Nursemaid’s Elbow

Nursemaid’s Elbow

Medical Student Pearl

 

Erika Maxwell

@ErikaMaxwell

Memorial University Class of 2023

Reviewed by: Dr. David Lewis


Case

A 10-month-old female is brought into the Emergency Department by her mother with a left arm injury. The infant had a fall from standing and the mother reached out to grab her and caught her left forearm. After the incident, the patient’s mother noticed that the infant was no longer using the arm. The child has no medical history and is not taking any medications. She is vitally stable.

On exam, the child’s left arm is limp and extended at her side. She is using her right arm and hand exclusively, including to grasp for items on the left side of her body (pseudoparalysis). There is no deformity, erythema, edema, or ecchymosis. The arm and hand are neurovascularly intact (strong brachial pulse, pink and warm).


Differential Diagnosis

  • Nursemaid’s elbow/pulled elbow/radial head subluxation
  • Elbow fracture
  • Wrist fracture or soft tissue injury
  • Shoulder dislocation

Background

A pulled elbow occurs most frequently in young children with the median age for presentation being 2 years [1]. The reason for this is debated in the literature with some sources saying that the annular ligament is weaker in children [2] and others saying that the radial head is smaller [1], both resulting in a less stable joint.

The most common mechanism of injury is axial traction (i.e. pulling on the arm or hand), but falls or rough play may also be responsible [2].


Anatomical Context

The annular ligament holds the radial head in place next to the ulna. When axial traction is applied by pulling the forearm or hand, the radial head may move underneath the annular ligament and trap it in the radiohumeral joint, against the capitellum [1].

Figure 1: The arm on the left displays a normal elbow, whereas on the right the radius is subluxated and trapping the annular ligament against the capitellum [3].


Signs and Symptoms [3]

  • Pain at elbow
  • Pseudoparalysis of injured arm
  • Extension or light flexion of injured arm, often pronated

Diagnosis and Management

A full examination of the upper limb is required. Leave obviously swollen or deformed areas until the end. Palpate the clavicle, humerus, forearm and gently move the joints (shoulder, wrist, and lastly elbow). Pulled elbows rarely result in joint swelling. If this is present an alternative diagnosis should be considered (e.g., supracondylar fracture).

If a pulled elbow is the only likely diagnosis, then it may be reasonable to proceed to a subluxated radial head reduction manoeuvre. However, when the history is not clear (e.g., unwitnessed mechanism involving siblings or a fall), then it is much safer to perform further diagnostic tests prior to manipulation. These include radiograph of the elbow to rule out fracture or elbow ultrasound to rule out joint effusion [4].


Reduction Technique

 This is done by supporting the elbow with one hand and using your other hand to move the patient’s arm through the recommended maneuvers. There are 2 different maneuvers to try, and they may be used alone or in combination [1-3,5].

  • Supinate the child’s forearm with your hand and flex the elbow

 

Figure 2: Demonstration of the supination/flexion maneuver [5]

  • Hyperpronate the child’s forearm

Figure 3: Demonstration of the hyperpronation maneuver [5]

Some research has indicated that the hyperpronation maneuver may be more effective and less painful for the patient [2,6], so it may be worth attempting this maneuver first.

If the maneuvers are successful, you may hear a click from the radial head as it moves back into place. The child may briefly cry as the subluxation is reduced. Movement recovery can take anywhere from a few minutes to several hours, but usually occurs within 30 minutes. The greater the delay from injury to presentation and subsequent reduction, the longer it will take for post reduction return to normal movement [2].

If a click is heard or felt during the manoeuvre it can usually be assumed that reduction has occurred. Ideally, it is recommended that the child remain under observation until normal movement returns. However, if delayed, it is reasonable to discharge the child with advice to return.

In any case where an x-ray or ultrasound has not been performed and the child does not rapidly start using their arm post manoeuvre, then imaging is required prior to any further manipulation.


Prognosis

Although a pulled elbow does not result in a permanent injury, it is important to inform the family that their child will be vulnerable to recurrent pulled elbows in the affected arm. Up to 27% of patients with a pulled elbow may experience a recurrence [7-8].


