07/2017 emssolutionsint.blogspot.com/2018/07/manejo-de-heridos-en-incidentes.html 

TERRORISMO Y SALUD PÚBLICA - "GESTIÓN SANITARIA DE ATENTADOS TERRORISTAS POR BOMBA"  emssolutionsint.blogspot.com/2013/08/terrorismo-y-salud-publica-gestion.html


75th Ranger Regiment Trauma Management Team (Tactical) Ranger Medic Handbook FREE pdf  emssolutionsint.blogspot.com.es/2018/02/75th-ranger-regiment-trauma-management.html

SPECIAL OPERATIONS FORCES Medical Handbook Free PDF  emssolutionsint.blogspot.com/2018/02/special-operations-forces-medical.html

Balística de las heridas: introducción para los profesionales de la salud, del derecho, de las ciencias forenses, de las fuerzas armadas y de las fuerzas encargadas de hacer cumplir la ley http://emssolutionsint.blogspot.com/2017/04/balistica-de-las-heridas-introduccion.html

Guía para el manejo médico-quirúrgico de heridos en situación de conflicto armado by CICR http://emssolutionsint.blogspot.com/2017/09/guia-para-el-manejo-medico-quirurgico.html

CIRUGÍA DE GUERRA TRABAJAR CON RECURSOS LIMITADOS EN CONFLICTOS ARMADOS Y OTRAS SITUACIONES DE VIOLENCIA VOLUMEN 1 C. Giannou M. Baldan CICR http://emssolutionsint.blogspot.com.es/2013/01/cirugia-de-guerra-trabajar-con-recursos.html

Manual Suturas, Ligaduras, Nudos y Drenajes. Hospital Donostia, Pais Vasco. España http://emssolutionsint.blogspot.com/2017/09/manual-suturas-ligaduras-nudos-y.html

Técnicas de Suturas para Enfermería ASEPEYO y 7 tipos de suturas que tienen que conocer estudiantes de medicina http://emssolutionsint.blogspot.com/2015/01/tecnicas-de-suturas-para-enfermeria.html

Manual Práctico de Cirugía Menor. Grupo de Cirugia Menor y Dermatologia. Societat Valenciana de Medicina Familiar i Comunitaria http://emssolutionsint.blogspot.com/2013/09/manual-practico-de-cirugia-menor.html

Protocolo de Atencion para Cirugia. Ministerio de Salud Publica Rep. Dominicana. Marzo 2016 http://emssolutionsint.blogspot.com/2016/09/protocolo-de-atencion-para-cirugia.html

Manual de esterilización para centros de salud. Organización Panamericana de la Salud http://emssolutionsint.blogspot.com/2016/07/manual-de-esterilizacion-para-centros.html

Asistencia de salud en peligro: la importancia de proteger al personal de salud en zonas de guerra PDF Gratis http://emssolutionsint.blogspot.com/2018/06/asistencia-de-salud-en-peligro-la.html

SERVICIOS PREHOSPITALARIOS Y DE AMBULANCIAS EN SITUACIONES DE RIESGO. PDF GRATIS http://emssolutionsint.blogspot.com/2018/06/servicios-prehospitalarios-y-de.html

PDF Update on Prehospital Trauma Courses, NAEMT, Alex Eastman, Lieutenant and Deputy Medical Director, City of Dallas http://emssolutionsint.blogspot.com.es/2016/12/phtls-prehospital-trauma-life-support.html

Tactical Emergency Casualty Care (TECC) Guidelines for First Responders with a Duty to Act Guías para Primeros Respondedores con Deber de Actuar “En Acto de Servicio” (Fuerzas de Seguridad, Bomberos no SEM)    emssolutionsint.blogspot.com/2018/07/tactical-emergency-casualty-care-tecc.html


TACMED Spain Medicina Tactica España  GRUPO  https://www.facebook.com/groups/311284402300505/

Stop the Bleed, the national campaign initiated by the White House in response to the many recent active shooter incidents in the U.S., has garnered significant attention and support over the past two years. Active shooter situations, coupled with research that has come out of the conflicts in Iraq and Afghanistan, have helped us clarify that the greatest cause of preventable death after trauma is uncontrolled hemorrhage, whether internal or external. In the treatment of myocardial infarction, it has long been said that “time is muscle.” Similarly in trauma, we now have a greater understanding that time is red blood cells and every RBC counts toward the ultimate survival of the trauma patient.
As a direct result of this realization, several neglected hemorrhage control techniques have become major components of civilian medical educational programs designed to train citizen responders, public safety personnel and medical care providers of all levels. These include techniques that were once performed only within the confines of the OR — such as packing a bleeding blood vessel — and interventions that were long frowned upon — namely, tourniquet application.
While these hemorrhage control techniques are not particularly difficult to learn and master, there are a number of pitfalls related to performing these interventions that can negatively affect the ultimate outcome of the trauma victim.

