Transcript Gunshots, Stabbings and Other Nefarious Acts

Penetrating Trauma
ECRN Mod II 2010 CE
Condell Medical Center EMS System
IDPH Site code #107200E-1210
Prepared by: Lt. William Hoover, Medical Officer
Wauconda Fire District
Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P
1
Objectives
• Upon successful completion of this module, the ECRN
will be able:
• Identify epidemiologic facts for firearm related
injuries
• Identify relationship between kinetic energy and
prediction of injury
• Identify how energy is transmitted from a
penetrating object to body tissue
• Identify characteristics of handguns, shotguns and
rifles
• Identify organ injuries associated with gunshot
injuries
2
Objectives cont’d
• Identify management goals for a patient with gunshot
wounds
• Identify items that could cause stab/penetration
trauma
• Identify potential internal organ injuries dependant on
item causing stab/penetration injury
• Identify management goals for a stab/penetrating
trauma patient
• Identify adult fluid challenge issues
3
Objectives cont’d
•
•
•
•
Identify adult fluid challenge dosages
Identify pediatric fluid challenge issues
Identify pediatric fluid challenge dosages
Identify indications for implementation of
intraosseous infusion
• Calculate pediatric fluid challenge dosages
4
Gunshots…
5
Gunshot Victims
6
Firearm Related Injuries
• Gunshot wounds are either penetrating or
perforating wounds
• Technical terms:
– Penetrating gunshots are when the bullet
enters, but does not come out of the body.
– Perforating gunshots are when the bullet
enters and exits the body
7
Perforating Gunshots
8
Penetrating gunshot
9
Entrance wound
• Surrounded by a
reddish-brown area
of abraded skin,
known as the
abrasion ring
• Small amounts of
blood
10
Mechanism of Energy Exchange
• As bullet passes through tissue, it decelerates,
dissipating and transferring kinetic energy to
tissues
– Cause of the injury is the kinetic energy
• Velocity more important than mass in
determining how much damage is done
– Small bullet at high speed will do more
damage than large bullet at slow speed
11
Mechanism of Energy Exchange
• High velocity
– High powered rifles; hunting rifles
– Sniper rifles
• Medium velocity
– Handguns, shotguns
– Compound bows and arrows (higher energy released)
• Low velocity
– Knives, arrows
– Falling through plate glass window, stepping on
things, bits flung by lawnmower
12
Medium & High Velocity
• These items are usually propelled by
gunpowder or other explosive
• Faster the object, the deeper the injury
• Causes damage to the tissue it impacts
• Creates a “pressure wave” which causes
damage frequently greater than the tissue
directly impacted
• If bone is struck, bone shatters and multiple
bone fragments are dispersed
13
Low velocity
• Usually a result of items such as knives that
are propelled by a person’s own power
– Also includes objects inadvertently stepped on
– Includes many objects a patient may be impaled
on
• Damage usually limited to the area directly in
contact with the object
14
Types of Firearms
• Pistols
– Revolver
– Semi-Automatic
• Shotguns
– Pump
– Semi-Automatic
• Rifles
– Bolt
– Lever action
15
Pistols – Medium Velocity
16
Shotguns – Medium Velocity
17
Rifles – High Velocity
18
Projectiles – High Velocity
• Rifle bullets are
designed to have
much greater
velocity than
shotgun bullets
• Different size of
casing provides
more or less
gunpowder
19
7 mm rifle shell – High Velocity
• Bonded design for deep
penetration and 90%+
weight retention
• Streamlined design
delivers ultra-flat
trajectories
• Devastating terminal
performance across a
wide velocity range
• Unequaled accuracy and
terminal performance for
long-range shots
20
Projectiles – Medium Velocity
• Shotgun ammunition
can be a variety of kinds
• Slugs are one large
bullet in the shell
• Some shells contain
numerous pellets of
various sizes
• This can influence
patient’s injuries
21
Shotgun Shell – Medium Velocity
12 Gauge Shotgun Slug
12 Gauge Shotgun with #6 shot
22
.38 caliber pistol ammunition
• Controlled expansion to
1.5x its original
diameter over a wide
range of velocities
• Heavier jacket stands up
to the high pressures
and velocities of the
highest performance
handgun cartridges
23
Compound Bows and Arrows –
Medium Velocity
24
Arrowhead Types – Medium Velocity
Target tips
Broadhead
25
Arrow injuries
26
Another ouch….
