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| ==FIRE: Focused Initial Rapid Evaluation==
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| A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.<ref name="Robin-2006">{{Cite journal | last1 = Robin | first1 = E. | last2 = Costecalde | first2 = M. | last3 = Lebuffe | first3 = G. | last4 = Vallet | first4 = B. | title = Clinical relevance of data from the pulmonary artery catheter. | journal = Crit Care | volume = 10 Suppl 3 | issue = | pages = S3 | month = | year = 2006 | doi = 10.1186/cc4830 | PMID = 17164015 }}</ref>
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| <span style="font-size:85%">Boxes in the salmon color signify that an urgent management is needed.</span>
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| <span style="font-size: 85%;">
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| '''Abbreviations''':
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| CBC, complete blood count;
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| CI, cardiac index;
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| CK-MB, creatine kinase MB isoform;
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| CVP, central venous pressure;
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| DC, differential count;
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| ICU, intensive care unit;
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| INR, international normalized ratio;
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| LFT, liver function test;
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| MAP, mean arterial pressure;
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| MVO2, mixed venous oxygen saturation;
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| PCWP, pulmonary capillary wedge pressure;
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| PT, prothrombin time;
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| PTT, partial prothrombin time;
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| SaO2, arterial oxygen saturation;
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| SBP, systolic blood pressure;
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| ScvO2, central venous oxygen saturation;
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| SMA-7, sequential multiple analysis-7.
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| </span>
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| {{Family tree/start}}
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| {{Family tree|boxstyle=width: 400px; text-align: left; font-size: 90%; padding: 0px;| | | | | A01 | | | |A01=<div style="padding: 15px;"><BIG>'''Does the patient have cardinal findings that increase the pretest probability of cardiogenic shock?'''</BIG>
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| ❑ Evidence of hypoperfusion
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| : ❑ [[Altered mental status|<span style="color: #000000;">Altered mental status</span>]]
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| : ❑ [[Cold extremities|<span style="color: #000000;">Cold extremities</span>]]
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| : ❑ [[Cyanosis|<span style="color: #000000;">Cyanosis</span>]]
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| : ❑ [[Oliguria|<span style="color: #000000;">Oliguria</span>]]
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| : ❑ Sustained hypotension
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| :: ❑ [[SBP|<span style="color: #000000;">SBP</span>]] <90 mm Hg for ≥30 min ''or''
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| :: ❑ [[MAP|<span style="color: #000000;">MAP</span>]] ↓ >30 mm Hg below baseline for ≥30 min
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| ❑ Presence of myocardial dysfunction after exclusion or correction of non-myocardial factors contributing to tissue hypoperfusion</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%;| |,|-|-|-|^|-|-|-|.| |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A02 | | | | | | A03 |A02=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 15px; font-weight: bold;"><BIG>YES</BIG></div>|A03=<div style="text-align: center; background: #FA8072; color: #F8F8FF; font-weight: bold; padding: 15px;"><BIG>NO</BIG></div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | |!| |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A04 | | | | | | A05 |A04=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 15px; font-weight: bold;"><BIG>Cardiogenic <br> shock <br> suspected</BIG></div>