Case continued:

Based on the patient’s history and physical exam, she was diagnosed with a pulled elbow. Using the supination and flexion maneuver followed by the hyperpronation maneuver, an audible click was elicited from the patient’s elbow. Shortly thereafter, she began using the arm again as if no injury had occurred and was discharged home.


Key points:

 

  1. A pulled elbow is a common upper limb injury in young children presenting to the Emergency Department
  2. Careful assessment may preclude the need for diagnostic imaging however if in any doubt further investigation should be performed prior to manipulation. Many physicians will never forget the time they used a pulled elbow reduction technique in a child with an unexpected supracondylar fracture
  3. HYPERPRONATE and/or SUPINATE & FLEX!
  4. Recurrence is common

References

  1. Aylor, M., Anderson, J., Vanderford, P., Halsey, M., Lai, S., & Braner, D. A. (2014). Reduction of pulled elbow. New England Journal of Medicine, 371(21), e32.
  2. Wolfram, W., Boss, D., & Panetta, M. (2018, December 18). Nursemaid Elbow. Medscape. Retrieved September 6, 2022, from https://emedicine.medscape.com/article/803026-overview#a5
  3. Boston Children’s Hospital. (2021). Nursemaid’s elbow. Retrieved September 6, 2022, from https://www.childrenshospital.org/conditions/nursemaids-elbow
  4. Varga, M., Papp, S., Kassai, T., Bodzay, T., Gáti, N., & Pintér, S. (2021). Two- plane point of care ultrasonography helps in the differential diagnosis of pulled elbow. Injury, 52(1), S21-24.
  5. Kilgore, K., & Henry, K. (2021). Nursemaid’s elbow. Society for Academic Emergency Medicine – Clerkship Directors in Emergency Medicine. Retrieved September 6, 2022, from https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/peds-em-curriculum/nursemaid%27s-elbow
  6. Lewis, D., Argall, J., & Mackway-Jones, K. (2003). Reduction of pulled elbows. Emergency Medicine Journal, 20, 61-62.
  7. Schunk, J. F. (1990). Radial head subluxation: epidemiology and treatment of 87 episodes. Annals of emergency medicine, 19(9), 1019-1023.
  8. Teach, S. J., & Schutzman, S. A. (1996). Prospective study of recurrent radial head subluxation. Archives of pediatrics & adolescent medicine, 150(2), 164-166.
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EMSJ CPD Recommendations

 Dr Mackenzie Howatt MD FRCPC, Director of CPD

 

I’ve listed below a few external CPD activities for your perusal. I’m hoping to be able to update you monthly on upcoming activities both internal and external to our department to make sure everyone is aware of at least some of the myriad activities out there. I have no involvement/personal stake in any of the listed activities.

 

External CPD Activities – Updated for January 2023


Clinical:

  1. CAEP -AIME – registration open for AIME (March 1 or March 2). Requires registration on CAEP website. https://caep.ca/cpd-courses/. AIME advanced Jan 28 and April 20 (both full but can be put on waitlist). AIME awake April 19. Different rates for CAEP and non CAEP members
  2. CAEP National conference – May 28-31. Toronto. Requires registration
  3. EMU – Emergency Medicine Update – April 26-28 Toronto. https://emupdate.ca/. 3 day in person conference with updates to clinical medicine.
  4. ICEM (International Conference on Emergency Medicine) – June 13-16, 2023.https://icem2023.com/ Taking place in Amsterdam.
  5. Annual Update in EM – Feb 25-28th – Whistler, BC. Arranged by UofT DEM.https://www.cpd.utoronto.ca/whistler/.
  6. EM cases Summit – Feb 2-4, 2023. Virtual, based out of Toronto on the “EM cases” group.https://emcasessummit.com/
  7. SRPC Rural and Remote Conference. in Niagara , April 20-22 2023. https://srpc.ca/rr2023
  8. PEM Review Course – Banff, Alberta, Jan 26-Jan 28th. Can attend virtually or in person.https://emo.simplesignup.ca/en/11845/index.php?m=eventSummary
  9. https://imagesim.com/ – An online repository of pediatric images (xray, US, etc) and cases used for resident or faculty education. Different “packages” can be purchased and you have access for 2 years to the particular images/cases. Based out of SickKids in Toronto.
  10. CAEP – Geriatric EM – mix of video modules and then live virtual course on May 27th. Register https://caep.ca/cpd-courses-2/geri_em/.
  11. CAEP “National Grand Rounds” – Overcoming organizational Shame” by Dr’s Sara Gray, and Dr. Dawn Lim. Jan 25th at 1500 atlantic. https://caep.ca/cpd-courses-2/caep-national-grand-rounds/
  12. CAEP/BEEM Journal Club rounds – “Chest pain in the ED – High risk or not, what do I do?” Wednesday Jan 18 @ 1500 Atl. https://caep.ca/beem-caep-rural-journal-club/
  13. Dalhousie – 48th Annual Dalhousie Spring Refresher – Emergency Medicine – can be in person (Halifax) or virtual. 2 day event. April 21 and 22. Registration not yet open.https://medicine.dal.ca/departments/core-units/cpd/conferences.html

