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11
Trauma Morbidity and Trauma Morbidity and MortalityMortality
September 2012 CESeptember 2012 CECondell Medical Center Condell Medical Center
EMS SystemEMS SystemSite Code: 107200E -1212Site Code: 107200E -1212
Prepared by: Sharon Hopkins, RN, BSN, EMT-PPrepared by: Sharon Hopkins, RN, BSN, EMT-PRev 9.19.12Rev 9.19.12
22
ObjectivesObjectives
Upon successful completion of this module, the EMS Upon successful completion of this module, the EMS provider will be able to:provider will be able to:
1. Identify by mechanism of injury and signs and1. Identify by mechanism of injury and signs and symptoms of major causes of increased risk ofsymptoms of major causes of increased risk of morbidity & mortality related to a traumatic injurymorbidity & mortality related to a traumatic injury (airway obstruction, flail chest, open pneumothorax,(airway obstruction, flail chest, open pneumothorax, tension pneumothorax, cardiac tamponade, aortictension pneumothorax, cardiac tamponade, aortic tear).tear). 2. Identify the significance and signs and symptoms of2. Identify the significance and signs and symptoms of crush injuries and compartment syndrome.crush injuries and compartment syndrome. 3. Describe treatment based on injury presented.3. Describe treatment based on injury presented.
33
Objectives cont’dObjectives cont’d
4. Identify transport destination decision.4. Identify transport destination decision. 5. Actively participate in case scenario reviews.5. Actively participate in case scenario reviews. 6. Perform the skills of needle decompression,6. Perform the skills of needle decompression,
cricothyrotomy, and QuickTrachcricothyrotomy, and QuickTrach 7. Successfully complete the post quiz7. Successfully complete the post quiz
with a score of 80% or better.with a score of 80% or better.
44
Thoracic TraumaThoracic Trauma
Responsible for 20-25% of all trauma Responsible for 20-25% of all trauma related deathsrelated deaths
Purpose of primary assessmentPurpose of primary assessment Determine the presence of any Determine the presence of any LIFE THREATSLIFE THREATS!!!!!!
What’s going to kill the patient the What’s going to kill the patient the fastest??fastest??
HypoxiaHypoxia HemorrhageHemorrhage
55
Trauma StatsTrauma Stats
Deaths at the scene are usually due to Deaths at the scene are usually due to injury of the heart and/or great vesselsinjury of the heart and/or great vessels
Deaths delayed by hours are usually due Deaths delayed by hours are usually due to airway obstruction, tension to airway obstruction, tension pneumothorax, hemorrhage, and pneumothorax, hemorrhage, and tamponadetamponade
Note: only a small portion of patients with Note: only a small portion of patients with traumatic injuries to the chest need ORtraumatic injuries to the chest need OR
66
Tissue HypoxiaTissue Hypoxia
Inadequate delivery of oxygen to tissues Inadequate delivery of oxygen to tissues can be caused by a variety of mechanismscan be caused by a variety of mechanisms
Start patient assessments with primary Start patient assessments with primary assessmentassessment
Any change in the patient condition and Any change in the patient condition and you should repeat the primary assessmentyou should repeat the primary assessment
A – B - C A – B - C
77
Causes of Tissue HypoxiaCauses of Tissue Hypoxia
Hypovolemia from loss of blood volumeHypovolemia from loss of blood volume Ventilation/perfusion mismatch due to Ventilation/perfusion mismatch due to
injury of lung tissueinjury of lung tissue Compromise to ventilations and or Compromise to ventilations and or
circulation due to a tension pneumothoraxcirculation due to a tension pneumothorax Pump failure from severe myocardial injury Pump failure from severe myocardial injury
or pericardial tamponadeor pericardial tamponade
88
Thoracic CageThoracic Cage
A skeletal protection to many organsA skeletal protection to many organs
LungsLungsHeartHeartGreat vesselsGreat vesselsSpinal cordSpinal cordLiverLiver
Trauma to the protective rib cage may also Trauma to the protective rib cage may also cause some injuriescause some injuries
StomachStomachSpleenSpleenPancreasPancreasKidneysKidneysTransverse colonTransverse colon
99
DiaphragmDiaphragm
Position: lies at the level following the curve of Position: lies at the level following the curve of the lower 6 ribs and connected to the xyphoid the lower 6 ribs and connected to the xyphoid processprocess
Main function: respirationsMain function: respirationsDescends/flattens on inspirationDescends/flattens on inspirationRises on exhalationRises on exhalation
Innervation: phrenic nerve which begins C3 to Innervation: phrenic nerve which begins C3 to C5 levelC5 level Injury above C3 unable to breatheInjury above C3 unable to breathe Injury below C5 can still breatheInjury below C5 can still breathe
1010
DiaphragmDiaphragm
1111
Diaphragm – A Moving TargetDiaphragm – A Moving Target
Palpate and place your finger tips at the lower Palpate and place your finger tips at the lower edge of your rib cageedge of your rib cage Keep your fingers in contact with your skin Keep your fingers in contact with your skin
Take a deep breathTake a deep breath Feel your rib cage flare outFeel your rib cage flare out Diaphragm drawn downward moving lungs and Diaphragm drawn downward moving lungs and
abdominal organs downward to accommodate lung abdominal organs downward to accommodate lung expansionexpansion
Now exhale Now exhale Feel your rib cage decrease in sizeFeel your rib cage decrease in size Your diaphragm rises as lung capacity decreasesYour diaphragm rises as lung capacity decreases
1212
Anatomy – Chest ContentsAnatomy – Chest Contents
Contents above the diaphragmContents above the diaphragmLungsLungsLower tracheaLower tracheaMain stem bronchiMain stem bronchiHeart and great vesselsHeart and great vesselsEsophagusEsophagus
These organs sit above the diaphragmThese organs sit above the diaphragm
1313
Anatomy – Chest ContentsAnatomy – Chest Contents
Contents in the lower chest cavity in upper Contents in the lower chest cavity in upper abdominal regionabdominal regionStomach Stomach KidneysKidneysSpleen Spleen PancreasPancreasLiverLiver
These organs are separated from the These organs are separated from the upper chest by the diaphragmupper chest by the diaphragm
If diaphragm ruptures, abdominal organs If diaphragm ruptures, abdominal organs can migrate into chest cavitycan migrate into chest cavity
1414
Is the injury thoracic or Is the injury thoracic or abdominal???abdominal???
