Appendix 1

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Appendices
These appendices provide additional information to enhance the doctor’s knowledge of trauma-related
issues.

 TABLE OF CONTENTS
1 Triage Scenarios ...........................................................................................................................................293–308
2 Injury Prevention .........................................................................................................................................309–314
Table 1, Haddon’s Factor-phase Matrix for Motor Vehicle Crash Prevention ............................................310

3 Biomechanics of Injury...............................................................................................................................315–336
Figure 1, Cavitation ..............................................................................................................................................318
Figure 2, Frontal Impact, Unrestrained Driver.................................................................................................320
Figure 3, Rear Impact, Improper and Proper Headrest Use...........................................................................321
Figure 4, Braking Vehicle—Restrained Occupant............................................................................................323
Figure 5, Collision—Unrestrained Occupant....................................................................................................324
Figure 6, Collision—Restrained Occupant ........................................................................................................325
Figure 7, Proper Versus Improper Lap Belt Application ................................................................................327
Figure 8, Adult Pedestrian Injury Triad ............................................................................................................328
Figure 9, Cavitation Results.................................................................................................................................331
Figure 10, Ballistics Tumble and Yaw ................................................................................................................332
Table 1, Missile Kinetic Energy ...........................................................................................................................333

4 Tetanus Immunization................................................................................................................................337–340
Table 1, Wound Classification.............................................................................................................................338
Table 2, Summary of Tetanus Prophylaxis for the Injured Patient ...............................................................339

5 Trauma Scores: Revised and Pediatric.....................................................................................................341–344
Table 1, Revised Trauma Score ...........................................................................................................................343
Table 2, Pediatric Trauma Score .........................................................................................................................344

6 Sample Trauma Flow Sheet .......................................................................................................................345–350
7 Ocular Trauma (Optional Lecture) ............................................................................................................351–356
8 Injury Care in Austere and Hostile Environments (Optional Lecture)..............................................357–372

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APPENDIX 1

1

APPENDIX

Triage Scenarios
 INTRODUCTION
This is a self-assessment exercise, to be completed before you arrive for the course. Please read through the
introductory information on the following pages before reading the individual scenarios and answering the
related questions. This skills station is conducted in a group discussion format in which your participation
is expected. Upon completion of this session, you will receive a booklet of prepared responses for each scenario.
The goal of this station is to apply trauma triage principles in multiple patient scenarios.
Upon completion of this session, the participant will be able to:

A. Define triage.
B. Understand and describe the principles involved and the factors that must be considered in the triage
process.

C. Apply the principles of triage with the use of actual scenarios.

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 APPENDIX 1
TRIAGE SCENARIOS
I. DEFINITION OF TRIAGE
Triage is a process by which management of multiple patient casualties is prioritized.

II. PRINCIPLES OF TRIAGE
A. Degree of Life Threat Posed by the Injury
(ABCDEs of Care)
The degree of life threat posed by each injury is determined by considering the order of priorities in the
primary survey of an individual patient and applying these same principles to groups of patients. In
this system the patient with an airway or breathing
problem takes priority over a patient with a circulatory or neurologic disability.

B. Injury Severity
The overall severity of injury in a particular patient
may be related not only to an individual injury, but
also to the effects of different injuries and how the
patient responds to all of these injuries in a global
sense. For instance, an isolated fracture may be of
low priority. However, when it is combined with another source of major hemorrhage, which increases
the overall injury severity, the priority level in the
triage process also may increase.

C. Salvageability
The patient with the most severe injury or the greatest threat to life is not necessarily the patient that
receives top priority when dealing with multiple patient scenarios. Consideration must be given to the
likelihood of survival of the patient. In this system
the patient who is least likely to survive in spite of
having the most severe injuries is often relegated to
a lower priority and is managed after patients who
are considered more salvageable.

D. Resources Including Capability of Personnel
and Equipment
The patient whose needs exceed the resource capabilities is given a lower priority until the necessary
resources are secured.

E. Time, Distance, Environment
An injury that can be managed very quickly, although of lower severity and lower life threat,
may be treated as a higher priority because of the

294

short length of time taken for correcting the identified problem. Distance for travel in transporting a
patient to definitive care and other environmental
factors also need to be considered in prioritizing
management of multiple patient scenarios.

