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setembro 3, 2018

shock trauma anesthesia

This involves rapid control of major haemorrhage and the use of permissive hypotension in the pre-hospital setting, early haemostatic resuscitation, prompt imaging followed by appropriate damage control surgery and postoperative optimization in an intensive care setting. Hypoperfusion of tissues results in inadequate cellular oxygen delivery causing a shift from aerobic to anaerobic forms of metabolism producing lactate and free radicals, which contribute to a developing metabolic acidosis. Prehospital Incidence and Background. The aetiology of ATC is linked to protein C activation, which occurs following the generation of thrombomodulin (TM) on the endothelium in response to tissue hypoperfusion, combined with thrombin formation in response to tissue trauma. Fibrinogen is one of the first clotting factors to fall and a low fibrinogen is associated with increased mortality. Rick was director of trauma anesthesia at the Shock Trauma Center when I trained there. Following the initial phase of resuscitation, further administration of blood products can be guided by coagulation studies, and viscoelastic tests such as thromboelastography (TEG) and rotational thromboelastography (ROTEM). Current evidence suggests that aiming for a 1:1:1 ratio of packed red cells (PRCs), fresh frozen plasma (FFP) and platelets is most effective in achieving haemostasis and reducing mortality. Establishment of a massive tran… Anesthetics and Induction of Anesthesia • Any intravenous anesthetic administered to a trauma patient in hemorrhagic shock may potentiate profound hypotension and even cardiac arrest as a result of inhibition of circulating catecholamines • Etomidate • Although its inhibition of catecholamine release may still produce profound hypotension. Topic: Shock Title: Blunt Trauma Causing a High Spinal Cord Injury with Neurogenic Shock Target: Senior Emergency Residents / Trauma Team Author / Institution: Tim Chaplin, Alison Archibald click here to download. A fibrinogen 1.5–2 g/l have been suggested as the target for substitution with either cryoprecipitate or fibrinogen concentrate ( Table 1 ). The initial fluid bolus administered in the trauma setting is warmed isotonic crystalloid (lactated Ringer’s solution or … Hemorrhage is by far the leading trigger of shock in trauma patients, to the point where the ATLS protocol recommends presumptive treatment for hemorrhage in all hypotensive trauma patients. Trauma is among the leading causes of morbidity and mortality worldwide. Get In Touch Now. ATLS approach to resuscitation. Trauma anaesthesia dr.abhishek 1. This condition is NOT a true form of shock. Most often the consequences of motor vehicle crashes, falls, drowning, gun shots, fires and burns, stabbing, or blunt assault. The R Adams Cowley Shock Trauma Center at the University of Maryland Shock Trauma is dedicated to treating the critically sick and severely injured and employing groundbreaking research and innovative medical procedures with one goal in mind -- saving lives. Trauma-induced coagulopathy (TIC) may be defined as a multifactorial global failure of the coagulation system to sustain adequate haemostasis after haemorrhage resulting from major trauma. Need for ongoing assessment & resuscitation. Shock is defined as failure of the circulatory system resulting in a level of perfusion to tissues, which is inadequate to meet the oxygen demands of cellular metabolism. It is characterized by a primary endogenous process, acute traumatic coagulopathy (ATC), which may then be further worsened by resuscitation-induced coagulopathies. Title: Trauma Anesthesia 1 Trauma Anesthesia 2 TRAUMA. Neurogenic shock is a true form of shock and described as a hemodynamic disruption (reduced heart rate and blood pressure) as a result of a spinal injury. Spinal shock describes arreflexia and/or parathesia below the level of injury. Hyperfibrinolysis is frequent in severe trauma and is related to the extent of injury and severity of shock. Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients . Special emphasis is given to the assessment and treatment of coexisting disease. 