Approach to Injuries of the Head & Spine Stephan Brenner, MD, MPH.

Approach to Injuries of the Head & Spine

Stephan Brenner, MD, MPH

Teaching ObjectivesBy the end of this session you will learn: • How to use the Glasgow Coma Scale (GCS).• How to immobilize patients with the “Log-roll”

maneuver. • When to transfer patients with head or spine

injuries.• How to prepare a patient with a head or spine

injury for transport.

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Traumatic Head & Spine Injuries• Anatomy and of the brain and spine.• Mechanisms of head and spine injuries.• Assessment of head and spine injuries.• Treatment of the head or spine injured

patient.• Referral or Discharge of head and spine

injured patients.

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Anatomy & MechanismCase:• A young man is riding his motorbike when he hits a

bump in the road. He is thrown off the bike. • He was not wearing a helmet and hit his head against a

rock at the roadside. He is • unconscious for about 2 minutes.• He then is able to get up on his

own and stops a passing car. The driver brings him to your casualty ward.

How are we going to evaluate and treat this patient?

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Anatomy & Mechanism:The Skull and Brain

• The brain is surrounded by bones (skull). • The brain is connected to the spinal cord through a hole

in the base of the skull.

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Anatomy & Mechanism

• Trauma can cause:– Intracranial bleeding or swelling

of the brain.– Increased pressure inside the

skull.• Rising Intra-Cranial Pressure (ICP)

causes:– Squeezing of brain (=Herniation).– Altered mental status or coma.– Neurologic deficits

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The Skull and Brain

Anatomy & Mechanism

•Causes: RTAs, falls, assaults.•Head injuries involving the

brain are called Traumatic Brain Injuries (TBI).• TBI is a common cause of

death in trauma patients!• TBI is a major cause of

lifelong disability after trauma!

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Head Injuries

Immediate (= direct) brain damage:

Once direct brain injury occurs, only symptomatic relief can be provided in the Casualty Ward (stabilization, prevention of further injury).

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Anatomy & MechanismTraumatic Brain Injuries (TBI)

Mild Concussion Brief LOC followed by memory loss (amnesia), headache, nausea, vomiting usually full recovery!

Severe Concussion

Prolonged LOC, altered mental status death or disability!

Anatomy & MechanismTraumatic Brain Injuries (TBI)

Delayed (= indirect) brain damage:• Preventable brain damage in Casualty Ward after

trauma occurs.

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Hypoxemia Protect Airway, control Breathing!

Hypoperfusion & Shock Immediate Fluid Resuscitation!

Brain Swelling (Edema, Contusion, Bleeding) Elevate head of bed to 30°!

Skull Fracture Give Antibiotics immediately!

Seizures Give Diazepam and Protect Airway!

Anatomy & MechanismHead Trauma in the Casualty WardTHEREFORE:•Everyone working in the Casualty Ward needs to be familiar with the accurate assessment, resuscitation, and timely referral and transfer of patients with severe head injuries!

•The survival and quality of life of every patient with head injury depends on the knowledge and skills of the Casualty Staff!

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Anatomy & MechanismThe Spinal column

Spinal column: • reaches from the upper

neck to the lower back. • consists of 24 vertebral

bones.• is divided into 4

sections.

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Spine Functions: Stability & Weight bearing

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Bone Structures• Vertebral bodies• Facet joints• Pedicles


Spine Functions: Stability & Flexibility

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Non-bony Structures• Intervertebral Discs• Longitudinal

Ligaments• Paraspinal Muscles


• Spine Functions: Central Nervous System

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Nerve Structures • Spinal Cord• Nerve Roots• Spinal Nerves

Anatomy & MechanismThe Spinal Cord

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• Protected inside the Spinal Canal.

• Originates from brain at the Foramen Magnum.

• Terminates at Vertebra L1.• Distal nerve roots form the

Cauda Equina inside the spinal canal below Vertebra L1.

Anatomy & MechanismThe Spinal Cord

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The 3 Major Spinal Tracts:• Corticospinal Tract

motor control, muscle contraction.

• Spinothalamic Tract pain and temperature sensation.

• Posterior column position sense, vibration, light touch.

Anatomy & MechanismSpine Injuries

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Cervical Spine:• Most vulnerable part of

spine• Involved in 50% of all

spinal injuries!• High risk of paralysis

from cord compression!