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| |A05=<div style="text-align: center; background: #FA8072; color: #FFFFFF; padding: 15px; font-weight: bold;"><BIG>'''Proceed to <br> [[shock resident survival guide|<span style="color: #FFFFFF;">shock resident survival guide</span>]] <br> to identify and correct the cause'''</BIG></div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A06 | | | | | | | | |A06=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''[[{{PAGENAME}}#Immediate management|<span style="color: #FFFFFF;">Immediate management ''(click for details)''</span>]]'''</BIG>
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| ❑ [[Intubation|<span style="color: #FFFFFF;">Intubation</span>]] with [[mechanical ventilation|<span style="color: #FFFFFF;">mechanical ventilation</span>]]
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| ❑ ± [[Norepinephrine|<span style="color: #FFFFFF;">Norepinephrine</span>]] IV infusion 0.1–2.0 μg/kg/min</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A07 | | | | | | | | |A07=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate Workup'''</BIG>
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| ❑ [[ECG|<span style="color: #FFFFFF;">ECG monitor</span>]]
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| ❑ [[Pulse oximeter|<span style="color: #FFFFFF;">Pulse oximeter</span>]]
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| ❑ [[Arterial blood gas|<span style="color: #FFFFFF;">Arterial blood gas</span>]]
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| ❑ [[Central venous catheter|<span style="color: #FFFFFF;">Central venous catheter</span>]]
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| ❑ [[Pulmonary artery catheter|<span style="color: #FFFFFF;">Pulmonary artery catheter</span>]]
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| ❑ [[CBC|<span style="color: #FFFFFF;">CBC</span>]]/[[Differential blood count (patient information)|<span style="color: #FFFFFF;">DC</span>]]/[[Basic metabolic panel|<span style="color: #FFFFFF;">SMA-7</span>]]/[[LFT|<span style="color: #FFFFFF;">LFT</span>]]/[[PT|<span style="color: #FFFFFF;">PT</span>]]/[[PTT|<span style="color: #FFFFFF;">PTT</span>]]/[[INR|<span style="color: #FFFFFF;">INR</span>]]
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| ❑ [[Troponin|<span style="color: #FFFFFF;">Troponin</span>]], [[CK-MB|<span style="color: #FFFFFF;">CK-MB</span>]]
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| ❑ [[Lactate|<span style="color: #FFFFFF;">Lactate</span>]]
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| ❑ [[CXR|<span style="color: #FFFFFF;">Chest radiograph</span>]]
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| ❑ [[Echocardiography|<span style="color: #FFFFFF;">Echocardiography</span>]]
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| ❑ [[Foley catheter|<span style="color: #FFFFFF;">Foley catheter</span>]]
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| ❑ [[ICU|<span style="color: #FFFFFF;">ICU admission</span>]]
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| ❑ [[Cardiology|<span style="color: #FFFFFF;">Cardiology consultation</span>]]
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| ❑ Hold [[antihypertensive|<span style="color: #FFFFFF;">antihypertensive medications</span>]]
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| </div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A08 | | | | | | | | |A08=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Hemodynamic optimization: preload'''</BIG>
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| ❑ '''Goal: [[PCWP|<span style="color: #FFFFFF;">PCWP</span>]] 14–18 mm Hg'''
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| : ❑ ↑ [[PCWP|<span style="color: #FFFFFF;">PCWP</span>]] by [[Normal saline|<span style="color: #FFFFFF;">normal saline</span>]] IV bolus 100–200 mL
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| : ❑ ↓ [[PCWP|<span style="color: #FFFFFF;">PCWP</span>]] by [[Furosemide|<span style="color: #FFFFFF;">furosemide</span>]] slow IV injection (over 1–2 min)
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| : ❑ ± Correct [[{{PAGENAME}}#Immediate management|<span style="color: #FFFFFF;"> pulmonary congestion '''''(click for details)'''''</span>]]
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| : ❑ ± [[Morphine|<span style="color: #FFFFFF;">Morphine</span>]] 2–4 mg slow IV injection (over 1–5 min)
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| </div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A09 | | | | | | | | |A09=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Hemodynamic optimization: afterload'''</BIG>
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| ❑ '''Goal: [[MAP|<span style="color: #FFFFFF;">MAP</span>]] >60 mm Hg, [[SVR|<span style="color: #FFFFFF;">SVR</span>]] 800–1200 dyn·s·cm<sup>−5</sup>'''
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| : ❑ If ↑ MAP & ↑ SVR: wean [[vasopressor|<span style="color: #FFFFFF;">vasopressors</span>]] ± [[vasodilator|<span style="color: #FFFFFF;">vasodilators</span>]]