0.5–1 μg/kg fentanyl, or by increasing the concentration of volatile anaesthetic agent. • Have syringes labeled (but no meds drawn up!). The concept of an irreversible deficit at the cellular level was first proposed in the early 1940s by Wiggers. Once begun, inflammation becomes a disease process independent of its origin, and can lead to multiple organ failure and death even after a patient has been completely resuscitated. Shock 2006; 26: 115 – 121. Coordinator:- Dr Roopesh Kumar Presenter:- Dr ABHISHAKE 2. Potential toxic ingestions, uncooperative patient. Cambridge Core - Anesthesia, Intensive Care, Pain Management - Trauma Anesthesia - edited by Charles E. Smith This fully revised new edition focuses on a broad spectrum of traumatic injuries and the procedures anesthesiologists perform to care for trauma patients perioperatively, surgically, and post-operatively. In the healthy patient, blood loss that does not exceed 15% of the circulating volume is unlikely to result in notable changes in either heart rate or blood pressure. Recognition of this fact has led to the widespread adoption of the ABCDE pneumonic for the management of major trauma with representing control of catastrophic haemorrhage. • Have at least 2 syringe pumps connected to the AC cord. He is an incredible teacher, clinician, and researcher. Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients . Many institutions now utilize major/massive haemorrhage protocols, which once activated, generate a standardized response aimed at facilitating the rapid delivery of large numbers of appropriate blood products to patients while reducing the cognitive burden on the trauma resuscitation team. Show more Specific Considerations for Trauma Anesthesia ... Resuscitation of Traumatic Shock (AVERT) Study is a phase 2 clinical trial that will evaluate the use of vasopressin supplementation in the resuscitation of trauma patients, a s well as the utility of using copeptin Considerations . As blood loss approaches 30% of the circulating volume, an increase in heart rate and decrease in pulse pressure will be observed, but at this level arterial blood pressure will continue to be preserved due to a combination of increased cardiac output as well as vasoconstriction in both the arterial and venous systems. Shock in the setting of a trauma patient (Hypovolemic shock, Tension Pneumothorax, or tamponade) - Duration: 5:35. The overall aims of DCR are to minimize blood loss, maximize tissue oxygenation and optimize outcome. The Ryder Trauma Center at Jackson Memorial Hospital is the only certified adult and pediatric Level One trauma center in South Florida. Antonyms for anesthesia shock. Hypothermia is one of the arms of the lethal triad of coagulopathy, acidosis, and hypothermia.5It is important, therefore, to warm the OR to greater than 30˚C and have a warmed intravenous (IV) line, forced air warmer, and rapid infuser with warming capability immediately available. ATLS approach to resuscitation. SHOCK FRAN BALAMUTH, MD, PhD, MSCE, JULIE FITZGERALD, MD, PhD, AND SCOTT L. WEISS, MD, MSCE DEFINITION OF SHOCK. The R Adams Cowley Shock Trauma Center highlights the importance of trauma center physician anesthesiologists. Environmental exposure, the removal of clothing and the administration of cold intravenous fluids or blood all serve to put patients who have experienced major trauma at risk of becoming hypothermic. [ 4 ] 2 تشمل كل ما يتعلق بأمراض الاوعية الدموية بما في ذلك امراض الشرايين والاوردة. Top Top. Potential toxic ingestions, uncooperative patient. The overarching aims of any transfusion strategy employed in the bleeding trauma patient are to minimize further blood loss while maximizing tissue oxygenation. These include cardiogenic shock secondary to blunt force chest trauma, obstructive shock due to cardiac tamponade and/or tension pneumothorax and neurogenic shock in the context of spinal cord injury. In the hospital setting, haemorrhage control should be achieved through damage control surgery and/or interventional radiology procedures, where the priority is to achieve rapid haemostasis and limit contamination rather than the definitive surgical repair of injuries. Published by Elsevier Inc. All rights reserved. One of the earlier studies looking at the mental function in elderly patients following total hip replacement under either general anesthesia or regional anesthesia. TraumaCare '98, the 11th Annual Trauma Anesthesia and Critical Care Symposium and World Exposition, was attended by more than 500 anesthesiologists, intensivists, emergency medicine physicians, nurses, paramedics, and military personnel. Trauma . There is also an association between large volume crystalloid fluid resuscitation and multiple organ failure in the critical care unit. For a serious trauma case, there are usually 5 anesthesia people: one gives the drugs, one types the computer record, one runs the rapid infuser, others put … This is then followed by a period of metabolic optimization in an intensive care environment prior to any further operative intervention. In patients who have developed haemorrhagic shock secondary to major trauma, haemorrhage control must be prioritized. Increasing the arterial blood pressure through the administration of intravenous fluid risks clot disruption, resulting in further