BASE HOSPITAL GROUP ONTARIO Chapter 2 for 12 Lead Training -RHYTHM PRACTICE- Ontario Base Hospital...
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Transcript of BASE HOSPITAL GROUP ONTARIO Chapter 2 for 12 Lead Training -RHYTHM PRACTICE- Ontario Base Hospital...
![Page 1: BASE HOSPITAL GROUP ONTARIO Chapter 2 for 12 Lead Training -RHYTHM PRACTICE- Ontario Base Hospital Group Education Subcommittee 2008 TIME IS MUSCLE.](https://reader038.fdocuments.us/reader038/viewer/2022103005/56649d0e5503460f949e3ee9/html5/thumbnails/1.jpg)
BASE HOSPITAL GROUPONTARIO
Chapter 2 for 12 Lead Training
-RHYTHM PRACTICE-
Ontario Base Hospital GroupEducation Subcommittee
2008
TIME IS MUSCLE
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OBHG Education Subcommittee
RHYTHM PRACTICE
AUTHOR
Tim Dodd, AEMCA, ACPHamilton Base Hospital
REVIEWERS/CONTRIBUTORS
Al Santos A-EMCA, ACP
Donna L. Smith AEMCA, ACPHamilton Base Hospital
2008 Ontario Base Hospital Group
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BASE HOSPITAL GROUPONTARIO
Let’s Have Some Fun!
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BASE HOSPITAL GROUPONTARIO
Sinus Mechanisms
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OBHG Education Subcommittee
Sinus Node
Normal Sinus Rhythm (NSR)
Sinus Bradycardia
Sinus Tachycardia
Sinus Arrhythmia
Sinus Arrest/Pause
Sinoatrial Exit Block
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OBHG Education Subcommittee
Normal Sinus Rhythm (NSR)
Rate: 60-100 beats/min
Rhythm: regular
P waves: uniform, + (upright) in lead II,
one precedes each QRS complex
PR interval: 0.12 - 0.20 seconds and
constant
QRS duration: < 0.12 sec
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OBHG Education Subcommittee
Normal Sinus Rhythm (NSR)
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OBHG Education Subcommittee
Sinus Bradycardia
Rate: less than 60 beats/min Rhythm: regular
P waves: uniform in appearance, upright
and one precedes each QRS complex
PR interval: 0.12 - 0.20 sec and constant
QRS duration: < 0.12 sec
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OBHG Education Subcommittee
Sinus Bradycardia
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OBHG Education Subcommittee
Sinus Tachycardia
Rate: greater than 100-150 beats/min Rhythm: regular
P waves: uniform, upright, one precedes
each QRS
PR interval: 0.12 - 0.20 sec and constant
QRS duration: < 0.12 sec
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OBHG Education Subcommittee
Sinus Tachycardia
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BASE HOSPITAL GROUPONTARIO
ENOUGH OF SINUS
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OBHG Education Subcommittee
Sinus Arrhythmia
Rate: 60-100 beats/min
Rhythm: irregular
P waves: uniform in appearance, upright,
one precedes each QRS
PR interval: 0.12 - 0.20 sec and constant
QRS duration: < 0.12 sec
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OBHG Education Subcommittee
Sinus Arrhythmia
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OBHG Education Subcommittee
Sinus Arrest/Pause Rate: usually normal but varies due to the
arrest Rhythm: irregular; the arrest is of
undetermined length P waves: uniform in appearance, upright,
one precedes each QRS PR interval: 0.12 - 0.20 sec and constant QRS duration: < 0.12 sec
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OBHG Education Subcommittee
Sinus Arrest/Pause
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OBHG Education Subcommittee
Sinoatrial Exit Block Rate: varies due to the pause Rhythm: irregular; each pause is the same
as the distance between two other P-P intervals
P waves: uniform in appearance, upright, one precedes each QRS
PR interval: 0.12 - 0.20 sec and constant QRS duration: < 0.12 sec
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OBHG Education Subcommittee
Sinoatrial Exit Block
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BASE HOSPITAL GROUPONTARIO
Atrial Dysrhythmias
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OBHG Education Subcommittee
Atrial Dysrhythmias
Premature Atrial Complexes (PACs) Wandering Atrial Pacemaker (WAP)
Supraventricular Tachycardia (SVT)
Wolff-Parkinson-White Syndrome (WPW)
Atrial Flutter
Atrial Fibrillation (A-Fib)
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OBHG Education Subcommittee
Premature Atrial Complexes (PACs)
Rate: depends on underlying rhythm Rhythm: regular with premature beats P waves: premature (earlier than expected)
and may differ in shape from sinus P waves PR interval: 0.12 - 0.20 sec and constant QRS duration: < 0.12 sec
Note: Ectopic complex
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OBHG Education Subcommittee
Premature Atrial Complexes (PACs)
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OBHG Education Subcommittee
Wandering Atrial Pacemaker (WAP)
Rate: usually 60-100 beats/min; if greater than 100 beats/min, it’s termed multifocal atrial tachycardia
