1. Penetrating Trauma ECRN Mod II 2010 CE Condell Medical Center EMS System IDPH Site code #107200E-1210
Prepared by: Lt. William Hoover, Medical Officer
Wauconda Fire District
Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives Identify epidemiologic facts for firearm related injuries
Upon successful completion of this module, the ECRN will be able:
Identify epidemiologic facts for firearm related injuries
Identify relationship between kinetic energy and prediction of injury
Identify how energy is transmitted from a penetrating object to body tissue
Identify characteristics of handguns, shotguns and rifles
Identify organ injuries associated with gunshot injuries

3. Objectives cont’d
Identify management goals for a patient with gunshot wounds
Identify items that could cause stab/penetration trauma
Identify potential internal organ injuries dependant on item causing stab/penetration injury
Identify management goals for a stab/penetrating trauma patient
Identify adult fluid challenge issues

4. Objectives cont’d Identify adult fluid challenge dosages
Identify pediatric fluid challenge issues
Identify pediatric fluid challenge dosages
Identify indications for implementation of intraosseous infusion
Calculate pediatric fluid challenge dosages

5. Gunshots…

6. Gunshot Victims

7. Firearm Related Injuries
Gunshot wounds are either penetrating or perforating wounds
Technical terms:
Penetrating gunshots are when the bullet enters, but does not come out of the body.
Perforating gunshots are when the bullet enters and exits the body

8. Perforating Gunshots

9. Penetrating gunshot

10. Entrance wound
Surrounded by a reddish-brown area of abraded skin, known as the abrasion ring
Small amounts of blood

11. Mechanism of Energy Exchange
As bullet passes through tissue, it decelerates, dissipating and transferring kinetic energy to tissues
Cause of the injury is the kinetic energy
Velocity more important than mass in determining how much damage is done
Small bullet at high speed will do more damage than large bullet at slow speed

12. Mechanism of Energy Exchange
High velocity
High powered rifles; hunting rifles
Sniper rifles
Medium velocity
Handguns, shotguns
Compound bows and arrows (higher energy released)
Low velocity
Knives, arrows
Falling through plate glass window, stepping on things, bits flung by lawnmower
Compound bows and arrows are more sophisticated than regular bows and arrows and produce higher energy which makes them a medium velocity weapon.

13. Medium & High Velocity
These items are usually propelled by gunpowder or other explosive
Faster the object, the deeper the injury
Causes damage to the tissue it impacts
Creates a “pressure wave” which causes damage frequently greater than the tissue directly impacted
If bone is struck, bone shatters and multiple bone fragments are dispersed
The focus of EMS is not so much to worry about “what kind of bullet was used” but to focus on the injury at hand to take care of. If the bullet type is known, it is just another piece of information passed onto the hospital staff. EMS should focus on “taking care of the hole”.

14. Low velocity
Usually a result of items such as knives that are propelled by a person’s own power
Also includes objects inadvertently stepped on
Includes many objects a patient may be impaled on
Damage usually limited to the area directly in contact with the object

15. Types of Firearms Pistols Shotguns Rifles Revolver Semi-Automatic Pump
Bolt
Lever action

16. Pistols – Medium Velocity

17. Shotguns – Medium Velocity

18. Rifles – High Velocity

19. Projectiles – High Velocity
Rifle bullets are designed to have much greater velocity than shotgun bullets
Different size of casing provides more or less gunpowder

20. 7 mm rifle shell – High Velocity
Bonded design for deep penetration and 90%+ weight retention
Streamlined design delivers ultra-flat trajectories
Devastating terminal performance across a wide velocity range
Unequaled accuracy and terminal performance for long-range shots

21. Projectiles – Medium Velocity
Shotgun ammunition can be a variety of kinds
Slugs are one large bullet in the shell
Some shells contain numerous pellets of various sizes
This can influence patient’s injuries

22. Shotgun Shell – Medium Velocity
12 Gauge Shotgun Slug
12 Gauge Shotgun with #6 shot

23. .38 caliber pistol ammunition
Controlled expansion to 1.5x its original diameter over a wide range of velocities
Heavier jacket stands up to the high pressures and velocities of the highest performance handgun cartridges

24. Compound Bows and Arrows – Medium Velocity

25. Arrowhead Types – Medium Velocity
Target tips
Broadhead

26. Arrow injuries

27. Another ouch…. How would you initially stabilize these wounds?
Goals of treatment - to prevent movement of the impaled object and to prevent further contamination. Will most likely need to splint the wrist in some fashion as well as stabilize the object.

