Pediatric Resuscitation

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Pediatric Resuscitation

• Core Rounds Oct 2007
• Marc Francis R5 FRCPC
• PEM Fellow year 1
• Dr. Roger Galbraith

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Objectives

• Case based
• Challenges
• New revisions to ACLS guidelines
• Numbers that will help you in a crunch
• Pediatric Airway
• IV access
• Controversies in resuscitation

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Personal reading

• Neonatal Resuscitation
• RSI dosing and drugs for pediatrics
• Inotropes and Pressors
• Detailed management of specific presentations

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Challenges of Pediatric Resuscitation

• Emotional
• Lack of patient verbal skills
• Patient fear
• Varying normal values for vital signs
• IV access
• Drug dosing
• Technical skills more challenging
• Parental presence

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Pediatric arrest
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• Comprehensive review 1966 2004
• 5363 pts in 41 different studies
• 12.1 survived to hospital discharge
• 4 survived neurologically intact
• Better outcomes with
• Trauma arrest
• Submersion injury
• Improved survival with
• Witnessed arrest
• Bystander CPR

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• Prospective observational study from a registry
  of cardiac arrests
• The rate of survival to hospital discharge
  following pulseless cardiac arrest was higher in
  children than adults
• 27 (236/880) vs 18 (6485/36,902)
• adjusted OR 2.29, 95CI (1.95-2.68)
• Of these survivors 65 of children and 73 of
  adults had good neurological outcome

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• First documented pulseless arrest rhythm was
  typically asystole or PEA in both children and
  adults
• Survival to hospital discharge with asystole and
  PEA was
• 24 in the children (135/563)
• 11 in the adults (2719/24,987)
• OR 2.73 (2.23-3.32)
• Children had better outcomes than adults despite
  fewer cardiac arrests due to VF or pulseless VT

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Etiologies

• Out-of-hospital
• SIDS
• Trauma (most common gt 6 months)
• Submersion
• Sepsis
• Cardiac diagnosis
• Pulmonary disease

• In-hospital
• Sepsis
• Respiratory failure
• Drug toxicity
• Metabolic disorders
• Arrhythmias

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Generally, of survivors

• Airway intervention saves 90
• IV access saves 9
• Drugs save 1

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Case 1

• You are at your daughters soccer game enjoying a
  cold one
• There is a large commotion on another pitch and
  they call for help
• A 4yo M suddenly collapsed on the field and is
  not breathing
• You rush to his side and find him to be apneic
  and pulseless.

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2005 ACLS

• Simplify resuscitation training and improve the
  effectiveness

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Caveats

• Most pediatric ACLS recommendations are class
  indeterminate
• Promising but low-level evidence or high-level
  but inconsistent evidence
• Extrapolation from adult evidence
• None are class I
• At least one RCT with excellent critical
  assessment and positive, homogeneous results

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2005 ACLS Key Points

• Push hard and fast
• Chest compressions at rate of 100/min
• Limit interruptions in chest compressions
• Universal compression to ventilation ratio
• 302 for all lone rescuers
• Each breath should be delivered over 1 second
• Attempted defibrillation than immediate CPR

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CompressionVentilation Ratio

• Single Provider
• Universally 302 for all age groups for single
  provider CPR except neonates

• 2 Provider CPR
• 302 for adult 2 providers
• 152 for infants and children two providers
• Continuous compressions when advanced airway in
  place at 8-10 bpm

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Pediatric Chest Compressions

• Rescuers may use 1 or 2 hands to give chest
  compressions
• Children gt1yo
• press at the nipple line
• Infants lt1yo
• Press just below the nipple line
• Use 2 fingers for compression in lone CPR
• 2 thumb encircling technique for 2-provider CPR

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Pediatric Chest Compressions

• Compress the chest 1/3 1/2 its depth
• Change compression provider every 2 mins

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• Mannekin based study with 40 subjects
• Compressions at 100/min for 2 consecutive periods
  of 3mins with 30 seconds rest in between
• Number of satisfactory chest compressions
  performed decreased progressively during
  resuscitation (plt 0.001)
• First min 82/min
• Second min 68/min
• Third min 52/min
• Fourth min 70/min
• Fifth min 44/min
• Sixth 27/min
• Effect was greater in female providers
• Providers did not perceive their own fatigue

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• The Coach comes over and says they have an adult
  AED inside the nearby arena.
• Do you want to use it?