Trauma below Trauma below the nipples (T4 or the nipples (T4 or 44thth intercostal intercostal space (ICS) can space (ICS) can cause both cause both intrathoracic and intrathoracic and intra-abdominal intra-abdominal injuriesinjuries
1515
Did you know???Did you know???
The adult thoracic cavity can hold up to The adult thoracic cavity can hold up to 3 L of blood for each side3 L of blood for each side What is the average adult blood volume?What is the average adult blood volume?
5.5 – 6.5 liters5.5 – 6.5 liters5.5 – 6.5 quarts5.5 – 6.5 quarts
1 liter = 1 quart1 liter = 1 quartApproximately 1.3 gallonsApproximately 1.3 gallons
Formula: 0.07 x weight in kg=liters of bloodFormula: 0.07 x weight in kg=liters of blood Ex: (adult) 0.07 x 80kg = 5.6 L Ex: (adult) 0.07 x 80kg = 5.6 L Ex: (newborn) 0.07 x 3kg = 0.2 L (200ml)Ex: (newborn) 0.07 x 3kg = 0.2 L (200ml)
1616
Pleural SpacePleural Space
A small area between 2 layers of pleuraA small area between 2 layers of pleura Normally filled with minimal fluidNormally filled with minimal fluid
Can potentially expand if filled with air or Can potentially expand if filled with air or bloodblood
Expansion is at the sacrifice of other organs in Expansion is at the sacrifice of other organs in the areathe area
Visceral pleuraVisceral pleura Directly lines lungsDirectly lines lungs
Parietal pleuraParietal pleura Inner lining of the chest wallInner lining of the chest wall
1717
MediastinumMediastinum
Midline area of the thoracic cavityMidline area of the thoracic cavity ContainsContains
HeartHeartAorta and pulmonary arteryAorta and pulmonary arterySuperior and inferior vena cavasSuperior and inferior vena cavasTracheaTracheaMajor bronchiMajor bronchiEsophagusEsophagus
1818
Mechanisms of InjuryMechanisms of Injury
Thoracic cage injuries can result from a Thoracic cage injuries can result from a variety of sourcesvariety of sources MVCMVC Motorcycle incidentsMotorcycle incidents FallsFalls CrushCrush Blunt Blunt Penetrating – firearms, knivesPenetrating – firearms, knives
1919
MOIMOI
Blunt trauma Blunt trauma Injuries more predictableInjuries more predictable
Penetrating injuriesPenetrating injuries Unpredictable organ injuryUnpredictable organ injury
Path of destruction can vary widelyPath of destruction can vary widely
2020
Major Signs/Symptoms of Chest Major Signs/Symptoms of Chest InjuriesInjuries
Shortness of breathShortness of breath Chest painChest pain ContusionsContusions Open woundsOpen wounds Sub Q emphysemaSub Q emphysema HemoptysisHemoptysis Distended neck veinsDistended neck veins Tracheal deviationTracheal deviation
CyanosisCyanosis ShockShock TendernessTenderness InstabilityInstability CrepitationCrepitation Altered breath soundsAltered breath sounds Asymmetrical chest Asymmetrical chest
movement including movement including paradoxical motionparadoxical motion
2121
Patient AssessmentPatient Assessment
Start with scene size-upStart with scene size-up Perform primary assessmentPerform primary assessment
Remember: Repeat ABC assessment if there Remember: Repeat ABC assessment if there is a change in patient conditionis a change in patient condition
Move into history taking with secondary Move into history taking with secondary assessmentassessment
EMS patients rarely have just one isolated EMS patients rarely have just one isolated injury with traumatic MOIinjury with traumatic MOI Signs and symptoms blur when injuries are Signs and symptoms blur when injuries are
mixed togethermixed together
2222
Airway ObstructionAirway Obstruction
Results in hypoxiaResults in hypoxia Tissue insult occurs quicklyTissue insult occurs quickly Once cells die, they are goneOnce cells die, they are gone Primary assessment starts with the Primary assessment starts with the
question:question: Is the airway open and do I need to Is the airway open and do I need to
apply manual c-spine control???apply manual c-spine control??? If the airway is not open, what do I need If the airway is not open, what do I need
to do???to do???
2323
Opening a Blocked AirwayOpening a Blocked Airway
In traumaIn traumaModified jaw thrustModified jaw thrust
In absence of traumaIn absence of traumaHead tilt/chin liftHead tilt/chin lift
Are secretions present?Are secretions present?Limit suctioning generally to Limit suctioning generally to <<10 seconds10 seconds
Are adjuncts required?Are adjuncts required?Is there a gag reflex?Is there a gag reflex?
