Emergency Medical Responder First on Scene TENTH EDITION

Emergency Medical Responder First on Scene TENTH EDITION CHAPTER 5 Introduction to Pathophysiology Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Objectives 1. Define the following terms a. b. c. d. e. f. g. h. Aerobic metabolism Anaerobic metabolism Cardiac output Cell membrane Cell nucleus Dead air space Dehydration DNA Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron continued on next slide Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Objectives 1. Define the following terms i. Edema j. Electrolytes k. Metabolism l. Patent m. Pathophysiology n. Perfusion o. Stroke volume p. Tidal volume Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron continued on next slide Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Objectives 2. Explain the importance of understanding basic pathophysiology. 3. Differentiate between the processes of aerobic and anaerobic cellular metabolism. 4. Explain the concept of perfusion, including the components necessary to maintain perfusion. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Objectives 5. Describe the composition of ambient air. 6. Explain how changes in respiratory system function can affect ventilation. 7. Describe the transport of oxygen and carbon dioxide in the blood. 8. Discuss factors that affect cardiac output. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Objectives 9. Describe the two ways the heart can fail resulting in decreased cardiac output. 10. Model a desire for Continuous Quality Improvement (CQI) both personally and professionally. 11. Value the importance of quality research and its connection to good patient care. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Topics Pathophysiology The Cardiopulmonary System Hypoperfusion and Shock Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

PATHOPHYSIOLOGY Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Pathophysiology • Pathophysiology § The study of how disease processes affect the body § Allows for better identification of certain signs and symptoms to a specific course of treatment Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Pathophysiology • The Cell § Basic unit of the human body • All organs and systems § Cell membrane • Outer protective layer of cell • Controls movement in and out of cell • Disease processes can alter effectiveness. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Pathophysiology • The Cell § Nucleus • DNA § Glucose is a basic nutrient for cell. • Converts to energy through metabolism continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Pathophysiology • The Cell § Water • Membrane regulates movement in and out. • Cells dry and die without enough water. • Cellular function is interrupted with too much water. • Influences the concentrations of electrolytes continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Pathophysiology • The Cell § Oxygen • Fuels metabolism • Aerobic metabolism - Normal glucose metabolism using oxygen - Carbon dioxide is a byproduct. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Pathophysiology • The Cell § Oxygen • Fuels metabolism • Anaerobic metabolism - Abnormal glucose metabolism without oxygen - Creates increased byproducts of carbon dioxide and lactic acid - Accumulated waste makes body acidic and toxic. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Figure 5. 1 a Aerobic metabolism requires an adequate supply of glucose and oxygen. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Figure 5. 1 b Anaerobic metabolism occurs when there is not enough oxygen. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Pathophysiology • Fluid Balance § The body is 60% water. § Balance is necessary for proper cellular function. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Pathophysiology • Fluid Balance § Body adjusts fluid levels through intake and elimination of fluids. • • Drinking fluids Sweating Breathing Urination continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Pathophysiology • Disruption of Fluid Balance § Dehydration • Not enough fluid intake • Excessive fluid elimination • Vomiting and diarrhea continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Pathophysiology • Disruption of Fluid Balance § Edema or swelling • Fluid trapped in the body's tissues from illness • Hands, legs and feet • Injury • Capillaries leak Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Think About It • A patient's fluid balance can easily be assessed externally. § Dry mucous membranes, sunken eyes, tachycardia, and low blood pressure can indicate dehydration. § Edema in the ankles and feet can give an indication of poor fluid distribution. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