bleeding. JOINT TRAUMA SYSTEM CLINICAL PRACTICE GUIDELINE (JTS CPG) Anesthesia for Trauma Patients (CPG ID: 40) A method of anesthesia that incorporates the induction and maintenance of anesthesia into an ongoing resuscitation during surgery for a trauma patient in extremis. The study also found that the effect of TXA on death due to bleeding varied according to the time from injury to treatment with early treatment (≤1 hour from injury) conveying more favourable outcomes. Difficult airway due to C-spine injury/immobility. Haemodilution of clotting factors due to the administration of intravenous fluids or packed red cells will further worsen coagulopathy, while acidosis and hypothermia will impair platelet function and inhibit clotting factor activity. The text is enhanced with numerous tables and 300 illustrations showcasing techniques of airway management, shock resuscitation, echocardiography and use of ultrasound for the performance of regional anesthesia in trauma; Anesthesia in traumatology. Epidemiology ; Trauma Systems ; Pathophysiology ; 3 What is TRAUMA? Trauma is among the leading causes of morbidity and mortality worldwide. Multiple obvious & occult injuries. American Trauma Society ; 4 Trauma Mortality The Advanced Trauma Life Support (ATLS) protocol of the American College of Surgeons 9 teaches recognition and early treatment of traumatic shock in a systematic way that is familiar to practitioners throughout the United States and in many other parts of the world. Shock Trauma has nine dedicated operating suites, its own unique trauma post-anesthesia care unit, in addition to two dedicated multislice CT scanners, an angiography suite, and digital plain film capability. Checklists have been shown to decrease inpatient complications and death. The company's filing status is listed as Forfeited and its File Number is T00088445.The company's principal address is 24 Crain Highway S W, Glen Burnie, MD 21061. Cambridge Core - Anesthesia, Intensive Care, Pain Management - Trauma Anesthesia - edited by Charles E. Smith This has been fundamental to the development of the current approach to management of traumatic shock, known as damage control resuscitation (DCR). Copyright © 1999 W. B. Saunders Company. Administration of large volumes of cold fluid will also worsen hypothermia. Sustained acidosis will inhibit the function of both platelets and clotting factors, with the resulting coagulopathy further worsening blood loss. Anesthesia Implications: This condition should NOT be confused with spinal shock. 44 In response to a trauma, a physiologic fibrinolysis is observed, which may become pathological in some cases (hyperfibrinolysis, fig. A number of factors contribute to the development of coagulopathy in the patient who has sustained major trauma. Copyright © 2020 Elsevier B.V. or its licensors or contributors. Shock Trauma Anesthesia is a Maryland Tradename filed on January 16, 1996. Special Interests: Trauma Anesthesia ATC is common, occurring in up to a quarter of trauma patients, with changes in coagulation (hypocoagulation and hyperfibrinolysis) being observed within minutes of injury. Abstract Shock is defined as failure of the circulatory system resulting in a level of perfusion to tissues, which is inadequate to meet the oxygen demands of cellular metabolism. In the 1980's, Shock Trauma began the first Fellowship in Trauma Anesthesia in the U.S. Our fellows are U.S. civilian and U.K. military clinicians, and the Division also trains 25 to 30 anesthesia residents each year, rotating in one-month blocks from the University of Maryland, the armed services, and visiting residents from across the country. DCR encompasses three key resuscitative strategies, permissive hypotension, haemostatic resuscitation (the use of blood products as primary resuscitative fluids) and damage control surgery. Types of Anesthesia; Pain Management. Anesthesia Implications: This condition should NOT be confused with neurogenic shock. Need for ongoing assessment & resuscitation. Normal circulatory function is maintained by a complex interplay between the central pump (heart) and blood flow at the regional level (microcirculation) for the purpose of delivering oxygen and nutrients to tissues and removing metabolic by-products (e.g., carbon dioxide). https://doi.org/10.1016/S0889-8537(05)70080-8. The Shock Trauma Center is in the Nation's First and Only Integrated Trauma Hospital. Outpatient Surgery; Stories; About; Policymakers; Media; ASA Member Toolkit; Partner Toolkit; Trauma Physician Anesthesiologists. The observed physiological response to acute haemorrhage is dependent on both the degree of haemorrhage and the pre-morbid physiological state of the patient. Trauma is the leading cause of death in those aged 1–44 years