If necessary, stroke eyelashes to check for blink If necessary, stroke eyelashes to check for blink reflexreflex
2424
Airway ManeuversAirway Maneuvers
Modified jaw thrustModified jaw thrust Used in presence Used in presence
of suspected or of suspected or known traumaknown trauma
Head tilt/chin liftHead tilt/chin lift
2525
Interventions for Obstructed Interventions for Obstructed AirwaysAirways
Cricothyroid membrane - Need to know Cricothyroid membrane - Need to know landmarks – patient can’t waitlandmarks – patient can’t wait
2626
QuickTrachQuickTrach
Device sized for Device sized for adult (4.0 mm) or adult (4.0 mm) or peds (2.0 mm)peds (2.0 mm)
Kit contains items Kit contains items noted to the rightnoted to the right
Need to add skin Need to add skin prep material and prep material and BVMBVM
2727
Adjuncts for Obstructed AirwayAdjuncts for Obstructed Airway
QuickTrach – emergency cricothyrotomyQuickTrach – emergency cricothyrotomy 1 medic assembles equipment1 medic assembles equipment 1 medic locates and palpates cricothyroid 1 medic locates and palpates cricothyroid
membranemembrane Run finger up from sternal notchRun finger up from sternal notch Cricoid cartilage first rigid ringCricoid cartilage first rigid ring Membrane is above the cricoid cartilageMembrane is above the cricoid cartilage
Prep skinPrep skin Insert needle at 90 degree angleInsert needle at 90 degree angle Aspirate air to confirm needle entry into tracheaAspirate air to confirm needle entry into trachea
2828
Quicktrach cont’dQuicktrach cont’d
Change angle of insertion to 60Change angle of insertion to 6000 sliding sliding catheter sheath forward until red stopper is catheter sheath forward until red stopper is flush with skinflush with skin
Remove red stopperRemove red stopper Hold needle & syringe firmly and slide plastic Hold needle & syringe firmly and slide plastic
cannula forward til hub of catheter snug to skincannula forward til hub of catheter snug to skin Remove needle and syringeRemove needle and syringe Begin to ventilate via BVM – hold equipment Begin to ventilate via BVM – hold equipment
securelysecurely Assess for placement – BS, chest rise & fallAssess for placement – BS, chest rise & fall Secure catheter with ties providedSecure catheter with ties provided
2929
Needle CricothyrotomyNeedle Cricothyrotomy Provides emergency access to an Provides emergency access to an
otherwise blocked airwayotherwise blocked airway
3030
Needle CricothyrotomyNeedle Cricothyrotomy
Locate cricothyroid membraneLocate cricothyroid membrane Prep sitePrep site Insert large gauge catheter with syringe Insert large gauge catheter with syringe
attached into trachea – midline 45attached into trachea – midline 4500 angle angle Aspirate with syringe to confirm placementAspirate with syringe to confirm placement Advance catheter while withdrawing styletAdvance catheter while withdrawing stylet Attach 3.0 mm ETT hubAttach 3.0 mm ETT hub Ventilate with BVM via the 3.0 mm ETT hubVentilate with BVM via the 3.0 mm ETT hub Assess for BS and chest riseAssess for BS and chest rise Secure catheterSecure catheter Note: Will need to allow extra time for exhalationNote: Will need to allow extra time for exhalation
3131
Flail ChestFlail Chest
Fracture of 3 or more (2 or more in some Fracture of 3 or more (2 or more in some sources) adjacent ribs in 2 or more places eachsources) adjacent ribs in 2 or more places each Section becomes free floatingSection becomes free floating
Be suspicious for the presence of pulmonary Be suspicious for the presence of pulmonary contusionscontusions It takes tremendous force to break that many ribsIt takes tremendous force to break that many ribs Organs under the rib cage most likely traumatizedOrgans under the rib cage most likely traumatized Compromise to normal diffusion of OCompromise to normal diffusion of O22 and CO and CO2 2 is is
usually presentusually present
Flail chest does NOT automatically equal the Flail chest does NOT automatically equal the presence of a tension pneumothoraxpresence of a tension pneumothorax
3232
Flail ChestFlail Chest
Can be suspicious of condition during the Can be suspicious of condition during the primary assessmentprimary assessment Patient states “I can’t breathe”Patient states “I can’t breathe” The rib fractures cause significant pain as the The rib fractures cause significant pain as the
patient tries to take any breathspatient tries to take any breaths Patient is anxiousPatient is anxious May see paradoxical motion on visual May see paradoxical motion on visual
inspectioninspectionThis is often a later sign due to initial This is often a later sign due to initial
splintingsplinting
3333
Flail Chest and Primary Flail Chest and Primary AssessmentAssessment
DO NOT stop your primary assessmentDO NOT stop your primary assessment Just make note to go back to address why Just make note to go back to address why
there is respiratory distressthere is respiratory distress
Remember: the only 2 times to interrupt Remember: the only 2 times to interrupt YOUR primary assessment is to correct YOUR primary assessment is to correct an obstructed/closed airway or to control an obstructed/closed airway or to control major hemorrhagemajor hemorrhage
3434
Flail ChestFlail Chest
Tremendous force Tremendous force to fracture this to fracture this many ribsmany ribs
Notice how lateral Notice how lateral the clavicular the clavicular midline really is!!!midline really is!!!
Landmark essential Landmark essential IFIF patient develops patient develops a tension a tension pneumothoraxpneumothorax
3535
Flail Chest Key Signs /SymptomsFlail Chest Key Signs /Symptoms
Paradoxical motion on visual inspectionParadoxical motion on visual inspection Potential bruising or other marks on chest Potential bruising or other marks on chest
wallwall Crepitation and tenderness on palpationCrepitation and tenderness on palpation Decreased breath sound depending on Decreased breath sound depending on
degree of injury, splinting and presence of degree of injury, splinting and presence of pneumothoraxpneumothorax
3636
Flail ChestFlail Chest
3737
Flail Chest TreatmentFlail Chest Treatment
Supplemental oxygen therapySupplemental oxygen therapy Non-rebreather ONon-rebreather O22 if intubation not needed if intubation not needed
Cardiac monitoringCardiac monitoring Potential high for cardiac contusionPotential high for cardiac contusion
Stabilizing the chest wall is controversialStabilizing the chest wall is controversial Do not tape the chest wallDo not tape the chest wall Providing positive pressure ventilation (i.e.: Providing positive pressure ventilation (i.e.:
intubation on a ventilator) is the preferred intubation on a ventilator) is the preferred method of support which can be done in the method of support which can be done in the ED if not necessary in the field)ED if not necessary in the field)
3838
Open/Sucking Chest WoundOpen/Sucking Chest Wound
Air allowed to enter the thoracic space due Air allowed to enter the thoracic space due to an opening in the chest wallto an opening in the chest wall
Results from penetrating trauma Results from penetrating trauma Air drawn into pleural spaceAir drawn into pleural space Air will enter via the largest openingAir will enter via the largest opening
The hole created in the chest wall versus the The hole created in the chest wall versus the glottic openingglottic opening
Air entering the pleural space does not reach Air entering the pleural space does not reach the alveolithe alveoli
3939
Open/Sucking Chest WoundOpen/Sucking Chest Wound
Visual inspection reveals the woundVisual inspection reveals the wound May hear a sucking or bubbling soundMay hear a sucking or bubbling sound May feel subcutaneous emphysema May feel subcutaneous emphysema
around the areaaround the area Lightly palpate the area and feel a crackling Lightly palpate the area and feel a crackling
sensation under your finger tipssensation under your finger tips Noticed skin “puffed up”Noticed skin “puffed up”
4040
Open/Sucking Chest WoundOpen/Sucking Chest Wound
Immediate treatment as soon as the Immediate treatment as soon as the wound is found is to cover the wound with wound is found is to cover the wound with a gloved handa gloved hand
Then place an occlusive dressing over the Then place an occlusive dressing over the sitesite
Secure occlusive dressing on 3 sides Secure occlusive dressing on 3 sides Leaves a means of escape of air on the 4Leaves a means of escape of air on the 4 thth
side to avoid the potential of converting the side to avoid the potential of converting the injury to a tension pneumothoraxinjury to a tension pneumothorax
If wound is large, try defib pad over woundIf wound is large, try defib pad over wound
4141
Open/Sucking Chest WoundOpen/Sucking Chest Wound
QuestionQuestion If the patient develops a tension If the patient develops a tension
pneumothorax after the sucking chest wound pneumothorax after the sucking chest wound is sealed with an occlusive dressing, do you is sealed with an occlusive dressing, do you need to perform a needle decompression?need to perform a needle decompression?