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Thoracic Spine:• Least vulnerable to injury

(15% of all spinal injuries)• Relative protection from rib

cage.Lumbar Spine:• 30% of all spinal injuries• Most injuries occur in the

upper part of the L-spine (thoracolumbar junction)


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Causes:• High-velocity RTAs• Falls from a height• Sports injuries• Occupational injuries

Mechanisms:• Whip-Lash Injury • (Flexion-Extension Injury)• Axial Compression Injury


• Clinical Signs:

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Type of Injury: Symptoms: Neurologic compromise:

Sprains or Strains Pain no risk

Stable Fractures Pain low risk

Unstable Fractures Pain HIGH RISK!!

You will never know what type of spine injury you are dealing with when a patient arrives to the Casualty Ward!!

Anatomy & MechanismSpine Trauma in the Casualty WardTHEREFORE:

Never transport a patient with suspected spine injury in the sitting or prone position!!

•Everybody working in the Casualty Ward needs to be familiar with how to assess and treat a patient with suspected spine injury!•The survival and quality of life of every patient with spine injury depends on the knowledge and skills of the Casualty Staff!

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Strains & Sprains:• Trauma to spine muscles and

ligaments only.• Pain due to local soft tissue

inflammation.

Stable Spine Fractures:• Trauma to bone structures.• Only one column involved.• LOW RISK of spinal cord

compression.


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Unstable Spine Fractures:• Trauma to bone structures.• More than one column

involved.• HIGH RISK of spinal cord

compression!


Stable Fracture 1 column involved = low risk of spinal cord compression

Examples of Stable Spine Fractures

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Wedge Fracture Transverse Process Fracture


Unstable Fracture more than 1 column involved = high risk of spinal cord compression

Examples of Unstable Spine Fractures:

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Compression Fracture Flexion-Distraction Fracture


REMEMBER!• In EVERY trauma patient, ALWAYS suspect an unstable

spine fracture!

THEREFORE:• ALWAYS protect a trauma patient’s spine from bending or

moving (= spine precautions)! BECAUSE:• Spinal cord damage is IRREVERSIBLE!!

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Assessment & TreatmentCase:• The motorbike accident patient arrives at the hospital

and is walked to the Casualty Ward.

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• He complains about a headache and pain in his neck and back.

• He has bruises and abrasions to his face and forehead, shoulders and arms.

Does he have a muscle sprain, or a stable spine fracture, or an unstable spine fracture? What next are the next steps in assessing him?

Assessment & TreatmentArrival to the Casualty Ward

In any traumatically injured patient, the Casualty staff has to make sure that

SPINE PRECAUTIONS

are applied during every single step of the assessment & treatment process!

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Assessment & TreatmentSpine Precautions

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Wrong methods!! Correct methods!!


How to correctly apply Spine Precautions?1) Place the patient in an anatomical position:

supine on a hard surface straighten arms and legs always support the head!

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2) Immobilize the C-spine: Achieve normal alignment of the cervical spine. Instruct the patient not to bend or turn the head. One person must support the patient’s head and

neck until a cervical collar or other device is placed.

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Devices used to stabilize the C-spine:

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Stiff Cervical Collar

Rolled Towel

Sandbags (with a rolled towel beneath neck)


3) “Log-roll” the patient: Turn the patient “in one piece” without moving the

spine. Requires at least 2 health care providers. Must be used every time the injured patient has to be

moved for examination or transport.

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“Log-roll” maneuver:• 1 provider stabilizes the head and neck.• All other providers turn the patient’s shoulders, hips, and legs.

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Assessment & TreatmentPrimary Trauma Survey

While applying Spinal Precautions, the Primary Trauma Survey exam is started.

A - Airway: Is the patient able to talk? B - Breathing: Is the patient able to breath normally? C - Circulation: Are the BP and PULSE normal? D - Disability: Is the patient able to move all limbs? E - Exposure: Are there any other visible injuries

once the patient is undressed?

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• AIRWAY & BREATHING:

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Look for:• Foreign body in airway• Labored breathing• Blue skin (central cyanosis)

Check for:• Airway obstruction• Decreased breath sounds• Wheezing

Act accordingly!• Obstruction Clear Airway!• Labored breathing

Position Patient! (while protecting C-spine) Intubate! (if appropriate)

• Decreased one-sided breath sounds Needle Decompression!

• Wheezing, Cyanosis Give Oxygen!


CIRCULATION:Look for:• Cold Skin• Weak or Fast Pulse• Capillary Refill > 2 secondsCheck for:• Low Blood Pressure• Fast Heart Rate• Active Bleeding

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Act accordingly!•Cold skin Keep patient warm!•Low BP, fast pulse Give 1 L NS or LR IV bolus! Repeat fluid bolus as needed!•Profuse Bleeding Pressure dressing to wound!