 


Administrative/Leadership/Faculty Development/Education:

  1. Dalhousie CPD – “What if I say the wrong thing? Integrating EDIA into teaching” Online session, need to register: https://medicine.dal.ca/departments/core-units/cpd/faculty-development.html. Jan 24 5:30-7:00
  2. Physician Leadership Institute (PLI) – Through Joule (affiliated with CMA). Have a number of online leadership courses in the new year including: “Leadership starts with self-awareness”, “leadership for medical women”, “building and leading teams” “leading change” and “leading sustainable health systems”. There are also some “on demand” courses available as well. I think you need to be a CMA member to access the PLI courses. https://joulecma.ca/learning/physician-leadership-institute?_gl=1*ktqf2z*_ga*MTcxNjY1Njc0Mi4xNjcwOTQ1MDIz*_ga_91NZ7HZZ51*MTY3MDk0NTAyMy4xLjEuMTY3MDk0NTA0OC4zNS4wLjA
  3. CAEP – Better Together: moving towards Gender Equity in Emergency Medicine. https://caep.ca/cpd-courses-2/women-in-em-gender-equity/. April 5, 18th, and 25th at 8pm Atlantic.Online course designed to give physicians foundational knowledge in how female and non-binary trainees and physicians experience discrimination throughout medical training and in practice.

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Management of Supraventricular Tachycardia (SVT) in Pregnancy

 

Management of Supraventricular Tachycardia (SVT) in Pregnancy

Medical Student Clinical Pearl

 

Tyson Fitzherbert, DMNB Class of 2024

Reviewed by Dr. Luke Taylor and Dr. David Lewis

 


Case:

A 30-year-old pregnant (32 weeks) female presents to the emergency department with palpitations and chest discomfort. On ECG they are diagnosed with supraventricular tachycardia, a narrow complex arrythmia – how would you proceed?

 


Introduction:

Pregnant women have a higher incidence of cardiac arrhythmias. The exact mechanism of increased arrhythmia burden during pregnancy is unclear, but has been attributed to hemodynamic, hormonal, and autonomic changes related to pregnancy. A common arrhythmia in pregnancy is supraventricular tachycardia (SVT). SVT is a dysrhythmia originating at or above the atrioventricular (AV) node and is defined by a narrow complex (QRS < 120 milliseconds) at a rate > 100 beats per minute (bpm). The presentations of SVT in pregnancy are the same as the nonpregnant state and include symptoms of palpitations that may be associated with presyncope, syncope, dyspnea, and/or chest pain. Diagnosis is confirmed by electrocardiogram (ECG).

 


Figure 1: Rhythm strip demonstrating a regular, narrow-complex tachycardia, or supraventricular tachycardia (SVT).

In general, the approach to the treatment of arrhythmias in pregnancy is similar to that in the nonpregnant patient. However, due to the theoretical or known adverse effects of antiarrhythmic drugs on the fetus, antiarrhythmic drugs are often reserved for the treatment of arrhythmias associated with clinically significant symptoms or hemodynamic compromise. Below is a detailed description of the management of SVT in pregnancy.

