Toxicology For EMS

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Three EMS and ED-related toxicology case reviews; some of the references are dated but the information is still helpful to know

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Toxicology For EMS

  1. 1. Let's Talk the Tox <ul><li>Anne Clouatre, MHS, EMT-P </li></ul><ul><li>Porter, Littleton and Parker Adventist Hospitals </li></ul><ul><li>Emergency Medical Services </li></ul>
  2. 2. Welcome! <ul><li>Objectives: </li></ul><ul><ul><li>1. Distinguish toxic exposure based on patient presentation. </li></ul></ul><ul><ul><li>2. Formulate potential complications arising from toxic exposures. </li></ul></ul><ul><ul><li>3. Select the treatment modalities for toxic emergencies. </li></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  3. 3. Goal <ul><li>To become even more familiar with toxicologic emergencies by discussing real-life cases </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  4. 4. Topics <ul><li>Common toxic emergencies </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  5. 5. Toxic Facts <ul><li>Poisonings and drug abuse </li></ul><ul><ul><li>75% of cases in the U.S.A. occur in children under age 5, BUT </li></ul></ul><ul><ul><li>95% of the fatalities are adults </li></ul></ul><ul><ul><li>50% of adult ingestions are the result of suicide attempts </li></ul></ul><ul><ul><ul><ul><ul><li>Bresler and Sternbach; 1998 </li></ul></ul></ul></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  6. 6. Toxic Facts <ul><li>In 1996, the AAPCC recorded 2,155,952 cases of poison exposure. </li></ul><ul><li>The five categories with the largest number of fatalities: </li></ul><ul><ul><li>analgesics, antidepressants, stimulants and street drugs, cardiovascular drugs, and alcohols </li></ul></ul><ul><ul><li>Stackpool; 1998 </li></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  7. 7. Case One <ul><li>History </li></ul><ul><ul><li>Patient brought to ED by friends </li></ul></ul><ul><ul><li>State they think she “took some pills” </li></ul></ul><ul><ul><li>State that patient “got dumped” by her boyfriend today </li></ul></ul><ul><ul><li>Patient is quiet and is not readily offering any information </li></ul></ul><ul><ul><li>She appears to have been crying </li></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  8. 8. Initial Assessment <ul><ul><li>Pt. is a conscious, somewhat lethargic 18 y.o. female </li></ul></ul><ul><ul><li>She admits to ingesting an unknown amount of non-prescription pills approximately three hours ago </li></ul></ul><ul><ul><li>She complains of nausea </li></ul></ul><ul><ul><li>She answers questions appropriately with no obvious compromise of ABC </li></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  9. 9. Physical Findings <ul><ul><li>Skin - pale, warm, slightly diaphoretic; no obvious trauma, swelling, deformities, or track marks </li></ul></ul><ul><ul><li>BP - 108/60 </li></ul></ul><ul><ul><li>P - 110, RA pulse ox - 94% </li></ul></ul><ul><ul><li>R - 20 </li></ul></ul><ul><ul><li>T - 37.5 </li></ul></ul><ul><ul><li>Pupils - PERLA @ 3.5mm </li></ul></ul><ul><ul><li>EKG - sinus rhythm at 90 bpm </li></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  10. 10. Immediate interventions? <ul><li>Oxygen, IV, cardiac monitor </li></ul><ul><li>Pill identification and pill count </li></ul><ul><li>Labs: </li></ul><ul><ul><ul><li>Electrolytes, CBC </li></ul></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  11. 11. Case One <ul><li>Ideas for Possible Toxin(s)? </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  12. 12. Acetaminophen <ul><li>Minimal single acute toxic dose: </li></ul><ul><ul><ul><li>7.5 g for adults </li></ul></ul></ul><ul><ul><ul><ul><li>How many 325 mg tablets? (23-24) </li></ul></ul></ul></ul><ul><ul><ul><li>150 mg/kg for children </li></ul></ul></ul><ul><ul><ul><ul><li>50 kg? (23) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>40 kg? (16) </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Haddad, et al; 1998 </li></ul></ul></ul></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  13. 