III. APPLICATION OF TRIAGE
PRINCIPLES
Triage is often based on incomplete information
because the detailed information on the status of a
patient may not be immediately obvious. However,
decisions have to be made on the best information
available. Frequently it is not possible to obtain such
parameters as vital signs on the victims in multiple
casualties. Indeed, it is necessary in many instances
to make decisions by surveying an entire situation
at a distance and determining on that basis which
of the patients is the most severely injured. Simple
factors (eg, a patient shouting in agony as opposed
to one lying still with noisy breathing that can be
detected from a distance) could be cues that would
allow a decision to approach one patient with a potential airway problem before approaching another
patient who may have a fractured extremity causing
intense pain but not necessarily producing a major
threat to life.
An important concept is to avoid indecision and
proceed quickly with incomplete information because time is of the essence in the entire triaging process. In some situations, it may be possible to obtain
information such as vital signs, etc from prehospital
personnel. Such information should be used in prioritizing the management of multiple victims.
As a general rule, the order of priorities in multiple
victim scenarios is the same as in an individual patient where airway (A) takes priority over breathing
(B) and circulation (C). Therefore, the patient with
an airway problem is managed before a patient with
a circulatory problem. However, in some instances it
may be necessary to prioritize patients based on salvageability. For example, a patient who has the least
chance of survival, although being the most severely
injured, may not be managed before a patient who
can be stabilized very quickly and who has a problem that can be easily and rapidly reversed.
Triage decisions involving salvageability, in most
situations, are dependent on assessment of the need
for definitive care and not emergency care. Available
resources and time/distance factors must be considered when making these decisions. For example, 3
American College of Surgeons

APPENDIX 1 
TRIAGE SCENARIOS
patients with intraabdominal injuries present with
hypotension. They would be triaged differently if
1 had a fractured limb and the other 2 had severe
head injuries. Additionally, the 2 with severe head
injuries would be triaged differently if 1 also had a
suspected aorta disruption.
The triage process also involves identification of the
necessary resources for stabilizing patients. If these

Advanced Trauma Life Support

resources are not available, the patient may not be
given the same priority in the triage process.
Part of the triage process also may involve a determination of the most appropriate mode of transfer
as well as the most appropriate institution to which
the patient should be transferred based on the nature of the injuries and the resources required for
managing the patient definitively.

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 APPENDIX 1
TRIAGE SCENARIOS

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APPENDIX 1 
TRIAGE SCENARIOS

Triage Scenario I—Gas Explosion in the Gymnasium
Scenario: You are summoned to a triage area at a construction site where 5 workers are injured in a gas
explosion during the renovation of a gymnasium ceiling. After you quickly survey the situation, the
patient’s conditions are as follows:
Patient A—A young man is screaming, “Please help me, my leg is killing me!”
Patient B—A young woman is cyanotic, tachypneic, and breathing very noisily
Patient C—A 50-year-old man is lying in a pool of blood with his left trouser leg soaked in blood
Patient D—A young man is lying face down on a stretcher and not moving
Patient E—A young man is swearing expletives and shouting that someone should help him or he will
call his lawyer.
Questions for Response:
1. Identify what you perceive to be the primary problem requiring treatment.
Patient A is a young man screaming “Please help me, my leg is killing me!”
Possible Injury/Problem:________________________________________________________________
Patient B appears cyanotic and tachypneic, and is breathing very noisily.
Possible Injury/Problem:________________________________________________________________
Patient C is a 50-year-old man lying in a pool of blood with his left trouser leg soaked in blood.
Possible Injury/Problem:________________________________________________________________
Patient D is lying face down on a stretcher and not moving.
Possible Injury/Problem:________________________________________________________________
Patient E is swearing expletives and shouting that someone should help him or he will call his
lawyer.
Possible Injury/Problem:________________________________________________________________

(Proceed to next page for continuation of Scenario I.)