28. Principles of Wound Care
What are principles of wound care for the two previous wounds?
Scene safety – even in the ED
Control bleeding
Usually little to no bleeding while object still impaled
Prevent further damage
Immobilize the object in place
Gauze, tape, whatever it takes
Reduce infection
Prevent further contamination

29. Different Types of Knives
Knives come in a wide variety of shapes and sizes
The type of knife can influence the injuries a patient may have
Hilt/handle of knife does not necessarily tell how long the knife is

30. Anticipation of Injury
Trajectory may or may not be straight
Knowing anatomy helps anticipate organ injury
Anticipating organ injury helps in knowing what signs and symptoms to watch for
Anticipation of injury = proactive care
Head wound = monitoring level of consciousness
Chest wound = assessing lung sounds
Abdominal wound = assessing internal blood loss

31. Stabbings 15 year old stabbed in the head at a London bus stop
Cannot determine from the outer wound what the damage is internally
Assume the worse
Stabilization of impaled objects extremely crucial

32. Police Officer Stabbing What injuries do you suspect?
Evaluate for chest and abdominal injuries. Not knowing depth or trajectory of stabbing implement, can have organ injury that is angled away from external injury pattern.

33. Organ Injury
Lap sponge under fold of skin
Patient was shot with a MAC-10 machine gun and sustained a liver injury
Liver surface with injury noted to organ

34. Scene Safety Not exclusive to schools Fort Hood, TX Shooting (2009)
Colorado Church Shootings (2007)
Queens, NY Wendy’s Shooting (2000)
Atlanta Day Trader Shooting (1999)
San Ysidro McDonald’s Shooting (1984)

35. Field Management Goals
Critical patients need rapid transport per SOP
Difficult to assess internal damage in the field
Stop any visible bleeding that could cause hemorrhage  hypovolemia
Address airway issues
Tension Pneumothorax chest decompression
Suction to keep airway open
Intubate to secure the airway
Surgery is the answer to critical gunshots

36. Field Management Goals
Focus on the basics
If there is a hole – plug it
If there is bleeding – stop it
If they can’t breathe – ventilate

37. Region X Field Triage Criteria For Assessing Trauma Patients

38. Field Management Goals
Short on scene time! Under 10 minutes!
Immediate life threatening issues addressed
Good BLS skills
ALS treatment while enroute to the hospital
Report called as early as possible
Transport to Level 1 Hospital, if under 25 minutes
Transport to closest hospital if Level I >25 minutes away
Helicopter considered in unique situations
Helicopter is a consideration if there is any delay in ground transport being initiated (ie: lengthy extrication). If there is rapid access to the patient there should be minimal scene time and a decision to “load and go” and initiate rapid transport.

39. Patient Transport Decision From the Field
Critical and Category I trauma patients
Transported to highest level Trauma Center within 25 minutes
Aeromedical transport remains an option especially in lengthy extrication and distance from the hospital

40. Field Categorization of the Critical Patient
Systolic B/P < 90 x2
Pediatric patient B/P < 80 x2
Blood pressure values taken at least twice and 5 minutes apart
These patients transported to highest level Trauma Center within 25 minutes

41. Field Categorization of the Category I Trauma Patient
Unstable vital signs
GCS < 10 or deteriorating mental status
Best eye opening – 4 points max
Best verbal response – 5 points max
Best motor response – 6 points max
Respiratory rate <10 or >29
Revised trauma score < 11
Range 0-12
3 components added together
Converted GCS (3-15 score converted to 0-4 points)
0 - 4 points for respiratory rate
0 - 4 points for systolic blood pressure

42. Field Categorization of the Category I Trauma Patient
Anatomy of injury
Penetrating injuries to head, neck, torso, or groin
Combination trauma with burns > 20%
2 or more proximal long bone fractures
Unstable pelvis
Flail chest
Limb paralysis &/or sensory deficits above wrist or ankle
Open and depressed skull fractures
Amputation proximal to wrist or ankle
Language for skull fractures changing to open OR depressed skull fractures.