• How would
you initially
stabilize
these
wounds?
27
Principles of Wound Care
• What are principles of wound care for the two
previous wounds?
– Scene safety – even in the ED
– Control bleeding
• Usually little to no bleeding while object still
impaled
– Prevent further damage
• Immobilize the object in place
–Gauze, tape, whatever it takes
– Reduce infection
• Prevent further contamination
28
Different Types of Knives
• Knives come in a wide
variety of shapes and
sizes
• The type of knife can
influence the injuries a
patient may have
• Hilt/handle of knife
does not necessarily tell
how long the knife is
29
Anticipation of Injury
• Trajectory may or may not be straight
• Knowing anatomy helps anticipate organ
injury
• Anticipating organ injury helps in knowing
what signs and symptoms to watch for
• Anticipation of injury = proactive care
– Head wound = monitoring level of consciousness
– Chest wound = assessing lung sounds
– Abdominal wound = assessing internal blood loss
30
Stabbings
• 15 year old stabbed in
the head at a London
bus stop
• Cannot determine from
the outer wound what
the damage is internally
• Assume the worse
• Stabilization of impaled
objects extremely
crucial
31
Police Officer Stabbing
What injuries do you suspect?
32
Organ Injury
Patient was shot
with a MAC-10
machine gun and
sustained a
liver injury
Lap sponge under fold of skin
Liver surface with injury noted to organ
33
Scene Safety
• Not exclusive to schools
– Fort Hood, TX Shooting (2009)
– Colorado Church Shootings (2007)
– Queens, NY Wendy’s Shooting (2000)
– Atlanta Day Trader Shooting (1999)
– San Ysidro McDonald’s Shooting (1984)
34
Field Management Goals
• Critical patients need rapid transport per SOP
• Difficult to assess internal damage in the field
• Stop any visible bleeding that could cause
hemorrhage  hypovolemia
• Address airway issues
– Tension Pneumothorax chest decompression
– Suction to keep airway open
– Intubate to secure the airway
• Surgery is the answer to critical gunshots
35
Field Management Goals
Focus on the basics
If there is a hole – plug it
If there is bleeding – stop it
If they can’t breathe – ventilate
36
Region X
Field Triage Criteria For Assessing
Trauma Patients
37
Field Management Goals
•
•
•
•
Short on scene time! Under 10 minutes!
Immediate life threatening issues addressed
Good BLS skills
ALS treatment while enroute to the hospital
– Report called as early as possible
• Transport to Level 1 Hospital, if under 25
minutes
• Transport to closest hospital if Level I >25
minutes away
• Helicopter considered in unique situations
38
Patient Transport Decision From the
Field
• Critical and Category I trauma patients
– Transported to highest level Trauma Center
within 25 minutes
• Aeromedical transport remains an option
especially in lengthy extrication and
distance from the hospital
39
Field Categorization of the Critical
Patient
• Systolic B/P < 90 x2
– Pediatric patient B/P < 80 x2
• Blood pressure values taken at least twice and
5 minutes apart
• These patients transported to highest level
Trauma Center within 25 minutes
40
Field Categorization of the Category I
Trauma Patient
• Unstable vital signs
– GCS < 10 or deteriorating mental status
• Best eye opening – 4 points max
• Best verbal response – 5 points max
• Best motor response – 6 points max
– Respiratory rate <10 or >29
– Revised trauma score < 11
• Range 0-12
– 3 components added together
» Converted GCS (3-15 score converted to 0-4 points)
» 0 - 4 points for respiratory rate
» 0 - 4 points for systolic blood pressure
41
Field Categorization of the Category I
Trauma Patient
• Anatomy of injury
– Penetrating injuries to head, neck, torso, or groin
– Combination trauma with burns > 20%