• DISABILITY & MENTAL STATUS:

Look for:• Unconsciousness• Head Injury• Patient moving all 4 limbsCheck for:• AVPU or GCS score• Possibility of intoxication, • alcohol or drug abuse

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Act accordingly!•Patient is unconscious

Manage Airway! Intubate if appropriate! Check blood glucose level!•Seizure or Convulsion

Give Diazepam IV or PR!•Low AVPU or GCS score,

inability to move limbs Spinal Precautions at all

times!


AVPU Score:Assessment of consciousness in non-trauma patients focus on a patient’s general responsiveness to certain stimuli.

• A = patient is Alert & Awake• V = patient responds only to Verbal Stimulation• P = patient responds only to Painful Stimulation• U = patient is Unresponsive to any stimulation

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AVPU Example:A small boy fell off a tree and

hit his head.In the Casualty Ward, he has

his eyes closed and looks as if he is asleep.

He does not respond when his mother calls his name.

When the nurse pinches his hand, he screams and pulls his hand away.

What is the boy’s level of consciousness according to the AVPU score?


GCS = Glasgow Coma Scale:Assessment of consciousness in trauma patients assesses the patient’s specific responsiveness to certain

stimuli in 3 elements of patient behavior.

• Eye movements 4 points• Verbal response 5 points• Motor function 6 points

A fully conscious patient has a GCS score of 15 points.Severe head injury is present with a GCS of 8 or below.

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Glasgow Coma Scale:

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GCS Example 1:A woman was seriously injured in

a RTA and sustained severe head trauma.

She does not open her eyes when rubbed on the chest, but she starts moaning, flexes both arms, and stretches her legs. What is this woman’s GCS

score?


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GCS Example 2:A man involved in the same accident

has been unconscious since the event.

He does not open his eyes when rubbed on the chest, does not make any noises, turns both arms legs inward, and bends his hands and feet.

What is this man’s GCS score?


EXPOSURE (undress the patient!):

Look for:• Additional wounds & injuries

Check for:• Hypothermia

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Act accordingly!•Wounds and Injuries cover open wounds! immobilize broken limbs!•Hypothermia cover the patient!


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Inform the physician or medical assistant on call immediately if any of the ABCDEs are abnormal!!

Assessment & TreatmentSecondary Trauma Survey

1) Obtain a detailed history from the patient or an eyewitness (AMPLE History):

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A = Allergies? M = Medications? P = Past Medical Problems? L = Time of Last Meal? E = Event – What happened?

– What mechanism?


2) Do a detailed Physical Exam from head to toe, specifically looking for the following:• Dilated or unequal pupils.• Leakage of Cerebrospinal Fluid. • Detailed neurologic exam (sensation, motor function, reflexes).• Log-roll to check for trauma to back of head, spine tenderness,

bruising, step-offs.

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Signs of C-spine Injury:• Difficulties breathing

damage to phrenic nerve

• Flaccid upper extremities & loss of reflexes damage to anterior spinal cord

• Hypotension & bradycardia damage of the autonomic nervous system


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• Decreased abdominal wall tone damage at level of T-spine

• Decreased sensation or motor function in lower limbs damage at level of L-spine

• Decreased rectal tone damage at level of L-spine


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Abnormal Neurological Findings:• Decreased strength in arms

and legs anterior cord damage

• Decreased sensation in arms and legs (touch, proprioception, vibration) posterior cord damage

• Decreased pin prick discrimination in arms lateral cord damage


Spinal Shock:= complete shutdown of central neurologic

functions with spontaneous resolution after severe spinal cord damage.

• Flaccid paralysis and areflexia• Only diaphragmatic breathing, no chest wall

rise• Flexed posture of upper limbs• Priapism• Hypotension (= Neurogenic Shock)• Pain sensation only above clavicles

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Inform the physician or medical assistant on call immediately if any of the above symptoms are present!

Assessment & Treatment

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Case:• You applied spine precautions and put a cervical collar

on the patient.• During the primary survey, you only note more abrasions

along the left side of his body.• His GCS score is 15, his vital signs

are stable.• During the secondary survey, you

notice tenderness along the midline of his spine and decide to leave the collar on.

What should be the next step in the assessment?

Assessment & TreatmentRadiographic Evaluation

X-rays evaluation of the spine:• C-spine x-rays: 4 views

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X-rays evaluation of the spine:• T-spine/L-spine x-rays: 2 views

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How to read a c-spine x-ray:

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• Look for:– Loss of alignment

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• Look for:– Narrowing of spinal canal

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• Look for:– Increased distance between spinous processes

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• Look for:– Fracture of the spinous process

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• Look for:– Fracture of the vertebral body

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• Look for:- Bony deformities

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Assessment & Treatment

Case:• The patient was sent to the x-ray department on a stretcher.

