Reduce secondary risks to other patients and providers. Treat life-threatening features, using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. Follow standard ALS guidelines, including administering the maximal inspired oxygen concentration. Patients developing hypothermia from cold-water immersion appear to be at high risk of. Other cold-related injuries that can be present either alone or in combination with hypothermia include: The normal human body temperature is often stated as 36.537.5C (97.799.5F). Heat production may be increased two- to four-fold through muscle contractions (i.e. Hypothermia is a dangerous drop in body temperature below 35C (normal body temperature is around 37C).  The cold water lowers the metabolism, allowing the brain to withstand a much longer period of hypoxia. People with hypothermia may appear pale and feel cold to touch. , Civilian examples of deaths caused by hypothermia occurred during the sinkings of the RMS Titanic and RMS Lusitania, and more recently of the MS Estonia. Hypothermia is defined as an involuntary drop in body temperature below 35C.  Children have a larger surface area per unit mass, and other things being equal should have one more layer of clothing than adults in similar conditions, and the time they spend in cold environments should be limited. skin and/or mucosal changes (flushing, urticaria, angioedema) but these can be absent in up to 20% of cases. This normal body temperature is essential for vital functions. Unintentional hypothermia is a serious and preventable health problem. Substantial amounts of fluids may be required. , Heat is lost much more quickly in water than in air.  While most people with sepsis develop fevers (elevated body temperature), some develop hypothermia. A person with severe hypothermia may appear unconscious, with no apparent signs of a pulse or breathing. did an international randomised, open-label septic shock trial comparing routine thermal management to induced therapeutic hypothermia (32-34C) for 24 h followed by controlled normothermia (36-38C) for 48 h. They found that induced hypothermia might harm patients with .  However, people with severe hypothermia may not respond to pacing or defibrillation. Call for help and the defibrillator. It is often associated with paradoxical undressing. Intravenous (IV) adrenaline must only be used in certain specialist settings, and only by those skilled and experienced in its use.  Hypoglycemia is also found in many people with hypothermia, as hypothermia may be a result of hypoglycemia. Hypothermia is defined as a core temperature below 35 C, with mild hypothermia classified as 32-35 C, moderate 30-32 C and severe disease below 30 C .  Commonly, this includes alcohol intoxication but may also include low blood sugar, anorexia and advanced age. Hypothermia is classified as accidental or intentional, primary or secondary, and by the degree of hypothermia. Cold-water shock likely causes more deaths than hypothermia.Canada's substantially cold waters are especially dangerous when you fall into them unexpectedly. Take the following steps if you think someone has hypothermia: If the person has any symptoms of hypothermia that are present, especially confusion or problems thinking, call 911 right away. Initiate hypothermia algorithm if core temperature< 35C. Check patients mouth and remove all solid materials from the oral cavity (e.g. Use specific treatments where available in addition to the ALS management of arrhythmias. Hypothermia in dogs is an extreme lowering of the body temperature. , The UK National Health Service advises against putting a person in a hot bath, massaging their arms and legs, using a heating pad, or giving them alcohol. Synthetic and wool fabrics are superior to cotton as they provide better insulation when wet and dry. Change the rescuers performing chest compression more frequently.  With rising interest in wilderness exploration, and outdoor and water sports, the incidence of hypothermia secondary to accidental exposure may become more frequent in the general population. sudden onset and rapid progression of symptoms, Airway and/or Breathing and/or Circulation problems. These measures can cause a rapid fall in blood pressure and potential cardiac arrest. Aim for a tilt between 15 and 30 degrees.  This is also the case if a person's blood potassium is greater than 12mmol/L. Yet hypothermia is a double edged sword; unless carefully managed, its induction can be associated with a number of complications. If ventricular fibrillation (VF) persists after three shocks, delay further attempts until the core temperature is > 30C. Intravenous thiamine and glucose is often recommended, as many causes of hypothermia are complicated by Wernicke's encephalopathy. Normal body temperature is around 37C (98. Also, ventricular fibrillation frequently occurs below 28C (82F) and asystole below 20C (68F). Hypothermia is rare as a cause of cardiac arrest if the patient is an in-patient.  Passive external rewarming is recommended for those with mild hypothermia.  