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 APPENDIX 1
TRIAGE SCENARIOS

Triage Scenario I—Gas Explosion in the Gymnasium continued
2. Establish your patient priorities for further evaluation by placing a number #1 through #5 (with #1
being your highest priority and #5 being your lowest priority) in the space provided next to each
patient letter.
_____

Patient A

_____

Patient B

_____

Patient C

_____

Patient D

_____

Patient E

3. Briefly outline your rationale for prioritizing these patients in the manner you did.
Priority 1—Patient _____:
Rationale: ________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Priority 2—Patient _____:
Rationale: ________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Priority 3—Patient _____:
Rationale: ________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Priority 4—Patient _____:
Rationale: ________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Priority 5—Patient _____:
Rationale: ________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
(Proceed to next page for continuation of Scenario I.)

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TRIAGE SCENARIOS

Triage Scenario I—Gas Explosion in the Gymnasium continued
4. Briefly, describe what basic life support maneuvers or additional assessment techniques you would
employ to further evaluate the problem(s).
Priority 1—Patient _____:
Basic life support maneuvers or additional assessment techniques:________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Priority 2—Patient _____:
Basic life support maneuvers or additional assessment techniques:________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Priority 3—Patient _____:
Basic life support maneuvers or additional assessment techniques:________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Priority 4—Patient _____:
Basic life support maneuvers or additional assessment techniques:________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Priority 5 — Patient _____:
Basic life support maneuvers or additional assessment techniques:________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

(Proceed to Scenario II, which is a continuation of this scenario.)
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 APPENDIX 1
TRIAGE SCENARIOS

Triage Scenario II—Gas Explosion in the Gymnasium continued
Continuation of Scenario I:
1. Characterize the patients according to who receives basic or advanced life support care and describe
what that care would be. List the patients in the priority order as you identified them in Scenario I,
starting with your first priority. Insert a mark in the box under BLS and/or ALS according to your
decision of what the patient needs.
Patient

BLS

ALS

____________





Description of Care
_____________________________
_____________________________
_____________________________
_____________________________

____________





_____________________________
_____________________________
_____________________________
_____________________________

____________





_____________________________
_____________________________
_____________________________
_____________________________

____________





_____________________________
_____________________________
_____________________________
_____________________________

____________





_____________________________
_____________________________
_____________________________
_____________________________

(Proceed to next page for continuation of Scenario II.)

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TRIAGE SCENARIOS

Triage Scenario II—Gas Explosion in the Gymnasium continued
2. Prioritize patient transfers and identify destinations. Provide a brief rationale for your destination
choice.
Priority

Patient

1

____________

Destination



Trauma center



Nearest hospital

____________________________________________________________
____________________________________________________________
____________________________________________________________
2

____________



Trauma center



Nearest hospital

____________________________________________________________
____________________________________________________________
____________________________________________________________
3

____________



Trauma center



Nearest hospital

____________________________________________________________
____________________________________________________________
____________________________________________________________
4

____________



Trauma center



Nearest hospital

____________________________________________________________
____________________________________________________________
____________________________________________________________
5

____________



Trauma center



Nearest hospital

____________________________________________________________
____________________________________________________________
____________________________________________________________
3. In situations involving multiple patients, what criteria would you use to identify and prioritize the
management of these patients?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
4. What cues can you elicit that would be of assistance in triage?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
(Proceed to next page for continuation of Scenario II.)

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 APPENDIX 1
TRIAGE SCENARIOS

Triage Scenario II—Gas Explosion in the Gymnasium continued
5. Which patient injuries or complaints should receive treatment at the scene before prehospital personnel arrive?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
6. After prehospital personnel arrive, what techniques should be instituted and what principles govern
the order of initiation of such techniques? Attention should be directed at
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
7. In multiple patient situations, who should be transported? Who should be transported early?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
8. Who could have treatment delayed and be transported later?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
(Proceed to next page for Scenario III.)