 


Management:

Figure 2: Treatment algorithm for SVT in pregnancy.

 


General Considerations:

  • Non‐pharmacological treatment including vagal manoeuvres such as carotid massage and Valsalva manoeuvre are well tolerated and aid in management.
  • Intravenous adenosine can be used in all three trimesters, including labor.
  • Electrical cardioversion is an effective treatment method for hemodynamically unstable or drug-refractory patients, which has proven to be safe in all three trimesters, including labor. There are some examples of this leading to pre-term labor in the third trimester.
  • AV nodal blocking agents and anti-arrhythmic agents may be considered for cardioversion; see table below for effects in pregnancy and breast feeding.

 

 


Case Continued:

A modified Valsalva manoeuvre is performed with resolution to sinus rhythm after 2 attempts. The patient is discharged with OBGYN follow-up.

https://sjrhem.ca/modified-valsalva-maneuver-in-the-treatment-of-svt-revert-trial/

 


Further Reading


References:

  1. Patti L, Ashurst JV. Supraventricular Tachycardia. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www-ncbi-nlm-nih-gov.ezproxy.library.dal.ca/books/NBK441972/
  2. UpToDate – https://www.uptodate.com/contents/supraventricular-arrhythmias-during-pregnancy#H11407709
  3. Ibetoh CN, Stratulat E, Liu F, Wuni GY, Bahuva R, Shafiq MA, Gattas BS, Gordon DK. Supraventricular Tachycardia in Pregnancy: Gestational and Labor Differences in Treatment. Cureus. 2021 Oct 4;13(10):e18479. doi: 10.7759/cureus.18479. PMID: 34659918; PMCID: PMC8494174. https://www-ncbi-nlm-nih-gov.ezproxy.library.dal.ca/pmc/articles/PMC8494174/
  4. Ramlakhan KP, Kauling RM, Schenkelaars N, et al, Supraventricular arrhythmia in pregnancy, Heart 2022;108:1674-1681. https://heart.bmj.com/content/early/2022/01/26/heartjnl-2021-320451#T2
  5. Goyal A, Hill J, Singhal M. Pharmacological Cardioversion. [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www-ncbi-nlm-nih-gov.ezproxy.library.dal.ca/books/NBK470536/
  6. Vaibhav R. Vaidya, Nandini S. Mehra, Alan M. Sugrue, Samuel J. Asirvatham, Chapter 60 – Supraventricular tachycardia in pregnancy, Sex and Cardiac Electrophysiology. https://www-sciencedirect-com.ezproxy.library.dal.ca/science/article/pii/B9780128177280000607

 

 

 

 

 

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EMSJ CPD Recommendations – November 2022

Dr Mackenzie Howatt MD FRCPC, Director of CPD

External CPD Activities 

I’ve listed below a few external CPD activities for your perusal. I’m hoping to be able to update you monthly on upcoming activities both internal and external to our department to make sure everyone is aware of at least some of the myriad activities out there. I have no involvement/personal stake in any of the listed activities.

 

Clinical:

  1. CAEP -AIME – registration open for AIME Awake and Advanced in Jan 2023. AIME awake Jan 27th. AIME Advanced Jan 28th. Both in Halifax. Requires registration
  2. CAEP webinar – DOAC related bleeding management. Nov 30th 2 pm Atlantic. Requires online resgistration (free for CAEP members)
  3. CAEP National conference – May 28-31. Toronto. Requires registration
  4. EMU – Emergency Medicine Update – April 26-28 Toronto. https://emupdate.ca/. 3 day in person conference with updates to clinical medicine.
  5. ICEM (International Conference on Emergency Medicine) – June 13-16, 2023. https://icem2023.com/Taking place in Amsterdam.
  6. Annual Update in EM – Feb 25-28th – Whistler, BC. Arranged by UofT DEM.https://www.cpd.utoronto.ca/whistler/ .
  7. EM cases Summit – Feb 2-4, 2023. Virtual, based out of Toronto on the “EM cases” group. Tickets are available starting early November.https://emcasessummit.com/ . Not sure of the cost, and I suspect the videos are available after course for a fixed cost.