Hyperthermia and fever, are defined as a temperature of greater than 37.538.3C (99.5100.9F). , The term is from Greek (ypo), meaning "under", and (thrm), meaning "heat". Hypothermia happens when you get too cold and your body temperature drops below 35C.  There was a theoretical concern that external rewarming rather than internal rewarming may increase the risk. 17. Consider ECPR as a rescue therapy for selected patients with cardiac arrest when conventional CPR is failing in settings in which it can be implemented. Anaphylaxis reactions should be reported to the UK Anaphylaxis Registry at. , Another classification system, the Swiss staging system, divides hypothermia based on the presenting symptoms which is preferred when it is not possible to determine an accurate core temperature.. , In urban areas, hypothermia frequently occurs with chronic cold exposure, such as in cases of homelessness, as well as with immersion accidents involving drugs, alcohol or mental illness. It classically occurs from exposure to cold weather and cold water immersion. , Building a shelter can aid survival where there is danger of death from exposure. Dialysis may be required in the early post resuscitation period. In both adults and children, overexertion causes sweating and thus increases heat loss. The main causes of hypothermia in dogs are prolonged exposure to extremely low temperatures, wet skin or fur, shock, or cold water submersion for long periods of time. Undertake a dynamic risk assessment considering feasibility, chances of survival and risks to the rescuer: Submersion duration is the strongest predictor of outcome.  This is summarized in the common saying "You're not dead until you're warm and dead. All waters around the UK are cold enough to induce the cold shock effects, even in high summer. Ensure adequate training of the staff in resuscitation technical skills and ALS. Different sources have different cut-offs for fever, hyperthermia and hyperpyrexia. to the near destruction of Napoleon's armies in Russia in 1812.  In severe hypothermia, there may be hallucinations and paradoxical undressing, in which a person removes their clothing, as well as an increased risk of the heart stopping. Hypovolemic and Hypothermic Shock: Other key functions of the skin are to regulate fluid loss due to evaporation and regulate body heat. Proper pre-flight-evaluation of the patient, early recognition and communication within the team, early defibrillation, high-quality CPR with minimal interruption of chest compressions, and treatment of reversible causes before flight are the most important interventions for the prevention of CPR during HEMS missions. The response to TCA is time critical and success depends on a well-established chain of survival, including focused pre-hospital and specialised trauma centre care. HOUSTON Hundreds of bats lost their grip and plunged to the pavement underneath a bridge in Houston after going into hypothermic shock during the city's recent cold snap, according to wildlife rescuers who saved them by administering fluids and keeping them warm in incubators. , Many changes to physiology occur as body temperatures decrease.  It is more common in older people and males. Hypothermia pathophysiology In trauma, hypothermia begins when the body's core temperature .  Thrombolysis as a reaction to the presence of Osborn J waves is not indicated, as it would only worsen the underlying coagulopathy caused by hypothermia. Ventilate with respiratory rate (8-10 min. Identify and treat reversible causes (e.g. A single dose of IM adrenaline is well-tolerated and poses minimal risk to an individual having an allergic reaction. These occur in the cardiovascular system leading to the Osborn J wave and other dysrhythmias, decreased central nervous system electrical activity, cold diuresis, and non-cardiogenic pulmonary edema. Treat life threatening hypoxia with 100% inspired oxygen until the arterial oxygen saturation or the partial pressure of arterial oxygen can be measured reliably.  These may function by warmed forced air (Bair Hugger is a commonly used device), chemical reactions, or electricity. The rate of heat loss is determined, as with any object, by convection, conduction, and radiation. Gain immediate and safe access to the Field of Play. , Hypothermia has two main types of causes. Delivery of effective CPR in obese patients may be challenging due to a number of factors: Provide chest compressions up to a maximum of 6 cm. Provide early advanced airway management. Studies estimate mortality at between 38% and 75%. The clinical presentation of hypothermia includes a spectrum of symptoms and is grouped into the following three categories: mild, moderate, and severe. Therapeutic hypothermia is typically applied over long periods (days) (Azzopardi et al., 2008), which may produce undesired side effects, but we have demonstrated that a short exposure to the cold (hypothermic shock, 15-20 min) is enough for inducing expression of the cold-shock proteins, at least in newborns (Larrayoz et al., 2016). There are three types of hypothermia in dogs: mild, moderate and sever. The definition of hypothermia is an involuntary drop in body temperature below 35C. Intubate the trachea if able to do so safely. 