Rhythm: may be normal or irregular due to shift in ectopic atrial locations
P waves: size, shape and direction change (3 or more different P waves)
PR interval: may be normal or variable QRS duration: < 0.12 sec
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OBHG Education Subcommittee
Wandering Atrial Pacemaker (WAP)
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OBHG Education Subcommittee
Supraventricular Tachycardia (SVT/PSVT)
Rate: 120-250 beats/min Rhythm: regular P waves: not present PR interval: not measurable QRS duration: < 0.12 sec
Note: PSVT is an SVT
that starts/ends suddenly
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OBHG Education Subcommittee
Supraventricular Tachycardia (SVT)
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OBHG Education Subcommittee
Wolff-Parkinson-White Syndrome (WPW)
Rate: usually 60-100 beats/min (can be
associated with runs/episodes of A-Fib) Rhythm: regular P waves: uniform in appearance, upright, one
precedes each QRS PR interval: 0.12 - 0.20 sec and constant QRS duration: usually > 0.12 sec; slurred
upstroke of the QRS complex (delta wave)
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OBHG Education Subcommittee
Wolff-Parkinson-White Syndrome (WPW)
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OBHG Education Subcommittee
Atrial Flutter
Rate: atrial rate 250-450 beats/min; ventricular rate will not usually exceed 180 beats/min
Rhythm: atrial regular; ventricular regular or irregular
P waves: saw-toothed “flutter” waves PR interval: not measurable QRS duration: < 0.12 sec
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OBHG Education Subcommittee
Atrial Flutter
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OBHG Education Subcommittee
Atrial Fibrillation (A-fib)
Rate: variable
Rhythm: irregularly irregular
P waves: no identifiable P waves
PR interval: not measurable
QRS duration: < 0.12 sec
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OBHG Education Subcommittee
Atrial Fibrillation (A-fib)
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BASE HOSPITAL GROUPONTARIO
Junctional Rhythms
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OBHG Education Subcommittee
Junctional Rhythms
Premature Junctional Complex (PJC)
Junctional Rhythm
Accelerated Junctional Rhythm
Junctional Tachycardia
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OBHG Education Subcommittee
Premature Junctional Complexes (PJC)
Rate: usually normal but depends on the underlying rhythm
Rhythm: regular with premature beats P waves: may occur before, during or after the
QRS (inverted if visible) PR interval: if P visible, < or = to 0.12 sec QRS duration: < 0.12 sec
Note: Ectopic complex
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OBHG Education Subcommittee
Premature Junctional Complexes (PJC)
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OBHG Education Subcommittee
Junctional Rhythm
Rate: 40-60 beats/min Rhythm: regular P waves: not present or may occur
before, during or after the QRS (inverted if present)
PR interval: not measurable, but if present usually < or = to 0.12 sec
QRS duration: < 0.12 sec
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OBHG Education Subcommittee
Junctional Rhythm
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OBHG Education Subcommittee
Junctional Rhythm
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OBHG Education Subcommittee
Accelerated Junctional Rhythm
Rate: 61-100 beats/min Rhythm: regular P waves: not present or may occur
before, during or after the QRS (inverted if present; may be notched or S waved)
PR interval: not measurable, but if present usually < or = to 0.12 sec
QRS duration: < 0.12 sec
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OBHG Education Subcommittee
Accelerated Junctional Rhythm
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OBHG Education Subcommittee
Junctional Tachycardia
Rate: 101-180 beats/min Rhythm: regular P waves: not present or may occur
before, during or after the QRS (inverted if present)
PR interval: not measurable, but if present usually < or = to 0.12 sec
QRS duration: < 0.12 sec
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OBHG Education Subcommittee
Junctional Tachycardia
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BASE HOSPITAL GROUPONTARIO
Ventricular Rhythms
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OBHG Education Subcommittee
Ventricular Rhythms
Premature Ventricular Complexes (PVC's)
Idioventricular Rhythm
Ventricular Tachycardia (VT)
Torsades de Pointes (TdeP)
Ventricular Fibrillation (VF)
Asystole
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OBHG Education Subcommittee
Premature Ventricular Complexes (PVC's)
Rate: depends on underlying rhythm
Rhythm: regular with premature beats
P waves: absent
PR interval: none
QRS duration: > 0.12 sec, wide and
bizarre!