Administrative/Leadership/Faculty Development

  1. Dalhousie CPD – “Language Matters: Navigating Stigma and Respect Clinical Education and Patient Care”https://medicine.dal.ca/departments/core-units/cpd/faculty-development.html. Online webinar from 8-9 AM over Zoom. Free.

Education

  1. Dalhousie- Fundamentals of Teaching: Fundamentals of Clinical Teaching and Supervision – Nov 1 – Dec 13.  A hybrid course of offline readings, videos, quizzes, etc that ends with a 1hr live webinar on Dec 13. https://medicine.dal.ca/departments/core-units/cpd/faculty-development/programs/Fundamentals_Teaching.html. 100$ registration fee.
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Pediatric Hip Dislocation & Reduction

Pediatric Hip Dislocation & Reduction

Resident Clinical Pearl (RCP) – November 2022

Dr. Nick Byers , R2 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed/Edited by Dr. Brian Ramrattan


Case:
A 10 year old presents to the local emergency department after playing with their sibling. The child was “tackled” from behind. A history and physical exam inform you that the child has been healthy until now with a completely uneventful childhood. They are normal, healthy body habitus and laying on their right side, a pillow between their flexed left knee & hip, and straight right leg. This is the only position of comfort for the child. Neurovascular exam is normal and the child refuses to let you move the leg at all. Foot and ankle move normally. Xrays were obtained promptly. A dislocated hip was readily identified (note the arrow sign below).


Greater than 85% of traumatic pediatric hip dislocations are posterior. Male children are at a greater risk by a 4:1 ratio, and in younger patients, they often occur with minimal force, whereas older children tend to require much greater forces due to the strength of structures surrounding the joint. Fractures can be an associated injury, though it was not in this case. A general triad to consider when evaluating for posterior dislocation is an adducted, shortened, and internally rotated leg as seen below:


Treatment:

A simple dislocation should be treated with closed reduction under sedation, ideally within six hours of injury to reduce the risk of osteonecrosis of the femoral head.


Reduction techniques:

There are many reduction techniques discussed in the literature. Most involve in-line traction of the femur with abduction and external rotation as the leg lengthens, with counter-traction (or downward pressure) placed on the pelvis. This allows for the femoral head to enter the acetabulum gently.

A quick review of technique with attending staff present on shift included the following three options:

  1. The Allis maneuver (https://www.youtube.com/watch?v=zmk3vafjAd4): The physician stands on the stretcher with arms hooked under the flexed knee & hip (both at 90o) on the injured side and an assistant provides downward pressure on the pelvis. Hip extension and external rotation can be applied as the hip reduces.

2.  The Captain Morgan technique (https://www.youtube.com/watch?v=lQMWaFX-MeQ&t=6s): The physician flexes the injured hip and knee to 90o and places their foot on the stretcher at the injured hip of the patient, their knee under the patients. They then grasp the patient’s leg with one hand under the popliteal fossa and one at the ankle. With counter-traction/downward pressure on the pelvis by an assistant, the physician plantar-flexes their foot to put traction on the patient’s femur. External rotation and abduction can be applied with the lower leg as the hip is reduced.

3. The cannon technique: The stretcher is raised and the patient’s knee and hip are flexed to 90o with the popliteal fossa sitting directly over the physician’s shoulder, hands on the patient’s ankle (while facing the patients feet). An assistant stabilizes and provides downward pressure on the pelvis. The physician slowly stands up straight providing in-line traction on the femur until the hip is reduced.


Case Conclusion:

Once x-rays confirmed a posterior hip dislocation, closed reduction under sedation in the emergency department was performed by a resident and staff physician using the cannon technique. Post-reduction films and repeat neurovascular exams were normal and follow-up with orthopedics was in place before discharge home.