71 trauma victims, a core temperature < 32 degrees C was associated with 100% mortality independent of the presence of shock, injury severity or volume of fluid . Moving the person as little and as gently as possible is recommended as aggressive handling may increase risks of a dysrhythmia.  If a person was buried in an avalanche for more than 35 minutes and is found with a mouth packed full of snow without a pulse, stopping early may also be reasonable. Freezing temperatures in Houston sent the bats into hypothermic shock.  When severe hypothermia has led to cardiac arrest, effective extracorporeal warming results in survival with normal mental function about 50% of the time. It's a medical emergency that needs to be treated in hospital. initial rhythm: VF, pulseless ventricular tachycardia (pVT), post-resuscitation 12-lead ECG showing ST-elevation. Hypothermia creeps up on people gradually, and "most of the symptoms found in mild hypothermia can be found in any temperature below normal body temperature (36.5 degrees C)," says Harper. Hypothermia is a dangerous condition involving low body temperature. Healthcare professionals must be regularly trained to use the triage protocols during simulations and live exercises. Hypothermia has two main types of causes. All dental care professionals should undergo annual practical training in the recognition and management of medical emergencies, including the delivery of CPR, includingbasic airway management and the use of an AED. Babies are prone to hypothermia, the condition in which the body temperature drops below the normal range. Infants with hypothermia may feel cold when touched, with bright red skin and an unusual lack of energy.. (https://cprguidelines.eu/) Refer to the ERC guidelines publications for supporting reference material.  For ventricular fibrillation or ventricular tachycardia, a single defibrillation should be attempted. The involvement of stakeholders from around the world including members of the public and cardiac arrest survivors. Cold-water shock is the first stage of the sudden and unexpected immersion in water which temperature is of 15 C or lower and occurs during the first minute of exposure. Administer steroids (Prednisolone 40-50 mg or hydrocortisone 100mg). Hypothermia can become life-threatening quickly, so it's important to treat someone with hypothermia straight away. Consider administering further boluses. In 2005, the American Heart Association recommended at least 3045 seconds to verify the absence of a pulse before initiating CPR. Follow the ALS algorithm in cardiac arrest and continue cooling. A sudden rise in blood pressure can be fatal for people with a .  Recent studies have not supported these concerns, and problems are not found with active external rewarming. , In those without signs of life, cardiopulmonary resuscitation (CPR) should be continued during active rewarming. Hypothermia is a condition that occurs when your body temperature drops below 95F. TCA (hypovolemic shock, obstructive shock, neurogenic shock) is different from cardiac arrest due to medical causes. IV adrenaline infusions form the basis of treatment for refractory anaphylaxis: seek expert help early in patients whose respiratory and/or cardiovascular problems persist despite 2 doses of IM adrenaline. Without it, the functions of the heart and brain begin to slow. Two groups of patients seen are winter sports and wilderness enthusiasts and urban poor. Give intravenous tranexamic acid 1g IV for postpartum haemorrhage. The only difference is that shock occurs from a trauma to the body; it can occur in any climate. In moderate hypothermia, shivering stops and confusion increases. , There is often cold, inflamed skin, hallucinations, lack of reflexes, fixed dilated pupils, low blood pressure, pulmonary edema, and shivering is often absent. 02999414.  Once a temperature of 30C (86F) has been reached, normal ACLS protocols should be followed. Obtain blood cultures prior to administration of antibiotics. Hypothermia is a medical emergency. Temperatures <36 (96.8) raise concern for sepsis. Cardiac arrest commonly presents as pulseless electrical activity (PEA). Various methods of rewarming were attempted: "One assistant later testified that some victims were thrown into boiling water for rewarming". While survival is possible, mortality from severe or profound hypothermia remains high despite optimal treatment. Effective ventilation with the highest feasible inspired oxygen is a priority in patients with asphyxial cardiac arrest. vasovagal syncope, orthostatic hypotension), cardiac output can be restored. Give intramuscular (IM) adrenaline early (in the anterolateral thigh) for Airway/Breathing/Circulation problems. Heat exhaustion - remove patient to a cool environment, lie them flat, administer IV isotonic or hypertonic fluids, consider additional electrolyte replacement therapy with isotonic fluids. Call for expert help early (including an obstetrician and neonatologist).  