– 2 or more proximal long bone fractures
– Unstable pelvis
– Flail chest
– Limb paralysis &/or sensory deficits above wrist or
ankle
– Open and depressed skull fractures
– Amputation proximal to wrist or ankle
42
Patient Transport Decision From the
Field
• Category II trauma patients
– Transported to closest Trauma Center
• These are stable patients with significant mechanism of injury
• You know they are stable because of frequent reassessment
• There is the potential for these patients to become unstable
– Recognize that pediatric patients often pull you into false
sense of security (but so can adults)
• Peds patients maintain homeostasis as long as possible
and when compensation fails, they deteriorate fast
43
Field Categorization of the Category II
Trauma Patient
• Mechanism of injury
– Ejection from automobile
– Death in same passenger compartment
– Motorcycle crash >20 mph or with separation of
rider from bike
– Rollover – unrestrained
– Falls > 20 feet
• Peds falls > 3x body length
44
Category II Trauma Patient cont’d
• Mechanism of injury cont’d
– Pedestrian thrown or run over
– Auto vs pedestrian / bicyclist with > 5 mph impact
– Extrication > 20 minutes
– High speed MVC
• Speed > 40 mph
• Intrusion > 12 inches
• Major deformity > 20 inches
45
Category II Trauma Patient
• Co-morbid factors
– Age < 5 without car/booster seat
– Bleeding disorders or on anticoagulants
– Pregnancy > 24 weeks
46
Category III Trauma Patient
• All other patients presenting with traumatic injuries
– Fractures
– Sprains/strains
– Burns
– Falls
– Pain
• Provide routine trauma care
– Honor patients request for hospital choice as
much as possible
47
Field to Hospital Communication
• EMS to call early; update as needed
– Gives time for hospital staff and resources to be
mobilized
• The more critical the patient, most likely the
shorter the report
– Important details to be given
– Head to toe picture needs to be painted
– Just as important to give tasks not completed
• Intubation versus bagging
• IV access obtained or not
48
Abbreviated Radio Report
 Department name, vehicle number and receiving
hospital
 EMS to state, “this is an abbreviated report”
Provide nature of situation and SOP being
followed
Age and sex of patient
Chief complaint and brief history
Airway and vascular status
Current vital signs, GCS
Major interventions completed or being
attempted
ETA
49
Fluid
Challenges
50
Adult Fluid Challenge
• Adult fluid replacement is in 200 ml
increments (replacement formula 20 ml/kg)
• Storage issues
– IV bags are usually in ambulance, in bays
– Fluid eventually are at ambient temperatures
– 70° fluid into 98.60 body will cause core body
temperature to decrease
– Hypothermia results
– Cold patients become acidotic patients
51
Adult Fluid Challenge
• 200 ml increments
– Formula is 20 ml/kg
– Example
• 200 # patient = 100 kg
–100 kg x 20 ml/kg = 2000ml fluid challenge
– Reassess your patient as you are passing the
200 ml mark
– Monitor breath sounds for fluid overload
52
Adult Fluid Challenges
• Vascular issues
– Vessel damage results in extensive blood loss
– EMS infuses Normal Saline
– NS does not carry oxygen; NS solves volume issue
only
– Volume deficit can be filled, but patient still in
distress due to lack of oxygen carrying capacity (ie:
patient needs blood)
– Goal should not be to get a 120/80 blood
pressure, rather to stabilize
53
Adult Fluid Challenges
• If your patient’s blood is becoming pink (ie:
not red), they need more blood in the system!
• EMS typically does not carry blood in the field
• Important to accelerate transport to a facility
that can add the blood and do the surgery to
repair the underlying problem!!!
• Good BLS skills are more important than ALS
skills for these types of patients!