43. Patient Transport Decision From the Field
Category II trauma patients
Transported to closest Trauma Center
These are stable patients with significant mechanism of injury
You know they are stable because of frequent reassessment
There is the potential for these patients to become unstable
Recognize that pediatric patients often pull you into false sense of security (but so can adults)
Peds patients maintain homeostasis as long as possible and when compensation fails, they deteriorate fast

44. Field Categorization of the Category II Trauma Patient
Mechanism of injury
Ejection from automobile
Death in same passenger compartment
Motorcycle crash >20 mph or with separation of rider from bike
Rollover – unrestrained
Falls > 20 feet
Peds falls > 3x body length
Research has shown that the restrained patient in a rollover is rarely injured. If they are injured critically, their physiological parameters (ie: LOC, vital signs) would push them into the higher Category I level.

45. Category II Trauma Patient cont’d
Mechanism of injury cont’d
Pedestrian thrown or run over
Auto vs pedestrian / bicyclist with > 5 mph impact
Extrication > 20 minutes
High speed MVC
Speed > 40 mph
Intrusion > 12 inches
Major deformity > 20 inches

46. Category II Trauma Patient
Co-morbid factors
Age < 5 without car/booster seat
Bleeding disorders or on anticoagulants
Pregnancy > 24 weeks

47. Category III Trauma Patient
All other patients presenting with traumatic injuries
Fractures
Sprains/strains
Burns
Falls
Pain
Provide routine trauma care
Honor patients request for hospital choice as much as possible

48. Field to Hospital Communication
EMS to call early; update as needed
Gives time for hospital staff and resources to be mobilized
The more critical the patient, most likely the shorter the report
Important details to be given
Head to toe picture needs to be painted
Just as important to give tasks not completed
Intubation versus bagging
IV access obtained or not

49. Abbreviated Radio Report
Department name, vehicle number and receiving hospital
EMS to state, “this is an abbreviated report”
Provide nature of situation and SOP being followed
Age and sex of patient
Chief complaint and brief history
Airway and vascular status
Current vital signs, GCS
Major interventions completed or being attempted
ETA
Provided to Medical Control in situations where manpower is limited and / or the patient’s condition is critical.

50. Fluid
Challenges

51. Adult Fluid Challenge
Adult fluid replacement is in 200 ml increments (replacement formula 20 ml/kg)
Storage issues
IV bags are usually in ambulance, in bays
Fluid eventually are at ambient temperatures
70° fluid into body will cause core body temperature to decrease
Hypothermia results
Cold patients become acidotic patients
Body functions and response to medications less reliable in acidotic (and hypoxic) environment.

52. Adult Fluid Challenge 200 ml increments Formula is 20 ml/kg Example
200 # patient = 100 kg
100 kg x 20 ml/kg = 2000ml fluid challenge
Reassess your patient as you are passing the ml mark
Monitor breath sounds for fluid overload

53. Adult Fluid Challenges
Vascular issues
Vessel damage results in extensive blood loss
EMS infuses Normal Saline
NS does not carry oxygen; NS solves volume issue only
Volume deficit can be filled, but patient still in distress due to lack of oxygen carrying capacity (ie: patient needs blood)
Goal should not be to get a 120/80 blood pressure, rather to stabilize

54. Adult Fluid Challenges
If your patient’s blood is becoming pink (ie: not red), they need more blood in the system!
EMS typically does not carry blood in the field
Important to accelerate transport to a facility that can add the blood and do the surgery to repair the underlying problem!!!
Good BLS skills are more important than ALS skills for these types of patients!

55. Pediatric Fluid Challenges
Pediatric shock protocol
EMS carries Normal Saline
Formula for fluid challenge is 20 ml per kg
Can be administered up to three times total or up to 60 ml per kg total
Smaller container (patient size) means less fluid means less oxygen carrying capacity
Example:
30# patient = 14 kg (30  2.2)
14 x 20ml/kg = 280 ml fluid challenge
Fluid challenges are based on the patient’s weight. Frequent reassessment is required as you move toward your total calculated fluid challenge amount.