NO!!! – not usuallyNO!!! – not usually There is already a BIG hole in the chest wall that There is already a BIG hole in the chest wall that
air can escape fromair can escape from Just lift a corner of the dressing during exhalation Just lift a corner of the dressing during exhalation
for air to escapefor air to escape If there is no improvement, you might have to If there is no improvement, you might have to
decompress with a needledecompress with a needle
4242
You Evaluate…You Evaluate…
What’s right?What’s right? Wound immediately Wound immediately
covered with handcovered with hand
What’s wrong?What’s wrong? The care provider has no The care provider has no
gloves ongloves on
4343
Tension PneumothoraxTension Pneumothorax
A pneumothorax that generates and A pneumothorax that generates and maintains pressures greater than maintains pressures greater than atmospheric pressure in the thoraxatmospheric pressure in the thorax A one way valve is created and air flows into A one way valve is created and air flows into
the pleural space and cannot escapethe pleural space and cannot escape Most often associated with a traumatic Most often associated with a traumatic
event but can be spontaneousevent but can be spontaneous Can be a complication of treatment of an Can be a complication of treatment of an
open/sucking chest woundopen/sucking chest wound
4444
Tension Pneumothorax – Tension Pneumothorax – A Cascade of EventsA Cascade of Events
Air enters pleural spaceAir enters pleural space intrapleural pressure collapses lung, intercostal intrapleural pressure collapses lung, intercostal
bulging occurs, pressure exerted against bulging occurs, pressure exerted against mediastinummediastinum
Uninjured lung becomes compressedUninjured lung becomes compressed Vena cava compression Vena cava compression venous return venous return Cardiac output (CO) Cardiac output (CO) causing causing pulse; pulse; B/P B/P JVD present, narrowed pulse pressureJVD present, narrowed pulse pressure Tracheal shift is a Tracheal shift is a latelate but but rarerare sign (hard to view) sign (hard to view)
4545
X-ray - Tension PneumothoraxX-ray - Tension Pneumothorax
What’s wrong with this What’s wrong with this x-ray?x-ray? It should never have It should never have
been taken!been taken! Diagnosis is clinicalDiagnosis is clinical Arrow points to Arrow points to
completely collapsed completely collapsed lunglung
Dark filled images Dark filled images indicate air filled indicate air filled spacesspaces
Note tracheal shift to Note tracheal shift to the rightthe right
4646
Tension PneumothoraxTension Pneumothorax Typical signs and symptomsTypical signs and symptoms
Severe dyspneaSevere dyspnea Hyperinflation of affected sideHyperinflation of affected side Diminished, then absent breath soundDiminished, then absent breath sound Hyperresonance of affected sideHyperresonance of affected side DiaphoresisDiaphoresis CyanosisCyanosis JVDJVD TachycardiaTachycardia Altered mental statusAltered mental status Eventual hypotensionEventual hypotension
4747
Simple Simple PneumothoraxPneumothorax
There is a differenceThere is a difference These patient DO NOT require needle These patient DO NOT require needle
decompressiondecompression May not even auscultate decreased breath May not even auscultate decreased breath
sounds if collapse is smallsounds if collapse is small There is a clinical difference in There is a clinical difference in
presentation (i.e.: vital signs) from a presentation (i.e.: vital signs) from a simple to a tension pneumothoraxsimple to a tension pneumothorax
4848
Jugular Vein Distention - JVDJugular Vein Distention - JVD
JVD present when venous pressures are high JVD present when venous pressures are high and blood cannot easily drain into the right and blood cannot easily drain into the right atriumatrium Typically seen with tension pneumothorax,, cardiac Typically seen with tension pneumothorax,, cardiac
tamponade, right sided heart failure and volume tamponade, right sided heart failure and volume overloadoverload
Most appropriately measured with patient sitting Most appropriately measured with patient sitting at 45at 4500 angle and evaluating right side of neck angle and evaluating right side of neck May not be possible with traumatic injuryMay not be possible with traumatic injury
Note: Lack of JVD in supine position with Note: Lack of JVD in supine position with physical findings may indicate hypovolemic physical findings may indicate hypovolemic shockshock
4949
JVDJVD Jugular vein is prominent if distended at a Jugular vein is prominent if distended at a
point slightly higher than 1 inch above right point slightly higher than 1 inch above right clavicleclavicle
5050
Tension Pneumothorax TreatmentTension Pneumothorax Treatment
Rapid recognition is key!!!Rapid recognition is key!!! Severe dyspneaSevere dyspnea Distinct signs and symptomsDistinct signs and symptoms
Needle decompression to relieve Needle decompression to relieve intrapleural pressuresintrapleural pressures Administer supplemental OAdminister supplemental O22 via NRB via NRB
EquipmentEquipment Longest and largest needle you have – 3 Longest and largest needle you have – 3 inch inch
long and 12-14 gaugelong and 12-14 gauge Skin prep materialSkin prep material
5151
Needle Decompression LandmarksNeedle Decompression Landmarks
Finding Finding the Angle the Angle of Louis is of Louis is an easier an easier landmark landmark than than counting counting down rib down rib spacesspaces
Angle of Louis
2nd ICS
5252
Tension Pneumothorax TreatmentTension Pneumothorax Treatment
Needle decompressionNeedle decompression Identify 2Identify 2ndnd intercostal space (ICS) intercostal space (ICS)
Find Angle of LouisFind Angle of Louis Hang a Louis and slide into the 2Hang a Louis and slide into the 2ndnd ICS ICS From Angle of Louis, slide finger tips From Angle of Louis, slide finger tips
toward armpit crease toward armpit crease ORORPalpate down from MIDDLE of clavicle to Palpate down from MIDDLE of clavicle to
22ndnd ICS ICS Middle of clavicle more lateral than most Middle of clavicle more lateral than most
people identify; is male nipple linepeople identify; is male nipple line Insert needle over top of ribInsert needle over top of rib
5353
Landmarks for Needle DecompressionLandmarks for Needle Decompression
If needle placed too low and too close to sternum, tip may
end up placed in the heart
5454
Needle DecompressionNeedle Decompression
Goal of needle decompression:Goal of needle decompression: Provide a relief valve for air under tensionProvide a relief valve for air under tension
Do NOT need to make a flutter valveDo NOT need to make a flutter valve Air will enter the path of least resistance Air will enter the path of least resistance