1. Not using a tourniquet or waiting too long to apply it for life-threatening extremity bleeding

For many decades the traditional teaching has been that the application of a tourniquet was the procedure of last choice when it came to controlling bleeding from an arm or a leg. Only if all other hemorrhage control efforts failed was a tourniquet to be considered. Even then, it was used with great reluctance and caution out of concern for causing the subsequent amputation of the injured limb.
The experience gained over the past 15 years of combat has clearly demonstrated that recommended, commercially available tourniquets can, in fact, be used safely. Data from the U.S. military have shown that survival for trauma victims who have a tourniquet applied before they bleed into shock is 9 times greater than for victims who receive a tourniquet after they go into shock. In addition, the data show that tourniquets can be safely applied to an extremity for a period of up to 2 hours with no concern about amputation. In fact, there have been no amputations in the U.S. military as a direct result of tourniquet application in patients with an application time of 2 hours or less.
This time period falls well within the timeframe of care of most trauma patients treated in urban and suburban areas of the U.S. That means trained individuals should no longer have any hesitation to apply a tourniquet to an extremity for life-threatening external hemorrhage. The tourniquet should no longer be the last choice for hemorrhage control — it should be the first choice.

2. Not making a tourniquet tight enough to obliterate the distal pulse

Whenever a tourniquet is applied to an extremity for hemorrhage control, it should be made tight enough to completely obliterate the distal pulse. This is to ensure that no blood is getting past the tourniquet and into the extremity.
There are two important reasons for this. First, if blood is able to get beyond the tourniquet, the patient will continue to bleed, thus defeating the purpose of applying it in the first place. Second, if the tourniquet is not tight enough to act as an obstruction to arterial blood in-flow, it will more than likely serve as an obstruction to venous outflow. This increases the likelihood of developing compartment syndrome in the extremity, potentially resulting in muscle and nerve damage.

3. Not using a second tourniquet

In the majority of cases, the application of a single tourniquet will control the hemorrhage. There are instances, however, when one tourniquet has been placed and tightened as much as possible but it is still inadequate to control the bleeding. These situations typically occur when the wound is located on the lower extremity and the tourniquet has been applied to the thigh.
Experience shows that a single tourniquet may not be able to control hemorrhage — or obliterate the distal pulse — in trauma victims with large, very muscular thighs or those who are obese. In these cases, there should be no hesitation to apply a second tourniquet. Place the second tourniquet directly above and adjacent to the first tourniquet and tighten it as necessary until the bleeding stops.

4. Periodically loosening a tourniquet

For many decades, first aid classes taught that whenever a tourniquet was applied to an extremity, the tourniquet should be loosened every 15 to 20 minutes to allow blood to return into the arm or leg. The thinking was that by allowing blood to re-enter the extremity, fresh oxygen would be supplied to the extremity, making it better able to tolerate the tourniquet and thus survive longer. However, as one might guess, the result of loosening a tourniquet is that the victim begins to bleed again.
Early in the war in Iraq and Afghanistan, the U.S. military recommended the practice of periodic loosening. But after nearly causing the death of several soldiers from gradual exsanguination, the military changed its practice. The current recommendation is that once a tourniquet is applied and tightened, it should not be loosened or removed until the source of the hemorrhage can be controlled by some other means.

5. Using an improvised tourniquet

When a commercial tourniquet is not available, many individuals will attempt to fashion an improvised tourniquet using whatever materials are at hand. These often include materials such as belts, string, rope or shoelaces. The fact is that improvised tourniquets too often fail to accomplish the desired goal of hemorrhage control or lead to secondary complications.
For example, using a leather belt as a tourniquet is usually unsuccessful because the leather is too rigid and cannot be adequately twisted and tightened to stop the bleeding. String, rope and shoelaces can often be made tight enough to stop bleeding, but they are usually quite thin and narrow. All of the compression is applied to such a small area that they commonly result in damage to underlying structures such as nerves. Lastly, many improvised tourniquets cannot be tightened enough to obstruct arterial blood flow and only serve as venous tourniquets (see number 2 above).
The traditional teaching on constructing an improvised tourniquet was to roll or fold a cravat (or other fairly pliable material) to a width of approximately 2 inches and to tighten it with some sort of windlass. Most commercially available tourniquet products, particularly those recommended by the U.S. military, are at least 1.5 inches in width (or wider) and include the windlass. Wide tourniquets are better tolerated by the victim and less likely to cause damage to underlying structures.
In reality, improvising a tourniquet takes knowledge of the proper procedure and practice to accomplish in a timely fashion. If you are not practiced in improvising a tourniquet or there are no proper materials at hand, my recommendation is to apply direct pressure using your hands (see number 8 below).