56. Fluid Challenge Calculation Practice
6 year old patient weighs 66 pounds
66 pounds = 30 kg
Fluid challenge of 30 kg x 20 ml = 600 ml each time
15 year old patient weighs 175 pounds
175 pounds = 80 kg
Fluid challenge of 80 x 20ml = 1600 ml fluid
25 year old patient weighs 120 pounds
Adult gets fluid challenge in 200 ml increments
75 year old patient weighs 180 pounds
Adult gets cautious fluid challenge in 200 ml increments
Frequently monitor breath sounds to make sure patient can handle the fluid being infused. As a rule of thumb for the pediatric patient, if they need one fluid challenge, anticipate that they would need at least 2.
Pediatric fluid challenge amounts are usually well above the “200 ml” incremental mark EMS thinks about for the adult.

57. Fluid Challenges Precautions
All patients need to be monitored for potential CHF
Even a previously healthy patient can be thrown into CHF
Too much fluid too fast

58. Case Study #1 EMS dispatched for double shooting @ 0942
Ambulance 0942
Ambulance 0947
Flight for Life 0952
Scene secured by 1000
FFL in the 1000
Patient contact

59. Case Study #1 Ambulance enroute to landing zone @ 10:13
FFL on 10:15
FFL to Level 10:23
.38 caliber revolver pistol used in the shooting

60. Case Study #1
Patient #1
38 year-old female with multiple gun shot wounds
Found in the basement of the house
GSW to right hand (entry and exit)
GSW to right side of neck (entry) and lower right ribcage (exit)
GSW to right forearm (entry and exit)
GSW to right humerus (entry and exit)
GSW to left hand (entry and exit)

61. Case Study #1 Patient #1 cont’d Approximately 2 liters of blood loss
Responding to verbal stimuli
Pupils: PERL
Lungs: left (clear), right (rhonchi), normal effort
Skin: Pale, dry, cool with delayed capillary refill
Past medical history, meds & allergies unknown
Unable to obtain B/P, femoral 110

62. Case Study #1 Respirations 22 with SPO2 of 94% on room air
SPO2 increased to 99% after 15 L via NRB
ECG: Sinus tachycardia with rate of 110
Patient disoriented
GCS = 9; RTS = 10

63. Case Study #1 Treatment plan: Scene safety (field and in ED)
ABC’s performed
Rapid transport with early communication to receiving facility
Supplemental O2, IV enroute, monitor
Immobilization by c-collar, backboard & head immobilizers
Patient needs to be exposed for evaluation of multiple gunshot wounds

64. Case Study #1
Bleeding controlled to entry & exit wounds with trauma dressings
Oxygen administered at 15 L via NRB mask
IV of Normal Saline administered with 18 G in left extremity, wide open rate
EMS crew monitored lung sounds and femoral pulses throughout call
Patient transferred to FFL crew
CMC (as Medical Control) notified

65. Case Study #1 Is this a Category I or II trauma patient and why?
Systolic B/P below 90
GCS less than 10
RTS less than 11
Penetrating injuries to head, neck, torso or groin
Category I trauma patient

66. EZ IO Have you used one on a patient or cared for a patient with one?
High risk, low volume procedure

67. EZ IO Field indications Must meet all indications
Shock, arrest, or impending arrest
Unconscious/unresponsive to verbal stimuli
2 unsuccessful IV attempts or 90 seconds duration

68. EZ IO Contraindications Fracture of the tibia or femur
Infection at insertion site
Previous orthopedic procedure (knee replacement, previous IO insertion within 480)
Pre-existing medical condition (tumor near site, peripheral vascular disease)
Inability to locate landmarks (significant edema)
Excessive tissue at insertion site (morbid obesity)
Hold leg up off bed to allow excess tissue to fall dependently

69. EZ IO Equipment Lithium drill Needle EZ connect tubing Syringe
Battery powered for 1000 insertions
Needle
Blue needle – 25 mm (1) 15 G for patients over 88 pounds (40kg)
Pink needle – 15 mm (5/8) 15G for patients between 7 and 88 pounds (3kg – 40kg)
EZ connect tubing
Syringe
Saline to prime EZ connect tubing
Primed IV bag
Pressure bag/B/P cuff
Site prep material (ie: alcohol pad)

70. Equipment Case EZ connect tubing 10 ml syringe with saline
Helpful to keep 2 sets of needles of each size in equipment case – if failed attempt in one site, can attempt the opposite site. Helpful to add 2 IV start kits to the equipment case – then all equipment is available in one kit.
Needle sizes used in Region X