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AEDs in Children

• Recommended for children 1 year old
• In out of hospital arrest use the AED after 5
  cycles of CPR (2 mins)
• If the available AED does not have child pads can
  use a regular AED with adult pads
• Evidence is insufficient to recommend for or
  against the use of AEDs in infants under 1 year
  of age
• Class Indeterminate

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Shock dose

• Biphasic or Monophasic
• Initial Shock dose is the same
• 2J/kg initially
• 4J/kg subsequent

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Case 1 cont

• The AED shows Asystole and no shock is delivered.
• Paramedics arrives on scene and 3 rounds of Epi
  with good CPR are administered with no effect
• The Medic asks you if he should try high dose
  epinephrine???

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• Retrospective cohort study comparing high dose
  epi to standard epi in OOHCA
• N 65 pts lt18yo
• 40pts (62) HDE
• 13pts (20) SDE
• Outcome measures
• ROSC
• Return of organized electrical activity
• Hospital admission
• Hospital discharge
• Neuro outcomes
• HDE did not improve the rates of any of the
  outcomes

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High dose Epinephrine

• High dose Epi 0.1mg/kg IV/IO
• Routine use has never shown a survival benefit
• May be harmful particularly in asphyxia
• Currently is not recommended routinely
• Class III evidence
• Considered only in exceptional circumstances such
  as B-blocker overdose

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Case 2

• 13 month old Male. Attends daycare.
• Diagnosed with reactive airways in the past
• Mother has ventolin puffer he rarely uses
• Runny nose and cough for 3 days
• Then marked respiratory distress noted last 24hrs
  and no po intake
• Taken to resuscitation room

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Case 2

• Vitals
• T 38.2 C
• HR 179
• RR 56
• BP 81/56
• Sat 88 on RA
• Chemstrip 4.6

• Even before you examine the child.
• What is your impression of the vital signs

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Pediatric Vitals
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Heart rate normals

• gt200 is abnormal in any age group
• gt180 is usually abnormal unless in the first year
  of life

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Normal resting RR

• Newborn 30-60
• Infant (16 months) 30-50
• Infant (6-12 months) 24-46
• 1-4 yrs 20-30
• 4-6 yrs 20-25
• 6-12 yrs 16-20
• gt12 yrs 12-16
• gt60 abnormal in all age groups

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Estimate of Minimum Systolic BP

• Age Minimal Systolic BP
• (lowest 5)
• 0 1 month 60mmHg
• 1mth 1year 70mmHg
• 1yr 10yrs 70mmHg 2 (age)
• gt10yrs 90mmHg
• Less than 60mmHg is always abnormal

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Hypotension LATE!
SUDDEN!

• Compensated
• vs
• decompensated
• shock

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Case 2 Continued

• Generally
• looks unwell, pale and in marked distress
• CVS
• Tachy, normal HS, cap refill 4 secs, normal
  pulses
• Resp
• Tachypneic, suprasternal and scalene retractions,
  silent chest
• During next 5 mins patient becomes more drowsy
  and lethargic with apneic periods
• What do you want to do now..

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Numbers that can help in a crunch

• Estimate of weight
• 8 2 (age)
• SBP lowest 5
• 70 2 (age)
• Estimate of tube size
• age / 4 4
• Depth of ETT insertion
• ETT Size x 3

• Foley catheter size
• ETT size x2
• NG tube size
• ETT size x 2
• Chest Tube size
• ETT size x 4

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What if you cant remember doses

• Under stressful situations your brain turns to
  mush
• You stink at math
• BROSELOW TAPE!!!!

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• Examined 7500 kids in Ohio
• Compared actual weight to predicted weight by the
  Broslow
• Broslow colour predicted by height vs actual
  weight
• Overall percentage agreement 66.2
• Overall Kappa value was 0.61
• Accurately predicted ETT size in 71

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• Tape accurately predicted medication doses within
  10 in 55-60 of patients
• Kids were under dosed (by 10) 2.5 to 4.4 times
  more often than those over dosed (by 10) plt0.05
• Concluded that the Broselow tape inaccurately
  predicts weight in up to 1/3 of North American
  kids and could result in underresuscitation

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• A decision is made that the patient requires
  intubation
• What are the issues in intubating a child?

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Differences in Peds Airway

• 1) Big tongue and more soft tissues
• 2) Narrowest point at subglottis
• 3) Anterior/cephalad larynx
• 4) Short trachea
• 5) Prominent occiput
• 6) Big floppy epiglottis
• 7) Higher metabolic rate
• 8) Lower FRC
• 9) More compliant chest wall
• 10) Smaller airway caliber

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Anatomical Differences in Peds Airway
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To cuff or not to cuff.that is the question

• Cuffed endotracheal tubes may be used in infants
  (except newborns) and children in in-hospital
  settings provided that cuff inflation pressure is
  kept lt20 cm H2O
• One randomized controlled trial 3 prospective
  cohort studies and 1 cohort study document no
  greater risk of complications in children lt 8yo
• Khine HH, Corddry DH, Kettrick RG, et al.
  Comparison of cuffed and uncuffed endotracheal
  tubes in young children during general
  anesthesia. Anesthesiology. 199786627631

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Case 3

• 3yo M
• Sucking on large jaw breaker candy and onset of
  choking
• EMS called and currently on-route to ACH
• Initially coughing and wheezing
• 2 mins out patch saying has become cyanotic,
  silent and apneic
• Unresponsive and weak pulse on arrival.