13. Phases of Toxicity <ul><li>0.5-24 h - N/V, malaise, diaphoresis, transaminases may be  </li></ul><ul><li>24-72 h - N/V  , RUQ pain, LFT  , bili  , PT  , renal fxn  </li></ul><ul><li>72-96 h - hepatic necrosis, jaundice, hepatic encephalopathy, renal failure, multi-organ failure  death </li></ul><ul><li>4-14 d - liver heals completely </li></ul><ul><ul><ul><li>Haddad, et al; 1998 </li></ul></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  14. 14. Other labs to order <ul><li>Four hour acetaminophen level </li></ul><ul><ul><li>It is critical to know the time of the initial ingestion </li></ul></ul><ul><li>AST and ALT levels, bilirubin level, PT, creatinine level, pregnancy test, U/A, ASA; consider lipase and amylase </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  15. 15. Treatment <ul><li>What other treatment </li></ul><ul><li>should be started once </li></ul><ul><li>the ingestant is identified? </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  16. 16. Acetaminophen Antidote <ul><li>NAC: N -Acetylcysteine </li></ul><ul><ul><ul><li>140 mg/kg initial oral dose, followed by 70 mg/kg q4h x 17 doses </li></ul></ul></ul><ul><ul><ul><li>most effective within 16 hours up to 24 hours; IV protocols pending </li></ul></ul></ul><ul><ul><ul><li>metoclopramide, diphenhydramine,ondansetron, droperidol </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Haddad, et al; 1998 </li></ul></ul></ul></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  17. 17. NAC: N -Acetylcysteine <ul><li>Why use this antidote? </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  18. 18. Epidemiology <ul><li>First OD recognized in 1966 </li></ul><ul><li>Morbidity and mortality steadily  </li></ul><ul><li>135 deaths reported to AAPCC-TESS in 1994; more deaths than from any other pharmaceutical agent </li></ul><ul><li>AIHP is the most common cause for liver transplantation in UK, second most common reason in USA </li></ul><ul><ul><ul><ul><ul><li>Haddad, et al; 1998 </li></ul></ul></ul></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  19. 19. Acetaminophen <ul><li>Important points </li></ul><ul><ul><li>Try to gather all bottles </li></ul></ul><ul><ul><li>Critical to know the time of initial ingestion </li></ul></ul><ul><ul><li>Consider delayed onset of symptoms </li></ul></ul><ul><ul><li>Consider possibly of co-ingestants </li></ul></ul><ul><ul><li>Think of long-term organ damage </li></ul></ul><ul><ul><li>Start NAC ASAP </li></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  20. 20. Case Two <ul><li>History </li></ul><ul><ul><li>EMS was called to an office building on a possible overdose </li></ul></ul><ul><ul><li>Patient was found conscious, sitting in office in the presence of several co-workers </li></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  21. 21. Case Two <ul><li>History, continued </li></ul><ul><ul><li>Delivered emergent to ED due to unknown agent for alleged overdose </li></ul></ul><ul><ul><li>In-field interventions: </li></ul></ul><ul><ul><ul><li>oxygen, IV NS, blood glucose, cardiac monitor </li></ul></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  22. 22. Initial Assessment <ul><li>Patient is a 40 y.o. male complaining of feeling overwhelmed, depressed, and “not wanting to go on” </li></ul><ul><li>Patient admits to ingesting a large amount of antidepressant medication approximately one hour ago </li></ul><ul><li>He is awake, agitated, and anxious </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  23. 