71. EZ IO Procedure
Prime EZ connect tubing with saline; leave syringe attached (for flushing)
Locate and cleanse site
Proximal medial tibia
Prepare driver and needle set; remove safety cap
Insert needle at 900 angle
Remove stylet
Attach primed EZ connect tubing
Aspirate then flush line with remaining saline
Remove syringe only and connect primed IV set
Confirm needle placement

72. Identifying Site Proximal medial tibia
2 finger breadths below patella (to tibial tuberosity) and 1 finger breadth medially from tibial tuberosity
May or may not be able to identify the tibial tuberosity at 2 finger breadths below patella
As patient is lying supine, legs tend to roll slightly outward
This presents the flat surface of the tibia

73. EZ IO Sites Proximal medial tibia FYI - Additional sites available
Site approved for Region X EMS personnel
FYI - Additional sites available
Humeral
Ankle
Other EMS regions may use these additional sites
These additional sites may be accessed by MD inserting IO needle

74. Confirming EZ IO Placement
Sudden lack of resistance felt
Needle stands up by self
Bone marrow may be noted on aspiration
No resistance to flushing
IV runs with pressure applied to IV bag
No infiltration noted

76. Documentation OF EZ IO Insertion
Document usual IV insertion information
Time of insertion
Size IV bag used
Site, needle length, needle gauge
Amount of fluid infused in the field
Place fluorescent yellow arm band on patient’s wrist to indicate insertion (or attempt) of IO
Recommended to place on same side as insertion site
Arm band used for successful and unsuccessful insertions

77. Saline Lock/Extension Tubing
Field indication
To establish an extension line between the IV catheter and the IV tubing
Allows hospital staff to change IV tubing with less disturbance to the inserted IV catheter
To have access to circulation without the need for fluids
Equipment
IV start pak
IV catheter
Macrobore extension set (7.25 inches)
10 ml saline in syringe for priming tubing and flushing
Inserting extension tubing will make it easier for the hospital to switch out IV tubing if they need to. Having the extension tubing in place allows manipulation with tubing but will minimize movement of the catheter in the patient. This will discuss the risk of losing the line and decrease the chance of complications from excessive movement.

78. Region X SOP - Saline Lock
Routine medical care SOP states:
Establish 0.9 normal saline (NS) per IV/IO and adjust flow as indicated by the patient’s condition and age
May use a saline lock cap on IV catheter hub for stable patients (not needing fluid resuscitation)

79. “Saline Lock” Procedure
Establish an IV following sterile technique
Remove stylet
Insert distal tip of primed extension tubing/ saline lock into IV catheter
If administering fluids, IV tubing should be already attached to the extension tubing/saline lock
Adjust flow rate
If IV line is precautionary, flush extension tubing/saline lock with 10 ml sterile normal saline
Remove syringe
Do not need IV tubing or IV bag

80. Extension Tubing/Saline Lock
Connecting to IV catheter
Keep IV site as distal as possible
AC should not be your first choice
We are requesting to start getting into habit of adding this extension tubing to all IV starts

81. IV Equipment for Saline Lock
If patient needs fluid, attach primed IV tubing with bag to proximal end of extension tubing/saline lock
Wipe off blue clave port with alcohol prep pad
Push in and twist primed IV tubing to connect
Adjust flow rate as indicated
Document time, type, and size IV solution hung
Distal tip of clave inserted into IV catheter

82. Extension tubing/Saline Lock In Place
Extension tubing/saline lock properly secured
Insertion site not taped over
Clear view of insertion site through op-site/tegaderm dressing
Access to port available
Can easily attach primed IV tubing if need to begin fluid therapy

83. Improperly Secured IV Site
Insertion site taped over
Gauze bandaging under tape
Increased risk of infection
IV site properly covered with see
through dressing

84. Extravasation of Medication
To use the extension tubing/saline lock for infusion, must verify that the line is patent
Aspirate for blood return
Stop infusion if patient complains of pain/burning
Extravasation of IVP medication resulting in amputation of several fingers Patient c/o pain during IVP and medication delivering continued anyway.