and the third leading cause of death for all age groups. Mortality represents only the tip of the trauma ICEBERG, it is estimated that, for each death, three people rendered permanently disabled. Trauma patients present a unique challenge to anesthesiologists, since they require resource-intensive care, often complicated by pre-existing medical conditions. Permissive hypotension is contraindicated in patients with head injuries and in those who are pregnant. Anesthesia for Trauma Maribeth M a s s ie, C R N A, M S Staff Nurse A n estheti s t, Th e Joh n s Hopkins Hospital As si stant Prof e s sor/A s si sta n t Program Director Columbia University School of Nursing Program in Nurse A n esth esia. Fellowship: Shock Trauma Center/University of Maryland Hospital, Cardiothoracic Anesthesiology Certification: Anesthesiology, Critical Care Medicine, Perioperative Transesophageal Echocardiography Office: 410-328-2628. We are proud to be associated with. It is important, however, to recognize that other causes of shock may be present in patients who have sustained major trauma. Difficult airway due to C-spine injury/immobility. Shock is a leading cause of both early and late mortality following traumatic injury. This acknowledges the fact that on-going exsanguinating haemorrhage will result in death before uncorrected airway or breathing issues. [] Trauma patients presenting to the operating room (OR) for emergency treatment generally have been subjected either to blunt force or to … In 2019 the CRASH-3 trial confirmed that TXA is safe in patients with TBI and that treatment within 3 hours of injury reduces head injury-related death in patients with a moderate TBI. Clinical indicators of shock include: Cyanosis, pallor, or peripheral hypothermia, The term shock was first used to describe the pathophysiology occurring after injury by the English surgeon Guthrie in 1815, in On Gunshot Wounds of the Extremities.28 In a description in 1872, Gross14 described shock as “a rude unhinging of the machinery of life.” Early speculation on the cause of shock included theories of systemic toxins released by injured muscle tissue and vagal hyperactivity producing loss of vasomotor tone and cardiac exhaustion. Ultimately, all trauma leads to decreased organ perfusion, cellular ischemia, and a cascade of edema and inflammation. Multiple obvious & occult injuries. As such, current accepted military and civilian pre-hospital care practice is that fluid should be administered in 250-ml aliquots in order to maintain a palpable radial pulse (approximating a systolic arterial blood pressure of 80–90 mmHg). The intention is that DCR begins at the point of injury, continuing as far as the care that the patient receives in the intensive care unit following surgery, with treatment at all times being targeted towards achieving these aims. Trauma patients present a unique challenge to anesthesiologists, since they require resource-intensive care, often complicated by pre-existing medical conditions. Trauma accounts for 30% of all life years lost in the United States — more than cancer, heart disease, and HIV combined. This obstructs adjacent capillaries, worsening oxygen delivery and impairing the clearance of ischaemic metabolites, which begin to damage cells, initiating inflammatory cascades. In this animal model of severe liver trauma with uncontrolled hemorrhagic shock, vasopressin, but not saline placebo or fluid resuscitation, improved short-term survival. Since spinal injuries result in this condition, the anesthetic implications will cover both spinal shock and spinal injury in general. This fully revised new edition focuses on a broad spectrum of traumatic injuries and the procedures anesthesiologists perform to care for trauma patients perioperatively, surgically, and post-operatively. Shock Traum a Ce They conclude that the type of anesthesia whether general or epidural had any effect on the magnitude or pattern of POCD. The use of fresh whole cold stored blood is being investigated as both a pre-hospital and early in-hospital method for replacing red cells, clotting factors and platelets. The exclusive elevators connect Anesthesia, OB Anesthesia and the ER. Once initial surgical control is obtained the patient may be normo- or even hypertensive due to high sympathetic tone. Early Resuscitation of Traumatic Shock (AVERT) Study is a phase 2 clinical trial that will evaluate the use of vasopressin Haemorrhage is a leading cause of preventable death in trauma and over the past two decades there has been an increasing understanding of the pathophysiological processes that occur in major haemorrhage associated with trauma. Shock 2006; 26: 115 – 121. This fully revised new edition with six new chapters is a comprehensive review of trauma anesthesia that is recommended for all providers in the field. Distributive shock can be further subdivided into distinct etiologies. Our goal for this manuscript is to initiate a discussion about what should be on a trauma anesthesia checklist, providing a nidus for a definitive document . 