23. Initial Physical Findings <ul><li>Skin - pink/flushed, warm, dry </li></ul><ul><li>BP - 108/72 </li></ul><ul><li>P - 138, RA pulse ox - 94% </li></ul><ul><li>R - 22 </li></ul><ul><li>T - 39.0 </li></ul><ul><li>Pupils - reactive, slightly dilated </li></ul><ul><li>EKG - sinus tachycardia </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  24. 24. Twenty minutes after arrival <ul><li>12 Lead EKG </li></ul><ul><ul><ul><li>widened QRS interval </li></ul></ul></ul><ul><li>Seizure </li></ul><ul><ul><ul><li>generalized and brief </li></ul></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  25. 25. Case Two <ul><li>Ideas for Possible Toxin(s)? </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  26. 26. Antidepressants <ul><li>Cyclic </li></ul><ul><ul><li>First generation (tricyclic) </li></ul></ul><ul><ul><li>Second generation </li></ul></ul><ul><li>S.G. are less toxic </li></ul><ul><ul><li>“ ...more selective for the inhibition of serotonin and dopamine, the incidence of cardiac and neurologic toxicity has generally decreased” </li></ul></ul><ul><ul><ul><ul><ul><li>Goldfrank, et al; 1998 </li></ul></ul></ul></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  27. 27. Interventions? <ul><li>Maintain O 2 , IV, cardiac monitor </li></ul><ul><li>Administer activated charcoal </li></ul><ul><ul><li>Gastric lavage debatable </li></ul></ul><ul><li>Determine co-ingestants </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  28. 28. Interventions, continued <ul><li>Administer hypertonic NaHCO 3 </li></ul><ul><ul><li>50 mEq (1mEq/mL) to obtain an arterial pH of 7.50 - 7.55 </li></ul></ul><ul><li>Obtain a count of remaining pills </li></ul><ul><ul><li>took 50 tablets (50 mg each) </li></ul></ul><ul><li>Obtain frequent temperatures </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  29. 29. Labs <ul><li>CBC and ’lytes </li></ul><ul><li>BUN/creatinine </li></ul><ul><li>Hgb </li></ul><ul><li>PT </li></ul><ul><li>APAP </li></ul><ul><li>ABG </li></ul><ul><li>glucose </li></ul><ul><li>U/A </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  30. 30. Nervous System Toxidrome <ul><li>Central </li></ul><ul><ul><li>agitation, hallucinations, confusion, sedation, coma, seizures </li></ul></ul><ul><li>Peripheral </li></ul><ul><ul><li>hypertension, tachycardia, hyperthermia, mydriasis, dry and flushed skin, decreased GI motility, urinary retention </li></ul></ul><ul><ul><ul><ul><li>Goldfrank, et al; 1998 </li></ul></ul></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  31. 31. TCA Toxidrome <ul><li>cholinergic blockade </li></ul><ul><ul><li>hyperthermia, sinus tachycardia </li></ul></ul><ul><li>myocardial destabilization </li></ul><ul><ul><li>fast sodium channel inhibition and slowing of phase 0 depolarization </li></ul></ul><ul><ul><ul><li>(similar to class I antiarrhythmics) </li></ul></ul></ul><ul><li>decreased norepinephrine </li></ul><ul><ul><li>hypotension </li></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  32. 32. TCA Pearls <ul><li>QRS wider than 0.12 seconds </li></ul><ul><ul><li>at least 1000 ng/ml of medication </li></ul></ul><ul><ul><ul><li>therapeutic level is 100-200 ng/ml </li></ul></ul></ul><ul><ul><li>Precipitous crash </li></ul></ul><ul><ul><ul><li>usually within first 2 hours </li></ul></ul></ul><ul><ul><li>Control airway! </li></ul></ul><ul><ul><li>Pt. with poor prognosis </li></ul></ul><ul><ul><ul><li>More than 1 gram is life-threatening </li></ul></ul></ul><ul><ul><li>Aggressive and supportive care </li></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  33. 33. TCA Epidemiology <ul><li>“ TCAs are the most common cause of death due to prescription drug overdose in the US and are a leading cause worldwide.” </li></ul><ul><li>“… the number of deaths has remained essentially constant for the past 10 years.” </li></ul><ul><li>Haddad, et al; 1998 </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  34. 