6. Packing a wound with a hemostatic gauze product and assuming you are done

Hemostatic gauze is a commercially available product, usually comprised of a gauze roll that has been impregnated with a compound such as kaolin or chitosan. When packing a wound with one of these products, there are a number of important points to remember.
  • First, the bleeding point within the wound should be visualized. If the wound is full of blood, it should be gently wiped out so the bleeding vessel in the wound can be seen.
  • Second, the hemostatic gauze should be placed directly onto the visualized bleeding point and pressure should be maintained on the site while packing progresses.
  • Third, as much of the gauze as possible should be packed into the open wound. Most of these gauze rolls are 12 feet long. Your goal is to try to get the entire 12 feet packed into the wound.
  • Fourth, once the wound is packed, direct pressure must be applied directly on the packing and the wound for a period of at least 3 minutes (by the clock). These products do not just work by themselves; all of them require a period of direct pressure. It is the combination of packing and direct pressure that helps to control the hemorrhage. By packing the wound as tightly as possible with gauze and then applying pressure on top of the packing, the pressure is transmitted down into the wound and onto the bleeding vessel.
  • Finally, after the 3 minutes of direct pressure has elapsed, reassess. If the bleeding is controlled, wrap the site with some sort of elastic bandage such as an Ace bandage to hold the packing in place. If bleeding continues, pack more gauze on top and apply direct pressure once again.

7. Letting the victim’s discomfort and pain interfere with what you need to do

It should come as no surprise that all of these hemorrhage control interventions — tourniquet application, wound packing and direct pressure — increase the patient’s discomfort and cause significant pain. Recent military reports tell of soldiers who have lost most of a leg to an explosion and had a tourniquet applied to what remained of the extremity. These soldiers often report greater pain from the tourniquet than from the amputation itself.
A patient’s pain and discomfort should not dissuade you from doing what is necessary to control his or her bleeding. Tell the patient that you know what you are about to do will cause them pain, but it is necessary to stop the bleeding and save them from exsanguination. Provide analgesia as soon as is practicable given the situation.

8. Doing nothing when a tourniquet or wound packing supplies are not available

What do you do when hemorrhage control supplies are not available or have been used on another victim? The lack of a tourniquet or hemostatic gauze should not stop the effort to control bleeding. Even without any equipment, hemorrhage can often be controlled and stopped.
Direct pressure on a wound using two hands and body weight is an effective method of slowing bleeding or stopping it altogether. The downside, if you can call it that, is that this method of hemorrhage control takes time to be effective. In many cases, it will take 10 or more minutes of continuous pressure to stem the blood flow and form an adequate clot at the bleeding point. Most importantly, there should be no release of the pressure during this time to see whether it is being effective. Letting up on the pressure will let the hemorrhage begin anew and undo any benefit obtained up to that point.
If hemostatic gauze is not available, wound packing can still be accomplished using either plain gauze or any clean cloth. Both are equally effective as hemostatic gauze. The primary difference is time. Unlike with hemostatic gauze (which must be applied with direct pressure for a minimum of 3 minutes), wounds packed with plain gauze or cloth require pressure to be maintained for a longer period of time.

No one should die from uncontrolled hemorrhage

As was advocated by the Hartford Consensus on improving survival from active shooter events, no one should die from uncontrolled hemorrhage. Techniques and interventions that have been validated as effective following years of conflict — and avoiding common errors and pitfalls in application — will help both trained providers and citizen responders optimize survival for bleeding victims.
Peter T. Pons, MD, FACEP is professor emeritus in the Department of Emergency Medicine at the University of Colorado School of Medicine.

Recommended Resources
American College of Surgeons. Stop the Bleed. www.bleedingcontrol.org.
Strategies to Enhance Survival in Active Shooter and Intentional Mass Casualty Events: A Compendium. Bull Am Coll Surg. 2015;100(15)Suppl. [Access this resource here]
Kragh JF, Walters TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009;249(1):1-7.
Kragh JF, Walters TJ, Baer DG, et al. Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma. 2008;64(2 Suppl):S38-49.
Bulger EM, Snyder D, Schoelles K, et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014;18(2):163-73.
Watters JM, Van PY, Hamilton GJ, Sambasivan C, Differding JA, Schreiber MA. Advanced hemostatic dressings are not superior to gauze for care under fire scenarios. J Trauma. 2011;70(6):1413-9.