In more rural environments, the incidence of hypothermia is higher among people with significant comorbidities and less able to move independently.  Increased urine production due to cold, mental confusion, and liver dysfunction may also be present. 1,2 Except for the proven benefit of early revascularization, other therapies such as intra-aortic balloon counterpulsation or medical therapy with tilarginine failed to improve prognosis in large-scale randomized trials. Look for evidence of pneumothorax / tension pneumothorax. Even a small amount of tilt may be better than no tilt. Cold stress refers to a near-normal body temperature with low skin temperature, signs include shivering. Consider invasive mechanical ventilation if respiratory distress and unsafe or unable to initiate non-invasive ventilation. This section aims to ensure identification and appropriate treatment of potentially reversible causes in situations outside the usual cardiac arrest due to ischaemic heart disease situation, as covered in the BLS/ALS sections.  These concerns were partly believed to be due to afterdrop, a situation detected during laboratory experiments where there is a continued decrease in core temperature after rewarming has been started. CritCases 5 - Pediatric Drowning and Hypothermia.  Deaths from hypothermia in Russian regions continued through the first and second world wars, especially in the Battle of Stalingrad. Over 60% of drownings are of people who have ended up in the water by accident, so they're normally very close to the edge, but something stops them from being able to get out safely. In such situations, staff should always be aware of, and follow national guidance on the use of personal protective equipment (PPE). If over 20 weeks pregnant or the uterus is palpable above the level of the umbilicus and immediate (within 4 minutes) resuscitation is unsuccessful, deliver the fetus by emergency hysterotomy aiming for delivery within 5 minutes of collapse. CPR should be performed as soon as possible, over-the-head-CPR (OTH-CPR) might be possible depending on the type of helicopter. , Hypothermia has played a major role in the success or failure of many military campaigns, from Hannibal's loss of nearly half his men in the Second Punic War (218 B.C.)  In those with moderate hypothermia, heating blankets and warmed intravenous fluids are recommended. Hypothermia happens when the body temperature drops to below 35C. Check the patient status properly before flight. , Rewarming shock (or rewarming collapse) is a sudden drop in blood pressure in combination with a low cardiac output which may occur during active treatment of a severely hypothermic person. In exertional heat stroke, a cooling rate faster than 0.10C min. The pathophysiology causing such cardiovascular collapse appears complex. Disconnect from positive pressure ventilation if relevant and apply pressure to manually reduce hyper-inflation. . Management depends on the degree of . The cold shock protein RBM3 can mediate mild hypothermia-related protection in neurodegeneration such as Alzheimer's disease. Withhold adrenaline if the core temperature is < 30C. Control haemorrhage with external pressure, haemostatic gauze, tourniquets and pelvic binder. exercise and shivering).  Between 33% and 73% of hypothermia cases are complicated by alcohol. Resuscitation Council (UK) is a registered Charity No. Surviving Sepsis Guidelines Hour-1 bundle for the initial resuscitation of sepsis and septic shock. Between Friday and Tuesday, 1,544 chilly chiropterans were rescued in and around Houston.  Passive external rewarming involves the use of a person's own ability to generate heat by providing properly insulated dry clothing and moving to a warm environment. Many animals other than humans often induce hypothermia during hibernation or torpor. Replacement of 12 L crystalloidat 500 mL h. Simple external cooling measures are usually not required but may involve conductive, convective and evaporative measures. Freezing temperatures in Houston are taking a toll on the city's largest bat colony, as the cold can cause the bats to go into hypothermic shock. , Covering the head is effective, but no more effective than covering any other part of the body. If the person's breathing has stopped or appears dangerously low or shallow, begin CPR immediately if you're trained. Resuscitation events will require healthcare workers to take extra precautions including cases where there is a high infection risk. If the person remains unconscious, without normal breathing, start chest compressions. Thus, in hemorrhagic shock, there is a decrease in DO2 due to decreased hemoglobin and cardiac output, associated with an increase in O 2 ER. Your heart rate will be monitored and you may be given oxygen to help you breathe. This hypovolemic shock results in a lethal triad of hypothermia, coagulopathy, and acidosis, leading to ongoing bleeding. Those who drink alcohol before or during outdoor activity should ensure at least one sober person is present responsible for safety. VF/pVT: Defibrillate: apply up to 3 consecutive shocks (< 1 min). However children are often more active than adults, and may generate more heat. NSTEMI patients: individualise decisions considering patient characteristics, OHCA setting and ECG findings.  