(i.e.: the larger pathway)(i.e.: the larger pathway) Diameter of trachea larger than a 14 G needle Diameter of trachea larger than a 14 G needle
so air will enter via trachea into the lungs and so air will enter via trachea into the lungs and not through a 14G needle into the pleural not through a 14G needle into the pleural spacespace
5555
You Evaluate…You Evaluate…
What’s wrong?What’s wrong? Too low, tip may be Too low, tip may be
in the heartin the heart
Needle should have Needle should have been herebeen here
What’s right?What’s right? Catheter securedCatheter secured
X
5656
Pericardial/Cardiac TamponadePericardial/Cardiac Tamponade
Blood or fluid fills the pericardial sac Blood or fluid fills the pericardial sac surrounding the heartsurrounding the heart Sac does not expand but compresses into the Sac does not expand but compresses into the
heart limiting flow into the heartheart limiting flow into the heart
Penetrating trauma most frequent MOIPenetrating trauma most frequent MOI High mortality rate due to potential for High mortality rate due to potential for
rapid hemorrhagerapid hemorrhage
5757
Pericardial/Cardiac TamponadePericardial/Cardiac Tamponade AgitationAgitation TachycardiaTachycardia DiaphoreticDiaphoretic pulse strength & ratepulse strength & rate Muffled heart tonesMuffled heart tones Beck’s triad (next slide)Beck’s triad (next slide) Pulsus paradoxusPulsus paradoxus
Systolic B/P drops by 10 mmHg on inspirationSystolic B/P drops by 10 mmHg on inspiration Pulsus alternansPulsus alternans
Alteration between strong and weak pulsesAlteration between strong and weak pulses PEAPEA
5858
Beck’s TriadBeck’s Triad
Indicative of pericardial tamponade Indicative of pericardial tamponade (IF present)(IF present) This may be a LATE sign!This may be a LATE sign!
A grouping of 3 clinical signs A grouping of 3 clinical signs JVDJVDMuffled/distant heart tonesMuffled/distant heart tonesHypotensionHypotension
5959
Pericardial/Cardiac TamponadePericardial/Cardiac Tamponade
It takes as little as 150-300 ml to exert pressure It takes as little as 150-300 ml to exert pressure to impede contractile function on the heartto impede contractile function on the heart Removing as little as 20 ml may improve the Removing as little as 20 ml may improve the
contractile force to improve the patient’s conditioncontractile force to improve the patient’s condition
EMS goal: EMS goal: RAPIDRAPID IDENTIFICATIONIDENTIFICATION Then rapid transportThen rapid transport
There won’t be much intervention in the field There won’t be much intervention in the field that will save the patient’s life; they need that will save the patient’s life; they need transporttransport
6060
Aortic TearAortic Tear
Most commonly from blunt traumaMost commonly from blunt trauma MOI usually high speed MVC - especially MOI usually high speed MVC - especially
lateral impact - and falls from great heightslateral impact - and falls from great heights
High mortality rate – 85 - 95%High mortality rate – 85 - 95% GOAL:GOAL:
Rapid recognition of those patients that Rapid recognition of those patients that survive the initial impactsurvive the initial impact
Provide rapid and gentle transportation to a Provide rapid and gentle transportation to a Level I trauma center (Level I trauma center ( if within 25 minutes of if within 25 minutes of transport)transport)
6161
Aortic TearAortic Tear
Aorta fixed at 3 points in the thoracic Aorta fixed at 3 points in the thoracic cavitycavity
Shearing forces can separate the arterial Shearing forces can separate the arterial layers of this large, high-pressured vessellayers of this large, high-pressured vessel Due to high pressures, aortic lining becomes Due to high pressures, aortic lining becomes
a false spacea false space Rupture can occur without surgical repairRupture can occur without surgical repair
Death from rupture is usually quick; Death from rupture is usually quick; dissection progresses more slowlydissection progresses more slowly
6262
Aortic TearAortic Tear
Most commonly tear Most commonly tear just past the arch of just past the arch of the aortathe aorta
Less often at aortic Less often at aortic root (annulus) where root (annulus) where the aorta joins the the aorta joins the heart and the area heart and the area where aorta exits the where aorta exits the chest at the chest at the diaphragmdiaphragm
6363
Aortic TearAortic Tear
Typically patient complains of a severe Typically patient complains of a severe tearing chest paintearing chest pain
Pain may radiate to the backPain may radiate to the back Reduced pulse strength in lower extremitiesReduced pulse strength in lower extremities
Mark pulse spots if palpatedMark pulse spots if palpated
Pulse deficit between left & right upper Pulse deficit between left & right upper extremitiesextremities If suspected, palpate to compare both radial If suspected, palpate to compare both radial
pulsespulses
6464
NEW!!! Permissive Hypotension in NEW!!! Permissive Hypotension in TraumaTrauma
Restrictive fluid therapyRestrictive fluid therapy At least until hemorrhage is controlledAt least until hemorrhage is controlled Highly suggested for aortic problemsHighly suggested for aortic problems Not recommended in the patient without a pulseNot recommended in the patient without a pulse
Aggressive fluid replacement tends to increase Aggressive fluid replacement tends to increase total volume of blood losstotal volume of blood loss
Call Medical Control for guidelines if you feel Call Medical Control for guidelines if you feel your patient may benefit from restricted fluid your patient may benefit from restricted fluid resuscitationresuscitation May order trendelenberg positioningMay order trendelenberg positioning
6565
Region X SOP’s - Fluid ChallengeRegion X SOP’s - Fluid Challenge
Fluid given in 200 ml INCREMENTSFluid given in 200 ml INCREMENTS You assess as you goYou assess as you go For medical calls patient more likely will tolerate and For medical calls patient more likely will tolerate and
need the 20 ml/kg replacement formulaneed the 20 ml/kg replacement formula Every body holds a different amount of blood Every body holds a different amount of blood
volumevolume Adult average 5.2 – 6 liters (5.5 – 6.5 quarts or 10-12 Adult average 5.2 – 6 liters (5.5 – 6.5 quarts or 10-12
pints)pints) Average blood donation is 450 ml or less than 1 Average blood donation is 450 ml or less than 1
pintpint Child average 2 litersChild average 2 liters Infant average is 85 ml/kg or <300 mlInfant average is 85 ml/kg or <300 ml
6666
Blood Volume by AgeBlood Volume by Age
Do not judge the volume you see lying in Do not judge the volume you see lying in the street until you know whose blood it isthe street until you know whose blood it is
6767
How Low Can You Go?How Low Can You Go?