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Airway Obstruction

• Signs of severe airway obstruction
• Poor air exchange
• Increased breathing difficulty
• Silent cough
• Cyanosis
• Inability to speak or breath

• Children 1yo
• Abdominal thrust
• Infants 1yo
• Back slaps
• Chest thrust

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Airway Obstruction

• Under 1yo risk of organ damage with abdominal
  thrusts
• Give 5 back blows alternating with 5 chest
  thrusts
• Until relief or unresponsive

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Airway Obstruction

• Your Abdominal blows are unsuccessful
• Other options???
• McGill Forceps
• R mainstem intubation of FB
• Surgical airway

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Pediatric Surgical Airway

• Cricothyroidotomy
• Extremely difficult in kids lt10yo (Almost
  impossible)
• Too small an anatomical space for Seldinger kit
• Often Cricoid cartilage is the narrowest portion
  so does not bypass the obstruction

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Pediatric Surgical Airway

• Transtracheal jet ventilation
• 10 gauge needle or 14 gauge angiocath
• Standard wall source of O2
• Placed at the cricothyroid membrane or between
  the tracheal rings inferior to the cricoid
  cartilage
• 3cc Syringe with plunger removed and a 90 angle
  piece connected to an ambibag for kids lt5yo
• Pressurized Jet Ventilator for kids gt5yo

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Case 3 Continued

• You successfully transtracheal ventilate the
  patient below the obstruction and get good chest
  rise and return of Oxygenation
• The patient remains in PEA

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Case 4

• 14yo healthy Male
• Motorcycle at 70km/hr hit the back of a
  stationary truck
• Wearing Helmet
• Initially unconscious on scene and blood in
  airway
• EMS arrival has agonal respirations and then
  stops breathing.

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Case 4

• On STARS arrival patient receiving CPR and BVM
  ventilation
• PEA on the monitor
• Obvious facial trauma and bilateral UE fractures
• Distended abdomen with periumbilical bruising

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Case 4

• Bilateral needle decompression performed
• Successful crash ETT placed
• Attempts x 2 by STARS medical crew for IV line
  with no success
• Monitor continues to show organized electrical
  activity but pulseless.

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IV access in Peds

• Few things cause more distress to non-pediatric
  trained resuscitators
• Infants have small veins and often lots of SC
  tissues
• Even more difficult in the sick child or infant
  who is hypovolemic and peripherally shut down

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Vascular Access

• Peripheral IV
• Technically easy
• Difficult in small children
• Peripherally shut down
• Rate limited flow
• Central line
• Technically challenging and time consuming
• Femoral, Internal jugular, Subclavian
• Larger bore
• Interosseous (IO)

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The secret vein only anesthesia seems to know
about

• Great Saphenous Vein at the foot
• Consistently found just anterior to the medial
  malleolus
• May not be visible at surface
• Large vein which is easily cannulated

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Interosseous

• Useful in all ages
• Previous recommendation was after 90 seconds of
  attempts for PIV
• Now recommendation is immediately
• Allows for
• Fluids
• Drugs
• Bloodwork
• Technically easy
• Complications
• Compartment
• Infection

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ETT drug administration

• Administration of drugs into the trachea results
  in lower blood concentration than the same dose
  given by IV/IO route
• Recent animal studies
• Show that the lower epinephrine concentrations
  achieved when the drug is delivered by the
  endotracheal route may produce transient
  ß-adrenergic effects.
• These effects can be detrimental, causing
  hypotension, lower coronary artery perfusion
  pressure and flow, and reduced potential for ROSC

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Case 4 continued

• You get an IO running and after fluid
  resuscitation with 1 liter of NS and 1 round or
  Epi you get a pulse back
• The patient is transported to the ACH and remains
  comatose
• The ICU resident asks you if you think we should
  cool the patient???

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Hypothermia ACLS

• Induced hypothermia may be considered if the
  child remains comatose after resuscitation
• 32ºC to 34ºC for 12 to 24 hours
• Class IIb Evidence
• Extrapolated from Adult data
• The 2005 guidelines emphasize the importance of
  avoiding hyperthermia
• Providers should monitor temperature and treat
  fever aggressively
• Class IIb Evidence

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Case 5

• 4yo M 15kg
• Known prior allergy to bee stings
• Stung today at school
• Mother has Epi pen in a drawer at home
• EMS arrives with him at the ACH

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Exam

• Markedly swollen face and eyes
• Lips and uvula swollen
• Stridor noted
• Diffuse wheeze
• BP 70/51
• What would you like to do?