TACTICAL MEDICINE TACMED “Medicina Bona Locis Malis” tm. Good Medicine In Bad Places España by EMS Solutions International


MANUAL DE ATENCIÓN AL PARTO EN EL ÁMBITO EXTRAHOSPITALARIO. Ministerio de Sanidad, Servicios Sociales e Igualdad. España

¿Qué es el parto velado "Parto Empelicado" o nacer con bolsa intacta? by NATALBEN.com

Balística de las heridas: introducción para los profesionales de la salud, del derecho, de las ciencias forenses, de las fuerzas armadas y de las fuerzas encargadas de hacer cumplir la ley http://emssolutionsint.blogspot.com/2017/04/balistica-de-las-heridas-introduccion.html
Guía para el manejo médico-quirúrgico de heridos en situación de conflicto armado by CICR http://emssolutionsint.blogspot.com/2017/09/guia-para-el-manejo-medico-quirurgico.html

CIRUGÍA DE GUERRA TRABAJAR CON RECURSOS LIMITADOS EN CONFLICTOS ARMADOS Y OTRAS SITUACIONES DE VIOLENCIA VOLUMEN 1 C. Giannou M. Baldan CICR http://emssolutionsint.blogspot.com.es/2013/01/cirugia-de-guerra-trabajar-con-recursos.html

Manual Suturas, Ligaduras, Nudos y Drenajes. Hospital Donostia, Pais Vasco. España http://emssolutionsint.blogspot.com/2017/09/manual-suturas-ligaduras-nudos-y.html

Técnicas de Suturas para Enfermería ASEPEYO y 7 tipos de suturas que tienen que conocer estudiantes de medicina http://emssolutionsint.blogspot.com/2015/01/tecnicas-de-suturas-para-enfermeria.html

Manual Práctico de Cirugía Menor. Grupo de Cirugia Menor y Dermatologia. Societat Valenciana de Medicina Familiar i Comunitaria http://emssolutionsint.blogspot.com/2013/09/manual-practico-de-cirugia-menor.html

Protocolo de Atencion para Cirugia. Ministerio de Salud Publica Rep. Dominicana. Marzo 2016 http://emssolutionsint.blogspot.com/2016/09/protocolo-de-atencion-para-cirugia.html
Manual de esterilización para centros de salud. Organización Panamericana de la Salud http://emssolutionsint.blogspot.com/2016/07/manual-de-esterilizacion-para-centros.html
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¿Por qué el Desfibrilador TELEFUNKEN?
El DESFIBRILADOR de Telefunken es un DESFIBRILADOR AUTOMÁTICO sumamente avanzado y muy fácil de manejar.
Fruto de más de 10 años de desarrollo, y avalado por TELEFUNKEN, fabricante con más de 80 años de historia en la fabricación de dispositivos electrónicos.
El desfibrilador TELEFUNKEN cuenta con las más exigentes certificaciones.
Realiza automáticamente autodiagnósticos diarios y mensuales.

Incluye bolsa y accesorios.
Dispone de electrodos de "ADULTO" y "PEDIÁTRICOS".
Tiene 6 años de garantía.
Componentes kit de emergencias
Máscarilla de respiración con conexión de oxígeno.
Tijeras para cortar la ropa
Guantes desechables.

¿ Qué es una Parada Cardíaca?
Cada año solo en paises como España mueren más de 25.000 personas por muerte súbita.
La mayoría en entornos extrahospitalarios, y casi el 80-90 % ocasionadas por un trastorno eléctrico del corazón llamado"FIBRILACIÓN VENTRICULAR"

El único tratamiento efectivo en estos casos es la "Desfibrilación precoz".
"Por cada minuto de retraso en realizar la desfibrilación, las posibilidades de supervivencia disminuyen en más de un 10%".

¿ Qué es un desfibrilador ?
El desfibrilador semiautomático (DESA) es un pequeño aparato que se conecta a la víctima que supuestamente ha sufrido una parada cardíaca por medio de parches (electrodos adhesivos).

¿ Cómo funciona ?

El DESA "Desfibrilador" analiza automáticamente el ritmo del corazón. Si identifica un ritmo de parada cardíaca tratable mediante la desfibrilación ( fibrilación ventricular), recomendará una descarga y deberá realizarse la misma pulsando un botón.

El desfibrilador va guiando al reanimador durante todo el proceso, por medio de mensajes de voz, realizando las órdenes paso a paso.