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APPENDIX 1 
TRIAGE SCENARIOS

Triage Scenario III—Trailer-home Explosion and Fire
Scenario: An explosion and fire, due to a faulty gas line, has involved 1 trailer in a nearby trailer park.
Because of the close proximity of the incident to the hospital, the prehospital personnel transport the patients directly to the hospital without prior notification. The 5 patients, all members of the same family,
are immobilized on long spine boards when they arrive at your small hospital emergency department.
The injured patients are:
Patient A—A 45-year-old man is coughing and expectorating carbonaceous material. Hairs on his face
and head are singed. His voice is clear and he is complaining about pain in his hands, which have erythema and early blister formation.
VS: BP 120 mm Hg systolic, HR 100, and RR 30
Patient B—A 6-year-old girl appears frightened and is crying. She complains of pain from burns
(erythema/blisters) over her back, buttocks, and both legs posteriorly.
VS: BP 110/70 mm Hg, HR 100, and RR 25
Patient C—A 70-year-old man is coughing, wheezing, and expectorating carbonaceous material. His
voice is hoarse and he responds only to painful stimuli. There are erythema, blisters, and charred skin to
the anterior chest and abdominal walls and circumferential burns of both thighs.
VS: BP 80/40 mm Hg, HR 140, and RR 35
Patient D—A 19-year-old woman is obtunded but responds to pain when her right humerus and leg are
moved. There is no obvious deformity of the arm, and the thigh is swollen while in a traction splint.
VS: BP 140/90 mm Hg, HR 110, and RR 32
Patient E—A 45-year-old man is pale and spontaneously complaining of pain in his pelvis. There is clinical evidence of fracture with abdominal distention and tenderness to palpation. There is erythema and
blister of the anterior chest and abdominal walls and thighs. He also has a laceration to the forehead.
VS: BP 130/90 mm Hg, HR 90, and RR 25
Management priorities in this scenario can be based on information obtained by surveying the injured
patients at a distance. Although there may be doubt as to which patient is more injured, based on the
available information, a decision has to be made to proceed with the best information available at the
time.

(Proceed to the next page for questions related to this scenario.)

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 APPENDIX 1
TRIAGE SCENARIOS

Triage Scenario III—Trailer-home Explosion and Fire continued
1. Identify which patient(s) has associated trauma and/or inhalation injury in addition to body surface burns, and place a check in the box next to the patient letter.



Patient A



Patient B



Patient C



Patient D



Patient E

2. Using the table provided below,
a. Establish priorities of care in your hospital emergency department by placing a number (#1
through #5, with #1 being your highest priority and #5 being your lowest priority) in the space
provided for each patient letter in the column “Treatment Priority.”
b. Identify which patient has associated trauma and/or an airway injury and place a mark in the
appropriate column under “Associated.”
c. Estimate the percent of body surface area (BSA) burn for each patient and enter the percent for
each patient letter in the column “% BSA.”
d. Identify which patient is transferred to a burn center and/or to a trauma center and place a mark
in the appropriate column under “Transfer.”
e. Establish your priorities for transfer and enter your priority number under “Transfer Priority.”
Associated

Patient

Treatment
Airway Priority
Trauma
Injury

%
BSA

Transfer
Burn

Trauma

Transfer Priority

A
B
C
D
E

(Proceed to next page for Scenario IV.)

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APPENDIX 1 
TRIAGE SCENARIOS

Triage Scenario IV—Cold Injury
Scenario:
You are in your hospital when you receive a call that 5 members of a doctor’s family were snowmobiling
on a lake when the ice broke. Four family members fell into the lake water. The doctor was able to stop in
time and left to seek help. The response time of basic and advanced life support assistance was 15 minutes. By the time basic and advanced life support units arrived, 1 individual crawled out of the lake and
removed another victim from the water. Two individuals remained submerged, were found by rescue
divers, and were removed from the lake. Rescuers from the scene provided the following information.
Patient A—The doctor’s 10-year-old grandson was removed from the lake by rescuers. The ECG monitor shows asystole.
Patient B—The doctor’s 65-year-old wife was removed from the lake by rescuers. The ECG monitor
shows asystole.
Patient C—The doctor’s 35-year-old daughter, who had been in the lake and was helped out of the water
by her sister-in-law, has bruises to her anterior chest wall.
VS: BP 90 mm Hg systolic
Patient D—The doctor’s 35-year-old daughter-in-law, who had been submerged and crawled out of the
lake, has no obvious signs of trauma.
VS: BP 110 mm Hg systolic
Patient E—The 76-year-old retired doctor, who never went into the water, has no complaints except for
cold hands and feet.
1. Establish the priorities for transport from the scene to your emergency department and provide a brief
rationale for your decisions.
Rationale
Transport priority #1

Patient _____

____________________________________________
____________________________________________

Transport priority #2

Patient _____

____________________________________________
____________________________________________

Transport priority #3

Patient _____

____________________________________________
____________________________________________

Transport priority #4

Patient _____

____________________________________________
____________________________________________

Transport priority #5

Patient _____

____________________________________________
____________________________________________

(Proceed to next page for continuation of Scenario IV.)