34. TCA Epidemiology <ul><li>“ Typical victims of these overdoses were women, 20-29 years of age, who were living alone, were employed, and did not have a history of drug abuse or prior suicide attempts.” </li></ul><ul><li>Goldfrank, et al; 1998 </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  35. 35. Case Three <ul><li>History </li></ul><ul><ul><li>Pickup truck from a rural area brings in a patient with an unknown problem </li></ul></ul><ul><ul><li>Driver of truck states, “I dunno what’s wrong with my buddy. We were working outside at the farm and I just found him like this…he just collapsed and started puking…” </li></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  36. 36. Initial Assessment <ul><li>Your patient is a 60 y.o. male </li></ul><ul><li>He is confused, agitated and complaining of abdominal pain </li></ul><ul><li>His airway is open but his breathing and circulation are compromised </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  37. 37. Initial Assessment <ul><li>Ideas for Possible Toxin(s)? </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  38. 38. Rapid Intervention <ul><li>What should be the next step before proceeding to any other interventions? </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  39. 39. Physical Findings after Hazmat Decon <ul><ul><ul><li>Skin - pale, cool, diaphoretic </li></ul></ul></ul><ul><ul><ul><li>BP - 90/50 </li></ul></ul></ul><ul><ul><ul><li>P - 130, RA pulse ox - 89% </li></ul></ul></ul><ul><ul><ul><li>R - 28 </li></ul></ul></ul><ul><ul><ul><li>Pupils - midpoint </li></ul></ul></ul><ul><ul><ul><li>Breath sounds - wheezing, rhonchi </li></ul></ul></ul><ul><ul><ul><li>Lacrimation </li></ul></ul></ul><ul><ul><ul><li>Urinary incontinence </li></ul></ul></ul><ul><ul><ul><li>Twitching </li></ul></ul></ul><ul><ul><ul><li>EKG - second degree AV block, type II </li></ul></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  40. 40. Interventions? <ul><li>Make sure patient is adequately decontaminated </li></ul><ul><li>Try to find out the name of the suspected offending agent(s) </li></ul><ul><li>O 2 , suction, IV, cardiac monitor </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  41. 41. Interventions, continued <ul><li>Antidotes of Choice for Agricultural Insecticide </li></ul><ul><ul><li>Atropine </li></ul></ul><ul><ul><li>2-PAM </li></ul></ul><ul><ul><li>More atropine prn </li></ul></ul><ul><ul><li>RSI and intubation prn (rocuronium) </li></ul></ul><ul><ul><li>Chest x-ray </li></ul></ul><ul><ul><li>Supportive care </li></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  42. 42. What happens in OPP? <ul><li>acetylcholinesterase is inhibited </li></ul><ul><ul><li>increased amount of acetylcholine at the synaptic junction </li></ul></ul><ul><ul><li>results =  parasympathetic effects </li></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  43. 43. What happens in OPP? <ul><li> parasympathetic effects </li></ul><ul><ul><li>MUSCARINIC EFFECTS: SLUDGE </li></ul></ul><ul><ul><li>NICOTINIC EFFECTS: fasciculations, cramps, weakness, paralysis, cyanosis, tachycardia, elevated BP </li></ul></ul><ul><li>CNS EFFECTS: </li></ul><ul><ul><li>anxiety, ataxia, convulsions, coma, respiratory and circulatory depression </li></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  44. 44. Why use these antidotes? <ul><li>Atropine </li></ul><ul><ul><li>Initial dose: 1 - 2 mg for adults, 0.05 mg/kg for children </li></ul></ul><ul><ul><li>IV route preferred, IM acceptable </li></ul></ul><ul><ul><li>atropinization: flushing, drying of secretions, pupillary changes, increased HR if previously slow </li></ul></ul><ul><ul><li>repeat dose: 2 mg adults, 0.02 - 0.05 mg/kg for children; up to 24 hours </li></ul></ul><ul><ul><li>no effect on nicotinic receptors </li></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  45. 