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| : ❑ If ↓ MAP & ↑ SVR: [[vasopressor|<span style="color: #FFFFFF;">vasopressors</span>]] + [[inotrope|<span style="color: #FFFFFF;">inotropes</span>]]
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| : ❑ If ↓ MAP & ↓ SVR: [[vasopressor|<span style="color: #FFFFFF;">vasopressors</span>]] ± [[vasopressin|<span style="color: #FFFFFF;">vasopressin</span>]]
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| </div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A10 | | | | | | | | |A10=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Hemodynamic optimization: cardiac index'''</BIG>
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| ❑ '''Goal: [[CI|<span style="color: #FFFFFF;">CI</span>]] >2.2 L/min/m<sup>2</sup>'''
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| : ❑ ± [[Dobutamine|<span style="color: #FFFFFF;">Dobutamine</span>]]
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| : ❑ ± [[Milrinone|<span style="color: #FFFFFF;">Milrinone</span>]]
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| : ❑ ± [[IABP|<span style="color: #FFFFFF;">IABP</span>]], [[VAD|<span style="color: #FFFFFF;">VAD</span>]], or [[ECMO|<span style="color: #FFFFFF;">ECMO</span>]] if refractory</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A11 | | | | | | | | |A11=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''Immediate goals'''</BIG>
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| ❑ [[SaO2|<span style="color: #FFFFFF;">SaO2</span>]] >90%–92%
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| ❑ [[CVP|<span style="color: #FFFFFF;">CVP</span>]] 8–12 mm Hg
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| ❑ [[mixed venous oxygen saturation|<span style="color: #FFFFFF;">MVO2</span>]] >60%
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| ❑ [[SCVO2|<span style="color: #FFFFFF;">ScvO2</span>]] >70%
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| ❑ [[Hemoglobin|<span style="color: #FFFFFF;">Hemoglobin</span>]] >7–9 g/dL
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| ❑ [[Lactate|<span style="color: #FFFFFF;">Lactate</span>]] <2.2 mM/L
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| ❑ [[urine output|<span style="color: #FFFFFF;">Urine output</span>]] >0.5 mL/kg/h
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| ❑ ± Correct [[arrhythmia|<span style="color: #FFFFFF;">arrhythmia</span>]]
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| ❑ ± Correct [[electrolyte disturbance|<span style="color: #FFFFFF;">electrolyte disturbance</span>]]</div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A12 |-| A13 | | | | | |A12=<div style="background: #FA8072; color: #F8F8FF; padding: 15px;"><BIG>'''[[{{PAGENAME}}#Immediate management|<span style="color: #FFFFFF;">ACS likely? ''(click for details)''</span>]]'''</BIG>
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| ❑ [[cardiac biomarkers|<span style="color: #FFFFFF;">Positive cardiac biomarkers (cTnT, cTnI, or CK-MB)</span>]]
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| ❑ Symptoms of myocaridal ischemia
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| ❑ New significant ECG findings of myocardial ischemia
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| </div>
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| |A13=<div style="text-align: center; background: #FA8072; color: #F8F8FF; padding: 16px;"><BIG><BIG>'''YES, then manage as <br> UA/STEMI <br> and proceed to <br> [[{{PAGENAME}}#Acute Ischemia Pathway|<span style="color: #FFFFFF;">acute ischemia pathway</span>]]'''</BIG></BIG>
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| </div>}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| |!| | | | | | | | | |}}
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| {{Family tree|boxstyle=text-align: left; font-size: 90%; padding: 0px;| A14 | | | | | | | | |A14=<div style="text-align: center; background: #FA8072; color: #FFFFFF; font-weight: bold; padding: 15px;"><BIG>No, then proceed to <br> [[{{PAGENAME}}#Complete Diagnostic Approach|<span style="color: #FFFFFF;">complete diagnostic approach</span>]]</BIG></div>}}
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| {{Family tree/end}}
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| ==Acute Ischemia Pathway==
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| <!--return to top-->
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| ==References==
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| {{reflist|2}}
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| [[Category:Disease]]
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| [[Category:Pulmonology]]
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| [[Category:Emergency medicine]]
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| [[Category:Medicine]]
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| [[Category:Resident survival guide]]
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