Post reduction film:


References:

https://www.merckmanuals.com/professional/injuries-poisoning/dislocations/hip-dislocations

https://www.emnote.org/emnotes/captain-morgan-hip-reduction-technique

CASTED course manual, Arun Sayal

Traumatic hip dislocation during childhood. A case report and review of the literature. American Journal of Orthopedics (Belle Mead, N.J.), 01 Sep 1996, 25(9):645-649

https://usmlepathslides.tumblr.com/post/64398003332/posterior-hip-dislocation-posterior-hip

https://posna.org/Physician-Education/Study-Guide/Hip-Dislocations-Traumatic

https://www.ochsnerjournal.org/content/18/3/242/tab-figures-data

https://coreem.net/core/hip-dislocation/

https://westjem.com/case-report/emergency-physician-reduction-of-pediatric-hip-dislocation.html

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EMSJ CPD Recommendations – September 2022

Dr Mackenzie Howatt MD FRCPC, Director of CPD

External CPD Activities

I’ve listed below a few external CPD activities for your perusal. I’m hoping to be able to update you monthly on upcoming activities both internal and external to our department to make sure everyone is aware of at least some of the myriad activities out there. I have no involvement/personal stake in any of the listed activities.

 

Clinical:

  1. CAEP CPD – There is an upcoming Geriatric ER course on Oct 27 12-4 (eastern) 400$ for members. Course is mix of pre-recorded videos along with the 4 hour live virtual event. https://caep.ca/cpd-courses/
  2. CAEP CPD – “Pump  it up: updates on POCUS, Risk Stratification, and new meds for ED patients” – FREE online webinar – Oct 19 at 1 pm eastern. Need to Register via CAEP. https://caep.ca/cpd-courses/
  3. Dalhousie CPD – “Community Hospital Programs.” – Is a series of CPD events across NS, most of which has a virtual component. Is free to register. Many topics are primary care, but given current realities are presentations we are being asked to manage in the ED. Some appear relevant, some not. held from 7-8 pm on Tues-Thurs. https://medicine.dal.ca/departments/core-units/cpd/programs/nova-scotia-community-hospital-program.html
  4. Critical Care – Recorded lectures from a conference in the spring held in montreal are available “The Hospitalist and Resuscitationist”. You can “rent” the entire library for 375 for a years worth of access. Have not attended so can’t attest to quality, but have heard positive things. https://thinkingcriticalcare.com/

 

Leadership:

  1. CAEP CPD – Virtual leadership series Nov 3, 10, 17, 24 from 3-430 (eastern). 400/550 (member non member).
  2. NBMS – Foundations of Leadership certificate – multi week commitment for a 4 module leadership course. Free registration. Need to apply by Sept 19. 30 participant max. application can be found on NBMS website.

 

Faculty Development:

  1. Dalhousie CPD office puts on frequent Fac Dev topics that are available to us. They seem to have reasonable registration fees if affiliated with Dalhousie. Topics are on the page linked. https://medicine.dal.ca/departments/core-units/cpd/faculty-development.html

Administration:

  1. EDAC Nov 7 – Fully virtual. Based out of Toronto. Full day course on ED administration (For current or wanna-be admins). 500 dollars for the day
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Academic Emergency Physician – New opportunities for a great work/life balance, based in a centre of academic excellence…

The Department of Emergency Medicine, Saint John is recruiting! We are seeking Emergency Physicians who want to deliver clinical excellence within a thriving collegial academic environment.

 

Do you want to provide high-quality emergency medicine in the leading regional emergency department?

Are you interested in joining a team with an established research group that is internationally recognized, multi award winning and prolifically published? – Dal-EM New Brunswick Research Program

Do you have a passion for Point-of-care Ultrasound? Do you want to join the teaching faculty for our hugely popular PoCUS courses and conferences? – SJRHEM PoCUS Program

Are you a potential simulation expert or do you want to develop simulation in medical education skills and help grow our successful local and regional simulation program?

Are you an enthusiastic medical educator? Do you want to teach medical students at one of Canada’s newest medical school campuses?

Do you want to help train future Emergency Medicine physicians by joining our innovative Post Grad Education Program?

And do you want to do all this while living in Atlantic Canada’s natural playground surrounded by fresh waterways on one side and the ocean on the other, all in close proximity to a thriving historic uptown scene

 

Apply here:

Assistant Academic Head

Director of Continuing Professional Development

Communications Director

Emergency Medicine Physician

 

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PoCUS & COVID Severity

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