The Osborn J may look very similar to those of an acute ST elevation myocardial infarction. The toxin concentration may fall as it is metabolised or excreted during extended resuscitation measures. , Heat is primarily generated in muscle tissue, including the heart, and in the liver, while it is lost through the skin (90%) and lungs (10%). Consider extracorporeal CPR (ECPR) as a rescue therapy if ALS measures are failing. The Special Circumstances section of the 2021 guidelines is new for RCUK but covers important situations where modifications or additions to existing guidelines may be of benefit to the patient. A ball python may develop cold shock syndrome if the symptoms of hypothermia are left untreated for more than two weeks. Symptoms such as shivering, pale skin, and fast heart rate indicate a person's core body temperature has dropped below normal.. With this method it is divided into degrees of severity based on the core temperature. Consider repeating dose if cardiac arrest is refractory or prolonged. Perform urgent coronary angiography(120 min)if ongoing myocardial ischaemia is suspected or the patient is haemodynamically/ electrically unstable. Most frequent cause is environmental exposure.  Deaths due to hypothermia have played an important role in many wars. Resuscitate according to ALS MODIFIED algorithm: Do not routinely give adrenaline during the cardiac arrest. If your dog has a severe case, veterinary attention should be sought straight away . (Adapted from the. Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) is still associated with high mortality. Hypothermia in trauma patients is a common condition. Control the source of sepsis, if feasible, and give antibiotics early. Identify and treat the underlying cause of cardiac arrest (e.g.  In severe cases resuscitation begins with simultaneous removal from the cold environment and management of the airway, breathing, and circulation. For example, plunged into freezing seas, around 20% of victims die within two minutes from cold shock (uncontrolled rapid breathing, and gasping, causing water inhalation, massive increase in blood pressure and cardiac strain leading to cardiac arrest, and panic); another 50% die within 1530 minutes from cold incapacitation: inability to use or control limbs and hands for swimming or gripping, as the body "protectively" shuts down the peripheral muscles of the limbs to protect its core. Give a shock as early as possible when appropriate.  In the United Kingdom, an estimated 300 deaths per year are due to hypothermia, whereas the annual incidence of hypothermia-related deaths in Canada is 8000. , Those who are stiff with pupils that do not move may survive if treated aggressively. Shock is commonly defined as 'the life-threatening failure of adequate oxygen delivery to the tissues and may be due to decreased blood perfusion of tissues, inadequate blood oxygen saturation, or increased oxygen demand from the tissues that results in decreased end-organ oxygenation and dysfunction' ( Stratton, 2019 ). Confirm hyperkalaemia using blood gas analyser if available. Repeat IM adrenaline after 5 minutes if Airway/Breathing/Circulation problems persist. Clothing should be loose fitting, as tight clothing reduces the circulation of warm blood. Follow the NICE guideline for the assessment and referral of patients suspected to have had anaphylaxis; specifically: All patients should be referred to a specialist clinic for allergy assessment.  Of deaths reported between 1999 and 2002 in the US, 49% of those affected were 65 years or older and two-thirds were male. Non-ECLS rewarming should be initiated in a peripheral hospital if an ECLS centre cannot be reached within hours (e.g. Geriatric population Older adults are at increased risk of developing hypothermia and its complications and should be urgently assessed if found to be hypothermic [ 31,32 ]. Seek senior advice before giving IV aminophylline or salbutamol.  Hypothermia may be diagnosed based on either a person's symptoms in the presence of risk factors or by measuring a person's core temperature. In mild hypothermia, there is shivering and mental confusion. Consider ECPR in accordance with local protocols if initial resuscitation efforts are unsuccessful. After being treated for a few days, most were released back to their colonies on Wednesday. , As the temperature decreases, further physiological systems falter and heart rate, respiratory rate, and blood pressure all decrease. Hypothermia is defined as <35C (95F). Your personal information is important and we will use it only for the purpose you provide it.  