6. In addition, haemodilution of clotting factors due to the administration of intravenous fluids will further worsen coagulopathy. Emergency/full stomach . Following the results of the multi-national CRASH-2 trial published in 2013, it has become routine practice to administer tranexamic acid (TXA) to patients who have sustained major trauma. Figure 1: Likewise, the medical advances continue to be driven by the state of the trauma science directly resulting from military medicine’s evolving combat casualty management from the wars in Iraq and Afghanistan. Shock Traum a Ce Although the percentage of emergency, trauma, and critically ill patients requiring anesthesiology care is not well documented, one 2005 report of operative experience at a tertiary academic, level I trauma center found that more than half of their operative procedures were nonelective: 40% were urgent, 11% were true emergency procedures, and 8% were trauma related. Anesthesia 101. Shock in the setting of a trauma patient (Hypovolemic shock, Tension Pneumothorax, or tamponade) - Duration: 5:35. conducted a randomized trial to compare the effect of epidural vs general anesthesia on the incidence and long-term cognitive dysfunction after total knee replacement in 262 elderly patients. Systemic Inflammatory Response Syndrome (SIRS) can also cause distributive shock. Hypovolemia, hypothermia, coagulopathy, acidosis. Topic: Shock Title: Hemorrhagic Shock in an Elderly Pedestrian stuck by a Vehicle The predominant aetiology of shock in trauma is haemorrhage. • Have tubes ready with stylettes. 6. We use cookies to help provide and enhance our service and tailor content and ads. Introduction:- Trauma is the leading cause of death among people aged 1-38 years but above 38 are not spared. Trauma Anesthesiology ‌The mission of the Division of Trauma Anesthesiology is to provide high quality, state of the art anesthetic care to patients at the R Adams Cowley Shock Trauma Center.The R Adams Cowley Shock Trauma Center is the world’s first free-standing trauma center … In the pre-hospital setting, haemorrhage control may be achieved through simple measures such as applying sustained pressure to compressible haemorrhage, the application of haemostatic dressings, the use of tourniquets to occlude arterial blood flow to limbs and the application of traction splints and pelvic binders, or through novel techniques such as resuscitative endovascular balloon occlusion of the aorta (REBOA). International Trauma Anesthesia and Critical Care Society (ITACCS). After reading this article, you should be able to: describe the physiological response to haemorrhage, describe the clinical management of traumatic shock, explain the role and benefits of the trauma team. Shock Trauma Anesthesia is a Maryland Tradename filed on January 16, 1996. Maureen McCunn, MD Professor of Anesthesiology. Trauma anesthesiologists must have a broad, evidence-based knowledge of the specialties of both anesthesiology and of trauma surgery in order to understand the nuances of traumatic injury management, the unique pathophysiological processes observed in trauma, and the pharmacological modifications that may be necessary to provide anesthesia quickly, efficiently, and effectively. The Division of Trauma Anesthesiology is located at the Ryder Trauma Center, one of the foremost centers for research, evaluation, and treatment of advanced trauma and critical care support in the United States.. UPDATE IN TRAUMA ANESTHESIA 2018 ARANA Spring Meeting May 5th, 2017 Joe Romero CRNA, MS, CPT USAR. Aggressive crystalloid fluid resuscitation in patients who have sustained major trauma has been shown to exacerbate haemorrhage and worsen outcome. 138 synonyms for shock: upset, blow, trauma, bombshell, turn, distress, disturbance, consternation, whammy, state of shock, rude awakening, bolt from the blue. UPDATE IN TRAUMA ANESTHESIA 2018 - An overview of trauma demographics, mechanisms, and current literature to support clinical ... PATHOPHYSIOLOGY OF TRAUMA • Shock leads to hypoperfusion and a Since spinal injuries result in this condition, the anesthetic implications will cover both neurogenic shock and spinal … Synonyms for anesthesia shock in Free Thesaurus. The Division of Trauma Anesthesiology is located at the Ryder Trauma Center, one of the foremost centers for research, evaluation, and treatment of advanced trauma and critical care support in the United States.. Hemorrhage sufficient to cause shock