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 APPENDIX 1
TRIAGE SCENARIOS

Triage Scenario IV—Cold Injury continued
2. Upon arrival in the emergency department, all patients should have their core temperature taken.
Briefly, outline your rationale for the remainder of the primary assessment, resuscitation, and secondary survey of each patient.
Patient A: Priority #______: __________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Patient B: Priority #______: __________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Patient C: Priority #______: __________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Patient D: Priority #______: __________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Patient E: Priority #______: __________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

(Proceed to next page for Scenario V.)

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TRIAGE SCENARIOS

Triage Scenario V—Car Crash
Scenario: You are the only doctor available in a 100-bed community emergency department. One nurse
and 1 nurse’s aide are available to assist you. Ten minutes ago you were notified by radio that ambulances would be arriving with patients from a single motor vehicle crash. No further report is received.
Two ambulances arrive with 5 patients who were occupants in an automobile traveling at 60 miles (96
km)/hour before it crashed. The injured patients are:
Patient A—A 45-year-old man was the driver of the car. He apparently was not wearing a seat belt. Upon
impact, he was thrown against the windscreen. On admission, he is notably in severe respiratory distress. The prehospital personnel provide the following information to you after preliminary assessment.
Injuries include (1) severe maxillofacial trauma with bleeding from the nose and mouth, (2) an angulated
deformity of the left forearm, and (3) multiple abrasions over the anterior chest wall.
VS: BP 150/80 mm Hg, HR 120, RR 40, GCS Score = 8
Patient B—A 38-year-old woman passenger was apparently thrown from the front seat and found 30
feet (9 meters) from the car. On admission she is awake, alert, and complains of abdominal and chest
pain. The report you are given indicates that on palpating her hips, she complains bitterly of pain and
fracture-related crepitus is felt.
VS: BP 110/90 mm Hg, HR 140, RR 25
Patient C—A 48-year-old male passenger was found under the car. You are told that on admission he is
confused and responds slowly to verbal stimuli. Injuries include multiple abrasions to his face, chest, and
abdomen. Breath sounds are absent on the left, and his abdomen is tender to palpation.
VS: BP 90/50 mm Hg, HR 140, RR 35, GCS Score = 10
Patient D—A 25-year-old hysterical woman was extricated from the back seat of the vehicle. She is 8
months pregnant and complains of abdominal pain. Injuries include multiple abrasions to her face and
anterior abdominal wall. You are told that her abdomen is tender to palpation. She is in active labor.
VS: BP 120/80 mm Hg, HR 100, RR 25
Patient E—A 6-year-old boy was extricated from the floor of the rear seat. At the scene, he was alert and
talking. He now responds to painful stimuli by only crying out. Injuries include multiple abrasions and
an angulated deformity of the right lower leg. There is dried blood around his nose and mouth. You are
told that his vital signs are:
VS: BP 110/70 mm Hg, HR 180, RR 35

(Proceed to next page for questions related to Scenario V.)

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 APPENDIX 1
TRIAGE SCENARIOS

Triage Scenario V—Car Crash continued
1. Outline the steps you would take to triage these 5 patients.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
2/3. Establish your patient priorities by placing a number (#1 through #5, with #1 being your highest
priority and #5 being your lowest priority) in the space provided next to each lettered patient. In the
space provided here, also briefly outline your rationale for prioritizing these patients in the manner
you did.
Priority #_____
Patient A
Rationale:__________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Priority #_____
Patient B
Rationale:__________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Priority #_____
Patient C
Rationale:__________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Priority #_____
Patient D
Rationale:__________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Priority #_____
Patient E
Rationale:__________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

(Conclusion of Triage Scenarios)

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