Classes of shockClasses of shock Class I - <15% (<750 in the adult)Class I - <15% (<750 in the adult) Class II – 15-30% (750 – 1500ml in the adult)Class II – 15-30% (750 – 1500ml in the adult) Class III – 30-40% (1500-2000ml in the adult)Class III – 30-40% (1500-2000ml in the adult) Class IV - >40% (>2000ml in the adult)Class IV - >40% (>2000ml in the adult)
Compensated shock in Class I & IICompensated shock in Class I & II Decompensated shock by Class IIIDecompensated shock by Class III
Blood pressure falling is the keyBlood pressure falling is the key Blood pressure falling is also a Blood pressure falling is also a LATELATE sign sign
6868
Complications Related to Traumatic Complications Related to Traumatic InjuriesInjuries
EMS goal – Do no further harmEMS goal – Do no further harm Sometimes, doing our best just isn’t Sometimes, doing our best just isn’t
enoughenough Secondary injuries may develop based on Secondary injuries may develop based on
what we do or don’t do at first patient what we do or don’t do at first patient contactcontact
It’s simple – do the right thing at the right It’s simple – do the right thing at the right time and document accuratelytime and document accurately
6969
Complications: Crush InjuriesComplications: Crush Injuries
Traumatic insults of severe compressive Traumatic insults of severe compressive forcesforces Crush injury – an injury compressing a body partCrush injury – an injury compressing a body part
If short duration, local injury confined to injured partIf short duration, local injury confined to injured part
Crush syndrome – systemic effects of Crush syndrome – systemic effects of entrapment for longer than 4 hoursentrapment for longer than 4 hours A potentially life-threatening eventA potentially life-threatening event Limitation of effective & healthy circulationLimitation of effective & healthy circulation
Think cave-in’s, equipment entrapmentThink cave-in’s, equipment entrapment
7070
Crush SyndromeCrush Syndrome
Pressure remains imposed for long period Pressure remains imposed for long period of time (usually >4 hours)of time (usually >4 hours)
Traumatic rhabdomyolysis developsTraumatic rhabdomyolysis develops Crushed skeletal muscle disintegratesCrushed skeletal muscle disintegrates Release of metabolic by-products restricted to Release of metabolic by-products restricted to
the compressed area for as long as area the compressed area for as long as area remains compressedremains compressed Myoglobin – a muscle proteinMyoglobin – a muscle protein Phosphate & potassium (KPhosphate & potassium (K++) – from cell death) – from cell death Lactic acid – from anaerobic metabolismLactic acid – from anaerobic metabolism
7171
Crush SyndromeCrush Syndrome
When pressure released, metabolic When pressure released, metabolic by-products enter the central circulationby-products enter the central circulation
Cause severe metabolic acidosisCause severe metabolic acidosis Toxic to heart and kidneysToxic to heart and kidneys Myoglobin plugs kidney’s filtering systemMyoglobin plugs kidney’s filtering system Sodium, chloride and water flood into Sodium, chloride and water flood into
damaged tissue creating hypovolemiadamaged tissue creating hypovolemia Hyperkalemia reduces cardiac muscle Hyperkalemia reduces cardiac muscle
response to electrical stimuli response to electrical stimuli dysrhythmias dysrhythmias Aerobic process resumed producing more uric Aerobic process resumed producing more uric
acid increasing cellular acidity and injuryacid increasing cellular acidity and injury
7272
EMS Care of Crush InjuriesEMS Care of Crush Injuries Identify the potential patient prior to Identify the potential patient prior to
extricationextrication Scene safety is your fist priorityScene safety is your fist priority Goal of EMS:Goal of EMS:
Rapid transportRapid transport Adequate fluid resuscitationAdequate fluid resuscitation Diuresis – keep kidneys flushed and workingDiuresis – keep kidneys flushed and working Possibly systemic alkalinization Possibly systemic alkalinization
Corrects acidosis, hyperkalemia, prevents renal failureCorrects acidosis, hyperkalemia, prevents renal failure Hospital may need to send a team with meds like Hospital may need to send a team with meds like
sodium bicarbonate sodium bicarbonate
7373
EMS Care cont’dEMS Care cont’d
Cardiac monitoringCardiac monitoring Influence of potassium and lactate traveling to Influence of potassium and lactate traveling to
heart may cause dysrhythmiasheart may cause dysrhythmias Tenting or peaking of T waveTenting or peaking of T wave Prolonged PR intervalProlonged PR interval ST segment depressionST segment depression Widening QRS (high levels of KWidening QRS (high levels of K++))
NoteNote:: Apply the cardiac monitor prior to Apply the cardiac monitor prior to releasing the crushed area from entrapmentreleasing the crushed area from entrapment
Be prepared for rapid onset of shock after Be prepared for rapid onset of shock after release from entrapmentrelease from entrapment
7474
Tall, Peaked T waveTall, Peaked T wave Indicates excess potassium circulating in Indicates excess potassium circulating in
the bloodstreamthe bloodstream Normal potassium levels 3.5 – 5 meq/LNormal potassium levels 3.5 – 5 meq/L
Hyperkalemia (>5.5 meq/L) is a cardiac irritantHyperkalemia (>5.5 meq/L) is a cardiac irritant
7575
Compartment SyndromeCompartment Syndrome
Complication most commonly associated with Complication most commonly associated with closed injuries to the extremitiesclosed injuries to the extremitiesThink of the patient who has fallen and is in Think of the patient who has fallen and is in
one position for a period of time before a well-one position for a period of time before a well-being check finds thembeing check finds them
Major muscle groups contained in compartmentsMajor muscle groups contained in compartments Swelling of muscles will impede blood flow to Swelling of muscles will impede blood flow to