Únicamente si detecta este ritmo de parada desfibrilable (FV) y (Taquicardia Ventricular sin Pulso) permite la aplicación de la descarga. (Si por ejemplo nos encontrásemos ante una víctima inconsciente que únicamente ha sufrido un desmayo, el desfibrilador no permitiría nunca aplicar una descarga).

¿Quién puede usar un desfibrilador TELEFUNKEN?
No es necesario que el reanimador sea médico, Enfermero o Tecnico en Emergencias Sanitarias para poder utilizar el desfibrilador.

Cualquier persona (no médico) que haya superado un curso de formación específico impartido por un centro homologado y acreditado estará capacitado y legalmente autorizado para utilizar el DESFIBRILADOR (En nuestro caso la certificacion es de validez mundial por seguir los protolos internacionales del ILCOR International Liaison Committee on Resuscitation. y Una institucion de prestigio internacional que avale que se han seguido los procedimientos tanto de formacion, ademas de los lineamientos del fabricante como es el caso de eeii.edu

TELEFUNKEN en Rep. Dominicana es parte de Emergency Educational Training Institute de Florida. Estados Unidos, siendo Centro de Entrenamiento Autorizado por la American Heart Association y American Safety and Health Institute (Por lo que podemos certificar ILCOR) Acreditacion con validez en todo el mundo y al mismo tiempo certificar el lugar en donde son colocados nuestros Desfibriladores como Centros Cardioprotegidos que cumplen con todos los estanderes tanto Europeos CE como de Estados Unidos y Canada
Dimensiones: 220 x 275 x 85mm
Peso: 2,6 Kg.
Clase de equipo: IIb
Temperatura: 0° C – + 50° C (sin electrodos)
Presión: 800 – 1060 hPa
Humedad: 0% – 95%
Máximo Grado de protección contra la humedad: IP 55
Máximo grado de protección contra golpes:IEC 601-1:1988+A1:1991+A2:1995
Tiempo en espera de las baterías: 3 años (Deben de ser cambiadas para garantizar un servicio optimo del aparato a los 3 años de uso)
Tiempo en espera de los electrodos: 3 años (Recomendamos sustitucion para mantener estandares internacionales de calidad)
Número de choques: >200
Capacidad de monitorización: > 20 horas (Significa que con una sola bateria tienes 20 horas de monitorizacion continua del paciente en caso de desastre, es optimo por el tiempo que podemos permanecer en monitorizacion del paciente posterior a la reanimacion)
Tiempo análisis ECG: < 10 segundos (En menos de 10 seg. TELEFUNKEN AED, ha hecho el diagnostico y estara listo para suministrar tratamiento de forma automatica)
Ciclo análisis + preparación del shock: < 15 segundos
Botón información: Informa sobre el tiempo de uso y el número de descargas administradas durante el evento con sólo pulsar un botón
Claras señales acústicas y visuales: guía por voz y mediante señales luminosas al reanimador durante todo el proceso de reanimación.
Metrónomo: que indica la frecuencia correcta para las compresiones torácicas. con las Guias 2015-2020, esto garantiza que al seguir el ritmo pautado de compresiones que nos indica el aparato de forma acustica y visual, podremos dar RCP de ALTA calidad con un aparato extremadamente moderno, pero economico.
Normas aplicadas: EN 60601-1:2006, EN 60601-1-4:1996, EN 60601-1:2007, EN 60601-2-4:2003
Sensibilidad y precisión:
Sensibilidad > 90%, tip. 98%,
Especificidad > 95%, tip. 96%,
Asistolia umbral < ±80μV
Protocolo de reanimación: ILCOR 2015-2020
Análisis ECG: Ritmos cardiacos tratables (VF, VT rápida), Ritmos cardiacos no tratables (asistolia, NSR, etc.)
Control de impedancia: Medición9 de la impedancia continua, detección de movimiento, detección de respiración
Control de los electrodos : Calidad del contacto
Identificación de ritmo normal de marcapasos
Lenguas: Holandés, inglés, alemán, francés, español, sueco, danés, noruega, italiano, ruso, chino
Comunicación-interfaz: USB 2.0 (El mas simple y economico del mercado)
Usuarios-interfaz: Operación de tres botones (botón de encendido/apagado , botón de choque/información.
Indicación LED: para el estado del proceso de reanimación. (Para ambientes ruidosos y en caso de personas con limitaciones acusticas)
Impulso-desfibrilación: Bifásico (Bajo Nivel de Energia, pero mayor calidad que causa menos daño al musculo cardiaco), tensión controlada
Energía de choque máxima: Energía Alta 300J (impedancia de paciente 75Ω), Energía Baja 200J
(impedancia de paciente 100Ω)

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