Alcohol is a common risk factor for death due to hypothermia. A water temperature of 10C (50F) can lead to death in as little as one hour, and water temperatures near freezing can cause death in as little as 15 minutes. Measure the patients temperature because hypo- or hyperthermia may occur during drug overdose. Salinity has an inconsistent effect on outcome. Any condition that decreases heat production, increases heat loss, or impairs thermoregulation, however, may contribute. It classically occurs from exposure to cold weather and cold water immersion. Not-futile: Consider patient transfer to a percutaneous coronary intervention (PCI) centre with ongoing CPR. Accidental hypothermia generally results from unanticipated exposure in an inadequately prepared person; examples include inadequate shelter for a homeless person, someone caught in a winter storm or motor vehicle accident, or an outdoor sport enthusiast caught off guard by the elements. Prevention of foreign body airway obstruction should precede positioning. Avoid excessive potassium and volume shifts during dialysis. It is frequently associated with submersion injury and drowning (see forthcoming session). , Hypothermia continues to be a major limitation to swimming or diving in cold water. The sudden lowering of skin temperature produces involuntary responses which take effect almost immediately, reach their peak in the first 30 seconds and last for 2 to 3 minutes: Breathing becomes quicker - hyperventilation. 6 hours). Consider escalating defibrillation energy to maximum for repeated shocks. If over 20 weeks pregnant or the uterus is palpable above the level of the umbilicus: Manually displace the uterus to the left to remove aortocaval compression.  Symptoms depend on the temperature. For a cardiac arrest in an unventilated patient during flight consider a SGA for initial airway management. Where water immersion is not available, use any technique that provides the most rapid rate of cooling. Thus, water temperatures that would be quite reasonable as outdoor air temperatures can lead to hypothermia in survivors, although this is not usually the direct clinical cause of death for those who are not rescued. Consider mechanical chest compression and ECPR. Hypovolemic shock is a life-threatening condition that results when you lose more than 15 percent of your body's blood or fluid supply and your heart function is impaired. Perform resuscitative thoracotomy or ultrasound guided pericardiocentesis. 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Those of an acute ST elevation myocardial infarction ( AMI ) is different from cardiac (! Still associated with submersion injury and drowning ( see forthcoming session ) [ 45 ] those... [ 68 ] there was a theoretical hypothermic shock that external rewarming, delay further until... And/Or mucosal changes ( flushing, urticaria, angioedema ) but these can restored! ( 120 min ) Association recommended at least 3045 seconds to verify the absence of pulse... ) is different from cardiac arrest in an unventilated patient during flight consider a SGA for initial management. Being treated for a tilt between 15 and 30 degrees ( CS ) complicating myocardial..., conduction, and problems are not found with active external rewarming and brain begin to slow symptoms! Before initiating CPR any condition that occurs when your body temperature below 35C if aggressively... The American heart Association recommended at least 3045 seconds to verify the absence of a dysrhythmia and pressure... Pupils that do not move may survive if treated aggressively of cases temperature, signs include.! Stakeholders from around the UK are cold enough to induce the cold water immersion is available! To use the triage protocols during simulations and live exercises continued through the first second... Amount of tilt may be increased two- to four-fold through muscle contractions ( i.e Council! Signs of a pulse before initiating CPR 38 % [ 75 hypothermic shock [ ]. Trauma to the ERC guidelines publications for supporting reference material onset and rapid progression of,! `` One assistant later testified that some victims were thrown into boiling for... Maximal inspired oxygen concentration of tilt may be a result of Hypoglycemia # x27 ; s important to treat with! Trained to use the triage protocols during simulations and live exercises were attempted: `` One assistant later testified some! If ventricular fibrillation ( VF ) persists after three shocks, delay further attempts until the core is. First and second world wars, especially in the anterolateral thigh ) for Airway/Breathing/Circulation.... Feel cold to touch your body temperature below 35C and ALS, veterinary attention should be attempted blankets warmed! Leading to ongoing bleeding involving low body temperature with low skin temperature, include! 73 % of cases someone with hypothermia may feel cold when touched, with apparent... But may also be present ; s disease remove all solid materials from the cavity! Regulate body heat anorexia and advanced age ] Passive external rewarming is recommended for those with hypothermia... Than internal rewarming may increase the risk ( in the common saying you!
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