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Epi dosing in pediatrics

• Dose is always 0.01mg/kg
• In Anaphylaxis use 11000 epinephrine IM
• This is 1mg/ml 0.01ml/kg IM
• 10kg 0.1ml
• 20kg 0.2ml
• 30kg 0.3ml

• In Resuscitation use 110,000 epinephrine IV/IO
• This is 0.1mg/ml 0.1ml/kg IV/IO
• 10kg 1ml
• 20kg 2ml
• 30kg 3ml

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Case 6

• 8 month old male
• Found unresponsive and blue by parents at 0600 in
  the morning
• EMS called and patch in indicating they are 5
  mins out with Asystole on the monitor and doing
  CPR
• Unable to get IV access
• You are preparing the trauma room and the team
  for arrival of the patient.

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Case 6

• Patient arrives in asystole with no signs of life
• The nurse gets an IV line and you administer
  Epinephrine and Atropine IV followed by 1 minute
  of good CPR
• There is no response
• What now?

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When to quit?

• Prospective study of 300 kids in CPA
• No survivor received epinephrine
• Sirbaugh et al. Annals of Emerg Med 1999.
  33(174)
• 101 kids with CPA or resp arrest
• No survivors needed resuscitative efforts for
  more than 20 minutes or gt 2 doses of epinephrine
• Schindler et al. New Eng J Med 1996. 335(1473-79)

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Termination of efforts

• Multiple other studies
• Small sample sizes, heterogeneous populations,
  retrospective designs, etc
• Some survival despite prolonged resuscitation
• Difficult to draw any firm conclusions
• Very little consensus in the literature to guide
  you
• PEA and Asystole may not carry the same prognosis
  in peds as it does in adults

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Current ACLS guidelines

• If a child fails to respond to two doses of
  epinephrine with a ROSC the child is unlikely to
  survive
• Resuscitative efforts may be ceased in pediatric
  CPA victims after 30 minutes unless exceptional
  circumstances exist
• i.e.
• primary hypothermic insult
• toxic drug exposure
• recurrent or refractory VF/VT

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• Cross sectional survey
• 160 PEM (70)
• 127 GEM (62)
• PEM were gt2x more likely to terminate
  resuscitative efforts if ROSC was not achieved by
  25 mins

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Case 6

• You administer a 2nd round of epinephrine with no
  effect and then ask if anyone has any other
  suggestions
• After 20mins of efforts you call the
  resuscitation and note the time of death
• The family members who have been present during
  the resuscitation are screaming for you to try
  and do something else
• They want to take the baby to another hospital
  hoping that they will be able to try something.

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Family Presence during resuscitaiton

• Traditionally family members were excluded
• The concept of family-centered care in the ED has
  now become more widespread
• Overwhelmingly family members are in favour or
  being present
• ED staff opinion has been mixed
• Many organizations now endorse family presence

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• Extensive Review of the ED literature
• Conclusions
• Family presence should be an option for routine
  invasive procedures in the ED
• Family presence should be an option for critical
  resuscitation and CPR in the ED
• All members of the resuscitation team must be in
  agreement
• Dedicated medical interpreter should accompany
  the patient
• If family leaves during a critical phase of the
  resuscitation all efforts should continue until
  family returns to allow final moments with their
  dying child
• Institutions should have guidelines
• Trainees should be provided with skills and
  experience in functioning under parental presence

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Pediatric Death in ED

• No formal training in coping with pediatric
  deaths
• With ED death there is usually no established
  relationship with the parents
• Viewed as particularly tragic with strong
  emotions
• Children aren't supposed to die
• It's not natural
• The child never had an opportunity to experience
  a full life

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Pediatric Death in ED

• CRISIS
• Powerful and often uncontrollable emotions
• Illogical or impaired decision-making abilities
• Recruiting other team members and family members
  for support

• GRIEF
• Begins with understanding that the child's death
  is real
• Allow (not force) family members to see or hold
  their dead child
• Prepare them for what they may see
• Opportunity to take a momento

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Pediatric Death in ED

• Address family feelings of guilt
• Reassure families that they did not contribute
  (either by acts of commission or omission) to the
  child's death
• Reassure families that every care procedure that
  could have been implemented in the ED was
  implemented is important
• Health team debriefing
• Strengths and weaknesses of the resuscitation
• Each team member can have an opportunity to ask
  questions or offer comments

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Questions?