45. Why use these antidotes? <ul><li>2-PAM </li></ul><ul><ul><li>specific antidote for OPP </li></ul></ul><ul><ul><li>regenerates acetylcholinesterase </li></ul></ul><ul><ul><ul><li>muscarinic, nicotinic, and CNS sites </li></ul></ul></ul><ul><ul><ul><li>may also detoxify OP molecule </li></ul></ul></ul><ul><ul><li>adminster ASAP </li></ul></ul><ul><ul><li>1 - 2 g for adults, 25 - 50 mg/kg for children; given IV over 30 minutes </li></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  46. 46. Why use these antidotes? <ul><li>Diazepam </li></ul><ul><ul><li>used in conjunction with atropine and 2-PAM </li></ul></ul><ul><ul><li>improves survival </li></ul></ul><ul><ul><li>decreases seizures and neuropathy </li></ul></ul><ul><ul><ul><li>decreases cardiac and brain morphologic damage caused by seizures from OPP </li></ul></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  47. 47. Epidemiology <ul><li>“ The World Health Organization estimates that approximately 3 million pesticide poisonings occur annually and cause more than 220,000 deaths.” </li></ul><ul><li>“ Approximately 249 million pounds of insecticides are used in the US annually at a cost of $2.4 billion.” </li></ul><ul><ul><ul><li>Haddad, et al; 1998 </li></ul></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  48. 48. More Obscure Toxicities Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  49. 49. Supportive Care <ul><li>Overlooking the basics can be deleterious </li></ul><ul><li>Difficult to know all treatments, so supportive care is important </li></ul><ul><li>For most toxic exposures there are not specific antidotes... </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  50. 50. The Toxic Summary <ul><li>Know your available resources </li></ul><ul><li>Always treat for the worse </li></ul><ul><li>Acetaminophen </li></ul><ul><li>Tricyclic Antidepressants </li></ul><ul><li>Organophosphates </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  51. 51. Toxic Wrap-up <ul><li>Objectives accomplished: </li></ul><ul><ul><li>1. Distinguish toxic exposure based on patient presentation. </li></ul></ul><ul><ul><li>2. Formulate potential complications arising from toxic exposures. </li></ul></ul><ul><ul><li>3. Select the treatment modalities for toxic emergencies. </li></ul></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  52. 52. Further Actions <ul><li>Review ED and EMS protocols - are any adjustments necessary? </li></ul><ul><li>Prepare your department to handle toxic emergencies…especially those requiring hazardous materials decontamination </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  53. 53. Special thanks to the following toxicology experts: <ul><li>Dr. Alvin Bronstein , Faculty; Rocky Mountain Poison and Drug Center, Denver, CO; Emergency Physician; UCHSC, Denver, CO </li></ul><ul><li>Dr. Ken Kulig, Dr. Jeffrey Brent, and Dr. Scott Phillips , Porter Regional Toxicology Center, Porter Adventist Hospital, Denver, CO </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  54. 54. Literature references: <ul><li>Clinical Management of Poisoning and Drug Overdose , Haddad, Shannon, and Winchester </li></ul><ul><li>Toxicologic Emergencies , Goldfrank, Flomenbaum, Lewin, Weisman, Howland, and Hoffman </li></ul><ul><li>Manual of Emergency Medicine , Bresler and Sternbach </li></ul><ul><li>Pre-hospital Emergency Care Secrets , Pons and Markovchick </li></ul><ul><li>Essentials of Emergency Medicine , Rund, Barkin, Rosen, and Sternbach </li></ul>Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  55. 55. Questions? Porter, Littleton and Parker EMS ~ 303-765-6EMS ~ www.emsteam.org
  56. 56. Thank you If you would like to use this presentation for your EMS group or if you have any questions, please call 303-765-6367 Porter, Littleton and Parker Adventist Hospitals Emergency Medical Services www.emsteam.org

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