nerves, blood vessels and other structuresnerves, blood vessels and other structures Most common site are lower extremitiesMost common site are lower extremities
7676
Compartment SyndromeCompartment Syndrome
Six P’sSix P’s Pain out of proportion – key finding!!!Pain out of proportion – key finding!!! PallorPallor ParalysisParalysis Paresthesia – pins & needles tinglingParesthesia – pins & needles tingling Pressure – feeling tension in extremityPressure – feeling tension in extremity Pulses – diminished or absentPulses – diminished or absent
Signs & symptoms not dependableSigns & symptoms not dependable
7777
Compartment SyndromeCompartment Syndrome
Difficult to assessDifficult to assess Motor and sensory usually intactMotor and sensory usually intact Distal pulses often presentDistal pulses often present Capillary refill with little to no changeCapillary refill with little to no change
More likely to develop beyond 6-8 hours More likely to develop beyond 6-8 hours post-injury or even laterpost-injury or even later
Key: patient complaining of pain out of Key: patient complaining of pain out of proportionproportion Don’t assume they are a wimpDon’t assume they are a wimp
7878
EMS Care of Compartment EMS Care of Compartment SyndromeSyndrome
Maintain high index of suspicionMaintain high index of suspicion Elevation single most important tool for EMSElevation single most important tool for EMS
Reduces edemaReduces edema Increases venous returnIncreases venous return Lowers compartment pressureLowers compartment pressure Helps prevent ischemia Helps prevent ischemia
Cold pack applied to severe contusionsCold pack applied to severe contusions Hospital care includes measuring pressuresHospital care includes measuring pressures
Normal pressure near zeroNormal pressure near zero Pressure >30mmHg restricts capillary flowPressure >30mmHg restricts capillary flow
Irreversible ischemic changes after 10 hoursIrreversible ischemic changes after 10 hours
7979
Hospital Intervention Compartment Hospital Intervention Compartment SyndromeSyndrome
Fasciotomy is surgical intervention to open Fasciotomy is surgical intervention to open fascia to allow for swelling without restrictive fascia to allow for swelling without restrictive pressurespressures
When pressures go down, patient taken back When pressures go down, patient taken back to surgery to close the wound left opento surgery to close the wound left open
8080
Transport CriteriaTransport Criteria Highest level Trauma Center within 25 minutesHighest level Trauma Center within 25 minutes
Unstable per vital signsUnstable per vital signs Anatomy of injury – life threatening injuryAnatomy of injury – life threatening injury
Closest Trauma CenterClosest Trauma Center Based on mechanism of injury with higher potential for Based on mechanism of injury with higher potential for
traumatic injury or traumatic arresttraumatic injury or traumatic arrest Patient is stablePatient is stable Patient may have co-morbidity increasing their risk level Patient may have co-morbidity increasing their risk level
with the insultwith the insult
Closest appropriate comprehensive EDClosest appropriate comprehensive ED Do not meet any of the above criteria or Ems unable to Do not meet any of the above criteria or Ems unable to
establish an airway establish an airway
8181
Case ScenariosCase Scenarios
Discuss the following casesDiscuss the following cases What is your general impression?What is your general impression? Discuss the primary assessmentDiscuss the primary assessment
Have you identified a life threatening Have you identified a life threatening condition?condition?
What is your intervention and when do you What is your intervention and when do you perform it?perform it?
Where does this patient get transported to?Where does this patient get transported to?
8282
Case Scenario #1Case Scenario #1
Respond to a call for Respond to a call for MVC – 2 vehiclesMVC – 2 vehicles
Your patient is a 16 y/o Your patient is a 16 y/o female restrained female restrained driver hit head-on driver hit head-on approximately 45 mph approximately 45 mph by a Suburbanby a Suburban
This is what you see This is what you see as you approach the as you approach the scenescene
8383
Case Scenario #1Case Scenario #1
+ seatbelt+ seatbelt Airbag deployedAirbag deployed Small staring at base of windshieldSmall staring at base of windshield Driver’s side window shattered; unable to Driver’s side window shattered; unable to
open dooropen door A & O x3; hystericalA & O x3; hysterical Active bleeding from noseActive bleeding from nose Multiple lacerations to face and extremitiesMultiple lacerations to face and extremities
8484
Case Scenario #1Case Scenario #1
Primary assessmentPrimary assessment Mental – Patient awake, A & O x3, hystericalMental – Patient awake, A & O x3, hysterical Airway – openAirway – open C-spine – manual control takenC-spine – manual control taken Breathing – rapid, without effortBreathing – rapid, without effort Circulation – bleeding from nose; pulse rapid and Circulation – bleeding from nose; pulse rapid and
regularregular
Life threats identified?Life threats identified? NoneNone So keep moving on the survey and keep looking for So keep moving on the survey and keep looking for
injuriesinjuries
8585
Case Scenario #1Case Scenario #1
If this patient had chest injuries, what clues If this patient had chest injuries, what clues would indicate:would indicate: Flail chestFlail chest
Multiple rib fractures found on palpationMultiple rib fractures found on palpation Pain with breathingPain with breathing
PneumothoraxPneumothorax Pain with breathingPain with breathing Decreased or absent breath soundsDecreased or absent breath sounds
Tension pneumothoraxTension pneumothorax Agitation, tachycardia, hypotension, absent BSAgitation, tachycardia, hypotension, absent BS
8686
Case Scenario #1 – EMS Care – Case Scenario #1 – EMS Care – What Would You Do?What Would You Do?