Note: Ectopic complex
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OBHG Education Subcommittee
Premature Ventricular Complexes (PVC's)
Note – Complexes not Contractions
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OBHG Education Subcommittee
PVC’s
Uniformed/Multiformed
Couplets/Salvos/Runs
Bigeminy/Trigeminy/Quadrageminy
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OBHG Education Subcommittee
Uniformed PVC’s
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OBHG Education Subcommittee
R on T Phenomena
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OBHG Education Subcommittee
Multiformed PVC’s
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OBHG Education Subcommittee
PVC Couplets
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OBHG Education Subcommittee
PVC Salvos and Runs
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OBHG Education Subcommittee
Bigeminy PVC’s
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OBHG Education Subcommittee
Trigeminy PVC’s
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OBHG Education Subcommittee
Quadrageminy PVC’s
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OBHG Education Subcommittee
Ventricular Escape Beats
Rate: depends on underlying rhythm
Rhythm: regular with late beats; occurs after
the next expected sinus beat
P waves: absent
PR interval: none
QRS duration: > 0.12 sec. wide and bizarre
Note: Ectopic complex
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OBHG Education Subcommittee
Ventricular Escape Beats
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OBHG Education Subcommittee
Idioventricular Rhythm
Rate: 20-40 beats/min
Rhythm: regular
P waves: absent
PR interval: none
QRS duration: > 0.12 sec
Note: “Wide and Slow, (Oh No!) it’s Idio”
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OBHG Education Subcommittee
Idioventricular Rhythm
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OBHG Education Subcommittee
Ventricular Tachycardia (VT) Rate: 101-250 beats/min Rhythm: regular P waves: absent PR interval: none QRS duration: > 0.12 sec. often difficult
to differentiate between QRS and T wave
Note: Monomorphic - same shape
and amplitude
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OBHG Education Subcommittee
Ventricular Tachycardia (VT)
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OBHG Education Subcommittee
V Tach
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OBHG Education Subcommittee
Torsades de Pointes (TdeP)
Rate: 150-300 beats/min
Rhythm: regular or irregular
P waves: none
PR interval: none
QRS duration: > 0.12 sec. gradual
alteration in amplitude and direction of
the QRS complexes
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OBHG Education Subcommittee
Torsades de Pointes (TdeP)
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OBHG Education Subcommittee
Ventricular Fibrillation (VF)
Rate: CNO as no discernible complexes
Rhythm: rapid and chaotic
P waves: none
PR interval: none
QRS duration: none
Note: Fine vs. coarse?
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OBHG Education Subcommittee
Ventricular Fibrillation (VF)
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OBHG Education Subcommittee
Ventricular Fibrillation (VF)
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BASE HOSPITAL GROUPONTARIO
…”…”Next time, try to remove his shirt!”Next time, try to remove his shirt!”
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OBHG Education Subcommittee
Asystole (Cardiac Standstill)
The Mother of all Bradycardias – Rob Theriault
Rate: none
Rhythm: none
P waves: none
PR interval: not measurable
QRS duration: absent
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OBHG Education Subcommittee
Asystole (Cardiac Standstill)
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OBHG Education Subcommittee
AsystoleThe Mother of all Bradycardias
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BASE HOSPITAL GROUPONTARIO
QUESTIONS?