54
Pediatric Fluid Challenges
• Pediatric shock protocol
– EMS carries Normal Saline
– Formula for fluid challenge is 20 ml per kg
– Can be administered up to three times total or up
to 60 ml per kg total
• Smaller container (patient size) means less
fluid means less oxygen carrying capacity
• Example:
• 30# patient = 14 kg (30  2.2)
– 14 x 20ml/kg = 280 ml fluid challenge
55
Fluid Challenge Calculation Practice
• 6 year old patient weighs 66 pounds
– 66 pounds = 30 kg
– Fluid challenge of 30 kg x 20 ml = 600 ml each time
• 15 year old patient weighs 175 pounds
– 175 pounds = 80 kg
– Fluid challenge of 80 x 20ml = 1600 ml fluid
• 25 year old patient weighs 120 pounds
– Adult gets fluid challenge in 200 ml increments
• 75 year old patient weighs 180 pounds
– Adult gets cautious fluid challenge in 200 ml increments
56
Fluid Challenges
• Precautions
– All patients need to be monitored for potential
CHF
– Even a previously healthy patient can be thrown
into CHF
• Too much fluid too fast
57
Case Study #1
•
•
•
•
•
•
•
EMS dispatched for double shooting @ 0942
Ambulance enroute @ 0942
Ambulance staged @ 0947
Flight for Life notified @ 0952
Scene secured by police @ 1000
FFL in the air @ 1000
Patient contact made @1002
58
Case Study #1
•
•
•
•
Ambulance enroute to landing zone @ 10:13
FFL on ground @ 10:15
FFL to Level I @ 10:23
.38 caliber revolver pistol used in the shooting
59
Case Study #1
• Patient #1
– 38 year-old female with multiple gun shot wounds
– Found in the basement of the house
GSW to right hand (entry and exit)
GSW to right side of neck (entry) and lower right
ribcage (exit)
GSW to right forearm (entry and exit)
GSW to right humerus (entry and exit)
GSW to left hand (entry and exit)
60
Case Study #1
• Patient #1 cont’d
– Approximately 2 liters of blood loss
– Responding to verbal stimuli
– Pupils: PERL
– Lungs: left (clear), right (rhonchi), normal effort
– Skin: Pale, dry, cool with delayed capillary refill
– Past medical history, meds & allergies unknown
– Unable to obtain B/P, femoral pulse @ 110
61
Case Study #1
• Respirations 22 with SPO2 of 94% on room air
– SPO2 increased to 99% after oxygen @ 15 L via
NRB
• ECG: Sinus tachycardia with rate of 110
• Patient disoriented
• GCS = 9; RTS = 10
62
Case Study #1
• Treatment plan:
– Scene safety (field and in ED)
– ABC’s performed
– Rapid transport with early communication to
receiving facility
– Supplemental O2, IV enroute, monitor
– Immobilization by c-collar, backboard & head
immobilizers
– Patient needs to be exposed for evaluation of
multiple gunshot wounds
63
Case Study #1
• Bleeding controlled to entry & exit wounds
with trauma dressings
• Oxygen administered at 15 L via NRB mask
• IV of Normal Saline administered with 18 G in
left extremity, wide open rate
• EMS crew monitored lung sounds and femoral
pulses throughout call
• Patient transferred to FFL crew
• CMC (as Medical Control) notified
64
Case Study #1
• Is this a Category I or II trauma patient and
why?
– Systolic B/P below 90
– GCS less than 10
– RTS less than 11
– Penetrating injuries to head, neck, torso or groin
• Category I trauma patient
65
EZ IO
• Have you used one on a
patient or cared for a
patient with one?