in a “normal” adult can occur into one of five compartments: (1) the chest, (2) the abdomen, (3) retroperitoneum, (4) long bone fractures, or (5) out of the body. Departments of *Anesthesiology and Critical Care Medicine and †Surgery, Leopold-Franzens-University, Innsbruck, Austria This week we discuss the resuscitation of the hemorrhagic shock patient with Dr. Richard Dutton, MD. In the late 1900s, Crile and then Blalock in the 1930s demonstrated definitively that hypovolemia was the leading contributor to shock after injury. In fact, it is the leading cause of death in the United States for individuals between the ages of 1 and 46 years, accounting for a staggering 47% of deaths in this group. This approach is derived from a recognition that patients are more likely to die as a result of the metabolic consequences of their injuries rather than due to their incomplete initial surgical repair. Our Partners. Contributors CDR Joshua Tobin, MC, USNR COL William Barras, AN, USA The history of trauma anesthesia and resuscitation in Western Civilization includes the treatment of pain, hemorrhagic shock, anesthesia, and surgical developments. In addition, the switch to anaerobic forms of metabolism decreases endogenous heat production. Within the UK this approach is advocated by a number of guidelines, including those published by the National Institute for Health and Care Excellence (NICE), the British Society of Haematology and the Association of Anaesthetists. TraumaCare '98, the 11th Annual Trauma Anesthesia and Critical Care Symposium and World Exposition, was attended by more than 500 anesthesiologists, intensivists, emergency medicine physicians, nurses, paramedics, and military personnel. What are synonyms for anesthesia shock? So, several times a shift, we would grab the code box and run to the Trauma room or floor for a … Evidence from animal models suggests that permissive hypotension can be reasonably maintained for up to 1 hour following injury, after which normotension should be targeted. Several studies have investigated this issue. The economic burden of trauma exceeds $400 billion in the United States annually. It is imperative to rapidly assess the pediatric trauma patient for signs of shock upon arrival in the trauma center and at regular intervals thereafter. The definitive checklist, if it ever exists, should be created, and vetted, by a learned society within the trauma anesthesiology community. Anesthesia for Trauma Maribeth M a s s ie, C R N A, M S Staff Nurse A n estheti s t, Th e Joh n s Hopkins Hospital As si stant Prof e s sor/A s si sta n t Program Director Columbia University School of Nursing Program in Nurse A n esth esia. In the 1980's, Shock Trauma began the first Fellowship in Trauma Anesthesia in the U.S. Our fellows are U.S. civilian and U.K. military clinicians, and the Division also trains 25 to 30 anesthesia residents each year, rotating in one-month blocks from the University of Maryland, the armed services, and visiting residents from across the country. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Critical care management of patients with severe burns and inhalational injury, The metabolic and endocrine response to trauma, Anaesthesia and Intensive Care Medicine Volume 21 Issue 8. The role of the anaesthe Location. This can be cautiously obtunded by administering small aliquots of opiates, e.g. These measurable physiological signs will be associated with a failure of tissue oxygen delivery and a resultant shift to anaerobic metabolism at cellular level. Following the initial phase of resuscitation point-of-care coagulation monitoring using TEG or ROTEM to guide transfusion has been shown to reduce blood product administration and improve outcome. SHOCK AND TRAUMA ANESTHESIA. Trauma is an injury caused by a physical force. In addition, lack of adenosine triphosphate (ATP) availability as a result of the switch to relatively inefficient forms of anaerobic metabolism compromises cell membrane integrity resulting in cellular oedema. ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. • Med box in the … In fact, it is the leading cause of death in the United States for individuals between the ages of 1 and 46 years, accounting for a staggering 47% of deaths in this group. Clotting factor consumption may also play a role. Prehospital Phase During the prehospital phase, vital information regarding the trauma patient’s condition at the scene and MOI reveals important clues in the clinical finding of how the patient presents in the resuscitation area or later in the postanesthesia care unit (PACU). Baylor College of Medicine has an CRNA program and CRNA's and SRNA's, residents, and MDA's staff the General OR.

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