85. Case Study #2 25 year-old male shot in the chest
Police are on the scene
Patient sitting on ground, leaning against car
Several small casings on ground near victim
Patient bleeding from small chest wound left anterior chest
Patient is anxious, pale, diaphoretic with elevated respiratory rate

86. Case Study #2 Patient alert and oriented x3
Complains of mild chest pain aggravated with deep breathing
VS: 122/86, 90 – 20
Hole noted in the left anterior chest about the 3rd intercostal space
No air seems to be moving through the hole

87. Case Study #2 Interventions required Immediately seal the open wounds
Dressing secured on 3 sides
High flow oxygen administered via non-rebreather
IV access established
Contact Medical Control
What Category trauma is this patient?
Category I – penetration of torso

88. Case Study #3 911 call to scene for a domestic incident
Upon arrival, summoned to the back yard for a 23 year-old female patient lying on the ground conscious and awake
Patient states she was running out of the house and tripped down the stairs
Tree branch noted impaled through right flank at level of umbilicus
VS: 124/100; 120; 22; SpO2 98%; warm & dry
No active bleeding

89. Case Study #3
What injuries do you anticipate knowing entry point and angle of impalement?

90. Case Study #3 Initial assessment performed to identify life threats
Airway – open
Breathing – without distress although patient is upset
Circulation – warm & dry; capillary refill 1 ½ seconds; pulse steady and palpable at the radial site
Disability & disrobe
AVPU – awake, cooperative, anxious

91. Case Study #3 Categorization? Interventions
Category I – penetrating object to torso
Interventions
Secure impaled object, prevent further movement
Manual control initially
Gauze padding around entrance site
Assess for exit wound

92. Case Study #3 What internal injury is anticipated? Abdominal
Solid organ – bleeding
Hollow organ – spilling contents causing contamination
Punctured vessels  hemorrhage
Chest
Punctured diaphragm
Punctured lung
Punctured heart
Punctured vessels

93. Case Study #3 Follow-up Patient taken to OR
Stabilization maintained to prevent movement of impaled object
Tree branch removed under direct visualization
Abdominal cavity cleaned and flushed
Patient did well and was discharged 5 days post-op

94. Case Study #4 EMS responded to a call at a tavern for a person shot
Upon arrival, the patient lying on their right side, blood noted under their head
Patient is breathing, radial pulse is palpable
They do not open their eyes; the patient moans when touched; the patient withdraws
What is first things first?
SAFETY, SAFETY, SAFETY

95. Case Study #4 Need to log roll patient protecting C-spine
Maintain clear airway
GCS
Eye opening – 1
Verbal response – 2
Motor response – 4
Total GCS - 7

96. Case Study #4 Cannot tell internal damage by external appearances only
Patient had small bone fragments that were pushed into the brain
Patient required neurosurgery evaluation

97. Case Study #4 Report from EMS
Description of wound(s) noted including body region
Type of weapon used if information is available
Distance from weapon if available
Closer the range, the more energy that is behind the bullet/shot the greater the internal damage
Note basic care provided (IV, O2, monitor)

98. Case Study #5 A patient presents as a walk-in to your facility
Approximately 2 hours ago, he was involved in a domestic disturbance
Patient states his girlfriend hit him in the upper chest and he continues to have some pain and is now worried regarding the injury
Awake and alert, vital signs stable
Dried blood noted on upper chest wall midline

99. Case Study #5 You can’t assess what you can’t see – remove clothing
What injuries do you anticipate?
Heart, lung, vessels
Trachea
Esophagus
Visible wound
Patient states he doesn’t know what he was hit with. Patient was aware of blood on his clothes after the confrontation.
Object viewed on x-ray

100. Case Study #5 – Operative View
Impaled object after removal
Was near pulmonary artery but no damage
Knife missed all vital structures

101. Case Closure
What saves lives when impaled/penetrating objects are involved?
Age and condition of patient
Younger patients and those in good health can tolerate the insult better
Rapid identification and transport from the field
Proper stabilization of the object to prevent further damage by movement
Rapid OR for direct visualization and repair

102. Bibliography
Hoover, C. Fluid Resuscitation Controversies. EMS Magazine. March 2010.
Proehl, J. Emergency Nursing Procedures, 4th Edition. Saunders
Region X SOP March 2007; amended January 1, 2008.
Smith, M. Lecture. “Working Together” EMS Conference 2010.
Wauconda Fire Department call records
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103. Bibliography cont’d www.remington.com<http://www.remington.com>
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