• High risk, low volume
procedure
66
EZ IO
• Field indications
– Must meet all indications
• Shock, arrest, or impending
arrest
• Unconscious/unresponsive
to verbal stimuli
• 2 unsuccessful IV attempts
or 90 seconds duration
67
EZ IO
• Contraindications
– Fracture of the tibia or femur
– Infection at insertion site
– Previous orthopedic procedure (knee
replacement, previous IO insertion within 480)
– Pre-existing medical condition (tumor near site,
peripheral vascular disease)
– Inability to locate landmarks (significant edema)
– Excessive tissue at insertion site (morbid obesity)
• Hold leg up off bed to allow excess tissue to fall
dependently
68
EZ IO Equipment
• Lithium drill
– Battery powered for 1000 insertions
• Needle
– Blue needle – 25 mm (1) 15 G for patients over 88 pounds
(40kg)
– Pink needle – 15 mm (5/8) 15G for patients between 7 and
88 pounds (3kg – 40kg)
•
•
•
•
•
•
EZ connect tubing
Syringe
Saline to prime EZ connect tubing
Primed IV bag
Pressure bag/B/P cuff
Site prep material (ie: alcohol pad)
69
Equipment Case
EZ connect tubing
10 ml syringe
with saline
Needle sizes used in Region X
70
EZ IO Procedure
• Prime EZ connect tubing with saline; leave syringe
attached (for flushing)
• Locate and cleanse site
– Proximal medial tibia
•
•
•
•
•
•
•
Prepare driver and needle set; remove safety cap
Insert needle at 900 angle
Remove stylet
Attach primed EZ connect tubing
Aspirate then flush line with remaining saline
Remove syringe only and connect primed IV set
Confirm needle placement
71
Identifying
Site
• Proximal medial tibia
– 2 finger breadths below patella (to tibial
tuberosity) and 1 finger breadth medially from
tibial tuberosity
– May or may not be able to identify the tibial
tuberosity at 2 finger breadths below patella
– As patient is lying supine, legs tend to roll slightly
outward
• This presents the flat surface of the tibia
72
EZ IO Sites
• Proximal medial tibia
– Site approved for Region X EMS personnel
• FYI - Additional sites available
– Humeral
– Ankle
• Other EMS regions may use these additional
sites
• These additional sites may be accessed by MD
inserting IO needle
Confirming EZ IO Placement
• Sudden lack of resistance
felt
• Needle stands up by self
• Bone marrow may be
noted on aspiration
• No resistance to flushing
• IV runs with pressure
applied to IV bag
• No infiltration noted
74
75
Documentation OF EZ IO Insertion
• Document usual IV insertion information
– Time of insertion
– Size IV bag used
– Site, needle length, needle gauge
– Amount of fluid infused in the field
• Place fluorescent yellow arm band on patient’s wrist
to indicate insertion (or attempt) of IO
– Recommended to place on same side as insertion
site
– Arm band used for successful and unsuccessful
insertions
76
Saline Lock/Extension Tubing
• Field indication
– To establish an extension line between the IV catheter and
the IV tubing
• Allows hospital staff to change IV tubing with less disturbance to
the inserted IV catheter
– To have access to circulation without the need for fluids
• Equipment
–
–
–
–
IV start pak
IV catheter
Macrobore extension set (7.25 inches)
10 ml saline in syringe for priming tubing and flushing
77
Region X SOP - Saline Lock
• Routine medical care SOP states:
– Establish 0.9 normal saline (NS) per IV/IO and
adjust flow as indicated by the patient’s condition
and age
– May use a saline lock cap on
IV catheter hub for stable
patients (not needing fluid
resuscitation)
78
“Saline Lock” Procedure
• Establish an IV following sterile technique
• Remove stylet
• Insert distal tip of primed extension tubing/ saline
lock into IV catheter
– If administering fluids, IV tubing should be already
attached to the extension tubing/saline lock
• Adjust flow rate
• If IV line is precautionary, flush extension
tubing/saline lock with 10 ml sterile normal saline
– Remove syringe
– Do not need IV tubing or IV bag
79
Extension Tubing/Saline Lock
• Connecting to IV catheter
– Keep IV site as distal as possible
• AC should not be your first choice
• We are requesting to start getting into habit of
adding this extension tubing to all IV starts
80
IV Equipment for Saline Lock
• If patient needs fluid, attach primed IV tubing with bag to
proximal end of extension tubing/saline lock
–
–
–
–
–
Wipe off blue clave port with alcohol prep pad
Push in and twist primed IV tubing to connect
Adjust flow rate as indicated
Document time, type, and size IV solution hung
Distal tip of clave inserted into IV catheter
81
Extension tubing/Saline Lock In Place
• Extension tubing/saline lock properly secured
– Insertion site not taped over
– Clear view of insertion site through op-site/tegaderm
dressing
– Access to port available
– Can easily attach primed
IV tubing if need to begin
fluid therapy
82
Improperly Secured IV Site
• Insertion site taped over
• Gauze bandaging under tape
– Increased risk of infection
IV site properly covered with see
through dressing
83
Extravasation of Medication
• To use the extension tubing/saline lock for
infusion, must verify that the line is patent
– Aspirate for blood return
– Stop infusion if patient complains of pain/burning
Extravasation of IVP
medication resulting in
amputation of several fingers.