THE CARDIOPULMONARY SYSTEM Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Cardiopulmonary System § Cardiovascular and respiratory systems work together. • Respiratory system • Transfers oxygen to the bloodstream • Cardiovascular system • Transports oxygen to the body's cells • Brings carbon dioxide back to the lungs for elimination Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Respiratory System § Structures • Airway • Lungs • Muscles of respiration continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Respiratory System § Airway • Movement of air in and out of the chest requires a patent airway. • Upper airway obstructions • Obstructions above the trachea prevent air from reaching the lower airway. - Altered mental status - Foreign bodies - Trauma continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Respiratory System § Airway • Lower airway complications • Bronchoconstriction increases airway resistance and decreases amounts of air that reaches the alveoli. - Asthma Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Figure 5. 2 (A) In the alveoli is where the exchange of oxygen and carbon dioxide take place. (B) The alveoli are surrounded by capillaries that bring in oxygen and venules that carry away carbon dioxide. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Respiratory System § Lungs • Diaphragm and chest wall responsible for pressure changes that stimulate breathing • Tidal volume • Air moved in and out in one breath continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Respiratory System § Lungs • Dead air space • Air remaining in the space between the mouth and alveoli - About 150 m. L continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Respiratory System Dysfunction § Disruption of respiratory control • Damage to the medulla oblongata • • • Stroke Brain tumors Infection Toxins and drugs Spinal cord injuries and diseases continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Respiratory System Dysfunction § Disruption of pressure • Chest cavity is a closed container. • Diaphragm, ribs and intercostal muscles change the size of the cavity. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Respiratory System Dysfunction § Disruption of pressure • Lungs are attached to the chest with two membranes. • Parietal pleura on the chest wall • Visceral pleura on the lung • Pleural space - May accumulate blood and air continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Respiratory System Dysfunction § Disruption of pressure • Expanded chest cavity creates negative pressure and lets air in. • Relaxed chest cavity creates positive pressure and forces air out. • Hole in the chest wall affects the changes in pressure. • Blood or air in the pleural space creates a hemothorax or a pneumothorax. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Respiratory System Dysfunction § Disruption of lung tissue. • Damage to lung tissue reduces ability for gas exchange. • • Trauma Pneumonia Infection Reduced oxygen levels and increased carbon dioxide levels Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Respiratory System Compensation § Brain monitors carbon dioxide levels in blood. • Increases or decreases respiration rate and tidal volume as needed Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Cardiovascular System § Blood • Transport system of the body • Insufficient quantity leads to poor circulation. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Cardiovascular System § Blood vessels are pathways. • Arteries • Carries oxygenated blood away from the heart • Veins • Carries deoxygenated blood to the heart continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Cardiovascular System § Blood vessels are pathways. • Arterioles • Feeds oxygenated blood to the capillaries • Capillaries • Offloads oxygen and picks up carbon dioxide continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Cardiovascular System § Blood vessels are pathways. • Pulmonary arteries • Carries deoxygenated blood from the heart to the lungs • Pulmonary veins • Carries oxygenated blood from the lungs to the heart continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Cardiovascular System § Blood pressure • Created by the beating heart to move blood around the body continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Cardiovascular System § Blood pressure • Diameter of blood vessels and volume of blood directly affects amount of pressure. • Dilated vessels and blood loss decreases pressure. - Hypotensive continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Cardiovascular System § Blood pressure • Diameter of blood vessels and volume of blood directly affects amount of pressure. • Constricted vessels or increased fluid in the blood increases pressure. - Hypertensive continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Cardiovascular System § Heart • 4 chambered pump designed to move blood • Stroke volume • Volume of blood ejected from the heart in one contraction continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Cardiovascular System § Heart • Cardiac output • Amount of blood ejected from the heart in one minute • Increased heart rate leads to increased CO. • If rate is too fast, output actually decreases. - >180 bpm in adults continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Cardiovascular System § Heart • Cardiac output • Autonomic nervous system response adjusts cardiac output. - Sympathetic "fight or flight" response - Parasympathetic response continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