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BASE HOSPITAL GROUPONTARIO
AtrioVentricular (AV) Blocks
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OBHG Education Subcommittee
Atrioventricular (AV) Blocks
First-degree AV block
Second-degree AV block, type I
(Wenckebach or Mobitz I)
Second-degree AV block, type II (Mobitz II)
Third-degree AV block (Complete AV Block)
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OBHG Education Subcommittee
First-degree AV block
Rate: depends on underlying rhythm
(usually regular)
Rhythm: regular
P waves: normal in size and shape
PR interval: > 0.20 sec but constant
QRS duration: < 0.12 sec
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OBHG Education Subcommittee
First-degree AV block
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OBHG Education Subcommittee
2nd Degree AV block Type I (Wenckebach/Mobitz Type I)
Rate: atrial rate > ventricular rate Rhythm: atrial reg.; ventricular irreg. P waves: normal in size and shape PR interval: lengthens with each cycle
until a P appears with no QRS complex QRS duration: < 0.12 sec (Periodically
dropped QRS complex!)
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OBHG Education Subcommittee
2nd Degree AV block Type I (Wenckebach/Mobitz Type I)
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OBHG Education Subcommittee
2nd Degree AV block Type II (Mobitz Type II)
Rate: atrial rate > the ventricular rate Rhythm: atrial reg.; ventricular irreg. P waves: normal in size and shape PR interval: within normal limits or
slightly prolonged but constant QRS duration: < 0.12 sec (Periodically
dropped QRS complex!)
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OBHG Education Subcommittee
2nd Degree AV block Type II (Mobitz Type II)
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OBHG Education Subcommittee
3rd Degree AV block (Complete AV Block)
Rate: atrial rate is > ventricular rate Rhythm: atrial reg.; ventricular reg. (P
waves plot through) P waves: normal in size and shape PR interval: no relationship (independent) QRS duration: narrow or wide depending
on location of pacemaker
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OBHG Education Subcommittee
3rd Degree AV block (Complete AV Block)
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OBHG Education Subcommittee
3rd Degree AV block
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BASE HOSPITAL GROUPONTARIO
Pacemaker Rhythms
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OBHG Education Subcommittee
Cardiac Pacemakers
DefinitionDelivers artificial stimulus to heartCauses depolarization and contraction
UsesBradyarrhythmiasAsystoleTachyarrhythmias (overdrive pacing)
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OBHG Education Subcommittee
Cardiac Pacemakers
FixedFires at constant rateCan discharge on T-waveVery rare
DemandSenses patient’s rhythmFires only if no activity sensed after preset
interval (escape interval)
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OBHG Education Subcommittee
Cardiac Pacemakers
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OBHG Education Subcommittee
Cardiac Pacemakers
Demand Pacemaker TypesAtrial
Fires atriaAtria fire ventriclesRequires intact AV conduction
VentricularFires ventricles
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OBHG Education Subcommittee
Cardiac Pacemakers
Demand Pacemaker TypesAtrial Synchronous
Senses atriaFires ventricles
AV SequentialTwo electrodesFires atria/ventricles in sequence
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OBHG Education Subcommittee
Cardiac Pacemakers
Special ConsiderationsPacemaker does NOT affect
treatment of cardiac arrestDo NOT defibrillate directly over
pacemaker generatorPacemakers may keep AEDs
from advising shock
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OBHG Education Subcommittee
Atrial Pacemaker (Single Chamber)
pacemaker
•Capture?
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OBHG Education Subcommittee
Ventricular Pacemaker (Single Chamber)
pacemaker
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OBHG Education Subcommittee
Dual Paced Rhythm
pacemaker
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OBHG Education Subcommittee
Pulseless Electrical Activity(PEA)
The absence of a detectable pulse and
blood pressure
Presence of electrical activity of the heart as
evidenced by ECG rhythm, but not VF or VT
= 0/0 mmHg+
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BASE HOSPITAL GROUPONTARIO
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BASE HOSPITAL GROUPONTARIO
QUESTIONS?
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BASE HOSPITAL GROUPONTARIO
Well Done!
Education Subcommittee
START QUIT