Flail chestFlail chest Supplemental OSupplemental O22
BVM for positive pressure ventilation if severeBVM for positive pressure ventilation if severe PneumothoraxPneumothorax
Supplemental OSupplemental O22
Watch for development tension pneumothoraxWatch for development tension pneumothorax Tension pneumothoraxTension pneumothorax
Needle decompression 2Needle decompression 2ndnd ICS ICS Place needle above the ribPlace needle above the rib
Avoid nerves and blood vesselsAvoid nerves and blood vessels
8787
Scenario #2Scenario #2
EMS has been called to the scene of a EMS has been called to the scene of a MVCMVC No witnessesNo witnesses Passer-by noticed MVC and called it inPasser-by noticed MVC and called it in
Patient has an altered level of Patient has an altered level of consciousnessconsciousness
What’s your primary assessment?What’s your primary assessment? Mental statusMental status ABC’s with c-spineABC’s with c-spine Identification of life threatsIdentification of life threats
8888
Scenario #2Scenario #2
The scene is safeThe scene is safe Your patient is in Your patient is in
the red carthe red car They are looking They are looking
around upon your around upon your arrivalarrival
They do not follow They do not follow commandcommand
They are confusedThey are confused You take charge of the c-spineYou take charge of the c-spine
8989
Scenario #2Scenario #2
Patient is wearing a seat beltPatient is wearing a seat belt Witnesses state the patient did not slow down Witnesses state the patient did not slow down
but just ran into the car in front of thembut just ran into the car in front of them
Airway – openAirway – open Breathing – rapid, regularBreathing – rapid, regular Circulation – clammy, pale, pulse regular Circulation – clammy, pale, pulse regular
and fastand fast No obvious bleedingNo obvious bleeding
9090
Scenario #2Scenario #2
No life threats are foundNo life threats are found Why would the patient be confused???Why would the patient be confused???
Head injuryHead injury Alcohol, drugsAlcohol, drugs HypoglycemiaHypoglycemia
Blood sugar checked – 35Blood sugar checked – 35
Treatment indicated?Treatment indicated? Gain IV accessGain IV access Administer D50Administer D50
9191
Scenario #2Scenario #2
IV infiltrates while pushing D50IV infiltrates while pushing D50 Now what???Now what???
Stop infusionStop infusion D/C lineD/C line Document eventDocument event Verbally give report to EDVerbally give report to ED
9292
Extravasation of IVP DextroseExtravasation of IVP Dextrose
Carefully monitor the site as you push any Carefully monitor the site as you push any medicationmedication
9393
Case Scenario #3Case Scenario #3
Female driver in small car had tree fall on Female driver in small car had tree fall on her car during a rain stormher car during a rain storm
Patient impaled with branch of treePatient impaled with branch of tree Are these chest or abdominal wounds?Are these chest or abdominal wounds?
Could be both Could be both depending on depending on inhalation or inhalation or exhalation at time of exhalation at time of injury and path of FBinjury and path of FB
9494
Case Scenario #3Case Scenario #3
How do you care for the open wound in How do you care for the open wound in the field?the field? Moist sterile saline dressing over the open Moist sterile saline dressing over the open
tissuetissue Covered with dry Covered with dry
dressingsdressings Avoid poking anything Avoid poking anything
into the woundinto the wound Observe for Observe for
eviscerationevisceration
9595
Case Scenario #3 – Pain Case Scenario #3 – Pain ManagementManagement
Fentanyl 0.5 mcg/kg IVP/IN/IOFentanyl 0.5 mcg/kg IVP/IN/IO May repeat in 5 minutes with same doseMay repeat in 5 minutes with same dose Max total 200 mcgMax total 200 mcg
Same formula for adult and pedsSame formula for adult and peds Less cardiovascular changes than Less cardiovascular changes than
morphinemorphine Less nausea from the medicationLess nausea from the medication As a synthetic narcotic, watch for As a synthetic narcotic, watch for
respiratory depressionrespiratory depression
9696
Case Scenario #3Case Scenario #3
Tree branch removed from patientTree branch removed from patient
9797
Case Scenario Case Scenario #4#4
Patient fell onto Patient fell onto bicyclebicycle
Patient agitated, Patient agitated, complains of inability to breathcomplains of inability to breath
Patient is dyspneic, tachycardiac, Patient is dyspneic, tachycardiac, becoming cyanotic, with JVD increasingbecoming cyanotic, with JVD increasing
Blood pressure falling (radial pulse harder Blood pressure falling (radial pulse harder to palpate)to palpate)
What’s your impression?What’s your impression? Tension pneumothorax Tension pneumothorax
9898
Case Scenario #4Case Scenario #4
What intervention is necessary?What intervention is necessary? Immediate needle decompressionImmediate needle decompression
What are the landmarks?What are the landmarks? 22ndnd ICS ICS Midclavicular lineMidclavicular line
Stay more lateral than you thinkStay more lateral than you think
9999
Needle DecompressionNeedle Decompression
22ndnd ICS, midclavicular ICS, midclavicular line – “X” marks the line – “X” marks the spotspot
When needle When needle inserted, listen for inserted, listen for hiss of released airhiss of released air
Should have Should have immediate immediate improvement in improvement in patientpatient
X
100100
Steps for Needle Steps for Needle DecompressionDecompression
Find the Angle of LouisFind the Angle of Louis Slide your fingers toward the Slide your fingers toward the
armpit creasearmpit crease Stop at the midpoint of the Stop at the midpoint of the
clavicleclavicle This is in-line (vertical) with the male nippleThis is in-line (vertical) with the male nipple The male nipple horizontally lies in the 4The male nipple horizontally lies in the 4 thth ICS ICS
Insert needle above the rib, advance and Insert needle above the rib, advance and begin to separate needle from catheterbegin to separate needle from catheter
Secure in placeSecure in place
101101
Needle DecompressionNeedle Decompression
Needle inserted above the rib Needle inserted above the rib Avoids puncturing the vessels or nervesAvoids puncturing the vessels or nerves
102102
BibliographyBibliography
Region X Advanced Life Support Standard Operating Region X Advanced Life Support Standard Operating Procedures February 1, 2012Procedures February 1, 2012
Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices Fourth Edition. Brady. 2013.Principles & Practices Fourth Edition. Brady. 2013.
Campbell, J. International Trauma Life Support for Campbell, J. International Trauma Life Support for Emergency Care Providers. 7Emergency Care Providers. 7thth edition. Pearson. 2012. edition. Pearson. 2012.
Caroline, N., Emergency Care in the Streets. 7Caroline, N., Emergency Care in the Streets. 7thth Edition. Edition. AAOS. 2013.AAOS. 2013.
Limmer, D., O’Keefe, M. Emergency Care 12Limmer, D., O’Keefe, M. Emergency Care 12thth Edition. Edition. Brady. 2012.Brady. 2012.
http://en.wikipedia.org/wiki/Beck's_triad_(cardiology)http://en.wikipedia.org/wiki/Beck's_triad_(cardiology) http://docpods.com/compartment-syndrome-in-the-lower-http://docpods.com/compartment-syndrome-in-the-lower-
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