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• He was given medication for the pain in his neck and head.

• He continues to be fully conscious and his vital signs remain stable.

• While you clean and dress his wounds, his c-spine film returns.

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What do you see and what should be done next?

Assessment & TreatmentMedical Therapy

If a head injured patient becomes less conscious, it might be due to intracranial swelling (edema, bleed) increased intracranial pressure herniation.•Mannitol 20% IV over 30-60 min

– 1 gram/kg for adults and children(usually not available in pharmacy)

•Dexamethasone (usually not available in pharmacy)– 12 mg IV then 4mg every 12 hours– Children: 0.5 mg/kg (maximal 10 mg)

•Furosemide 0.5 mg/kg IV in combination with first dose of dexamethasone

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If a head injured patient has an open skull fracture, cover for possible infection.• Co-amoxiclav

– adults: 600 mg IV every 8 hours– children: 25 mg/kg IV every 6 hours

• Tetanol 0.5 ml IM

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If a head injured patient is having convulsions, give:• Diazepam 5-10 mg IV or per rectum

For pain control, use NSAIDs, avoid Pethidine injections.• Diclofenac injection• Paracetamol per rectum

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Assessment & TreatmentReferral & Transfer

• All patients with neurologic deficits need to be seen by a neurosurgeon or spine surgeon as soon as possible (= definitive care).

• Once stabilized (ABCs controlled), transfer to a higher-level health facility must be arranged.

• If an injured patient is transferred, spinal precautions must be continued until arrival at the receiving facility!

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Assessment & TreatmentDischarge & Follow-Up

• All patients who – are neurologically stable– have no loss of consciousness– have no deterioration in mental status– have no evidence of unstable spine injuries– are not intoxicated

can safely be discharged home after all other injuries are taken care of.

• Head injured patients with above symptoms need to be observed in the hospital or might even require transfer.

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Assessment & TreatmentDischarge & Follow-Up

• All discharged patients need to be informed to return immediately if the following occurs:– Drowsiness, confusion, strange behavior– Vomiting and nausea– Convulsions and seizures– Clear fluid dripping from nose or ears– Severe or worsening headaches– Weakness or sensation loss in limbs

• All discharged patients have to be seen in OPD after 1 week for re-evaluation.

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Case Report 1

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• A woman is fetching water from a well and carries the vessel on her head. On the way back to the house, she stumbles and falls.

• The load on her head falls backwards and violently extends her head (= cervical hyperextension injury).

• She is unable to move and complains about weakness in both arms and legs (= quadriparesis).

Case Report 1

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• C-spine films taken in the hospital show no fracture and no narrowing of the spinal canal.

• Spine precautions are in place since she is still unable to move her limbs.

What is the prognosis?What is the treatment?

Case Report 2

• A 45-year-old carpenter fell off the roof of a 3-storey building and landed on his head.

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• He is fully conscious, able to move all 4 limbs, and is taken to the nearest Casualty Ward by a taxi in sitting position.

• He initially has normal vital signs and appears to be stable.

• While waiting on a bench to be seen by a health provider, he starts feeling weakness in all 4 limbs.

• Over the next hours, the patient develops tetraplegia and respiratory failure.

Case Report 2

• What made the patient deteriorate suddenly?• Which things were done wrong in this case?

• ALWAYS follow spine precautions in head or spine injured patients, even if they appear to be stable initially.

• ALWAYS perform C-spine immobilization in patients involved in RTAs or falls.

• ALWAYS do a timely assessment and early transfer to higher level facility if any signs of brain or spinal cord damage.

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Case Report 3

• A 10-year-old boy was struck by a car and thrown in the air, then hit the ground with his head and back.

• He sustained cuts and abrasions to his head and face.

• His family carried him to the Casualty Ward since he could not be aroused.

How should this boy be assessed?

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Case Report 3Primary & Secondary Trauma Survey reveal:• Airway protected.• Bilateral breath sounds, RR 20.• No acute bleeding, pulse 100, BP 110/60.• Not opening eyes, no verbal response, withdraws arms to

pain.• No other injuries or bone deformities after being

undressed.

• What is the boys AVPU and GCS score?• What next?

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Review Questions• What is the most common spine injury?

• What are spine precautions?

• What do we do when we “log roll” a patient?

• When do we stop spinal precautions?

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Resources and Literature used:• Ghana Standard Treatment Guidelines 2010• Management of Accidents and Emergencies, Ghana 2004

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ANY QUESTIONS?

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Approach to Injuries of the Head & Spine Stephan Brenner, MD, MPH.

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