The Cardiopulmonary System • Cardiovascular System § Heart failure • Electrical failure • Tachycardia • Bradycardia • Ventricular fibrillation • Mechanical failure • Trauma • Squeezing of the heart muscle • Loss of cardiac muscle due to cell death Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Think About It • The best way to assess a patient's tidal volume is to watch the chest rise and fall while counting the ventilations per minute. • Hypoxia leads to cell death. § Getting your patient on oxygen can delay the change to anaerobic metabolism. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Think About It • Low blood pressure can lead to hypoxia and cell death. What are some ways that EMRs can attempt to increase pressure? Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

HYPOPERFUSION AND SHOCK Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Hypoperfusion and Shock • Perfusion § Delivery of oxygen and nutrients and removal of waste to every cell and organ continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Hypoperfusion and Shock • Perfusion § All components of the cardiopulmonary system must be functioning. • Oxygen delivered all the way to the alveoli and carbon dioxide transported all the way out • Enough available blood, a functioning pump, and enough pressure to make the exchange Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Hypoperfusion and Shock • Hypoperfusion and Shock § Shock occurs when perfusion fails. • Hypoperfusion § Cells become hypoxic without perfusion of adequate oxygen. • Switch to anaerobic metabolism • Lactic acid and waste products build up. • Cells eventually die. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Hypoperfusion and Shock • Compensation § Sympathetic nervous system compensates for hypoperfusion. • • • Vessels constrict. Heart rate increases. Pupils dilate. Skin sweats. Brain responds to increased levels of carbon dioxide. • Increased and deeper respirations Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Hypoperfusion and Shock • Pediatric Compensation § One of the leading causes of death in pediatric patients. § Children compensate differently than adults. § Increased heart rate is the main mechanism. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Hypoperfusion and Shock • Pediatric Compensation § Vasoconstriction allows them to maintain blood pressure with significant volume loss. • Blood pressure is an unreliable factor during assessment. § Higher metabolism rates burn off oxygen faster. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Think About It • Recognizing compensation is an important element in the assessment of a patient because it can rapidly identify the patient in shock. • EMRs should always be on the lookout for telltale signs of shock such as increased heart rate, decreased blood pressure, and abnormal respiratory rates. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

SUMMARY Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Summary • Understanding pathophysiology helps you understand the basic and most important functions of the body and their critical dysfunctions. • Delicate balance of fluid in the body § Levels must be appropriate in the major spaces and balanced constantly to maintain life. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Summary • Aerobic metabolism § The normal way the body converts glucose into energy • Anaerobic metabolism § Not as efficient, and it creates significantly more waste product continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Summary • Perfusion § Combined function of the respiratory and cardiovascular systems. § All functions needed to order to deliver oxygenated blood to the cells • Oxygen is introduced into the body from the ambient air. § Respiratory system moves air in and out of the lungs. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Summary • Inspired air pairs with circulating blood for perfusion. § Appropriate quantities ensure adequate delivery of oxygen to the cells. continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Summary • The cardiovascular system § Transport mechanism for oxygen, carbon dioxide, and nutrients for the cells § Requires the presence of appropriate elements of blood, pressure within the system, and a functioning pump continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Summary • Cellular metabolism § Relies upon a constant supply of glucose and oxygen • Normal metabolism relies upon perfusion and the successful operation of the cardiopulmonary system. Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

REVIEW QUESTIONS Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Review Questions 1. How is the process of aerobic metabolism different from the process of anaerobic metabolism? 2. What is perfusion and what are the components necessary to maintain it? 3. How do changes in respiratory function affect ventilation? continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Review Questions 4. How are oxygen and carbon dioxide transported in the blood? 5. What are the factors that affect cardiac output? continued on next slide Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

Review Questions 6. What are the two ways the heart can fail and result in decreased cardiac output? 7. What are the responses by the body when the sympathetic nervous system is stimulated? Emergency Medical Responder: First on Scene, 10/e Christopher J. Le Baudour | J. David Bergeron Copyright © 2016, 2011, 2009 by Pearson Education, Inc. All Rights Reserved

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