Patient c/o pain during IVP
and medication delivering
continued anyway.
84
Case Study #2
•
•
•
•
•
25 year-old male shot in the chest
Police are on the scene
Patient sitting on ground, leaning against car
Several small casings on ground near victim
Patient bleeding from small chest wound left
anterior chest
• Patient is anxious, pale, diaphoretic with
elevated respiratory rate
85
Case Study #2
• Patient alert and oriented x3
• Complains of mild chest pain aggravated with
deep breathing
• VS: 122/86, 90 – 20
• Hole noted in the left anterior chest about the
3rd intercostal space
– No air seems to be moving through the hole
86
Case Study #2
• Interventions required
– Immediately seal the open wounds
• Dressing secured on 3 sides
– High flow oxygen administered via non-rebreather
– IV access established
– Contact Medical Control
• What Category trauma is this patient?
–Category I – penetration of torso
87
Case Study #3
• 911 call to scene for a domestic incident
• Upon arrival, summoned to the back yard for a 23
year-old female patient lying on the ground
conscious and awake
• Patient states she was running out of the house and
tripped down the stairs
• Tree branch noted impaled through right flank at
level of umbilicus
• VS: 124/100; 120; 22; SpO2 98%; warm & dry
• No active bleeding
88
Case Study #3
• What injuries do you
anticipate knowing
entry point and angle
of impalement?
89
Case Study #3
• Initial assessment
• performed to identify life threats
– Airway – open
– Breathing – without distress although patient
is upset
– Circulation – warm & dry; capillary refill 1 ½
seconds; pulse steady and palpable at the
radial site
– Disability & disrobe
• AVPU – awake, cooperative, anxious
90
Case Study #3
• Categorization?
– Category I – penetrating object to torso
• Interventions
– Secure impaled object, prevent further movement
• Manual control initially
• Gauze padding around entrance site
• Assess for exit wound
91
Case Study #3
• What internal injury is anticipated?
– Abdominal
• Solid organ – bleeding
• Hollow organ – spilling contents causing
contamination
• Punctured vessels  hemorrhage
– Chest
• Punctured diaphragm
• Punctured lung
• Punctured heart
• Punctured vessels
92
Case Study #3 Follow-up
• Patient taken to OR
• Stabilization maintained to prevent movement
of impaled object
• Tree branch removed under direct
visualization
• Abdominal cavity cleaned and flushed
• Patient did well and was discharged 5 days
post-op
93
Case Study #4
• EMS responded to a call at a tavern for a person
shot
• Upon arrival, the patient lying on their right
side, blood noted under their head
• Patient is breathing, radial pulse is palpable
• They do not open their eyes; the patient moans
when touched; the patient withdraws
• What is first things first?
– SAFETY, SAFETY, SAFETY
94
Case Study #4
• Need to log roll patient
protecting C-spine
• Maintain clear airway
• GCS
–
–
–
–
Eye opening – 1
Verbal response – 2
Motor response – 4
Total GCS - 7
95
Case Study #4
• Cannot tell internal
damage by external
appearances only
• Patient had small bone
fragments that were
pushed into the brain
• Patient required
neurosurgery
evaluation
96
Case Study #4
• Report from EMS
– Description of wound(s) noted including body
region
– Type of weapon used if information is available
– Distance from weapon if available
• Closer the range, the more energy that is
behind the bullet/shot the greater the internal
damage
– Note basic care provided (IV, O2, monitor)
97
Case Study #5
• A patient presents as a walk-in to your facility
• Approximately 2 hours ago, he was involved in
a domestic disturbance
• Patient states his girlfriend hit him in the
upper chest and he continues to have some
pain and is now worried regarding the injury
• Awake and alert, vital signs stable
• Dried blood noted on upper chest wall midline
98
Case Study #5
• You can’t assess what you can’t see – remove
clothing
• What injuries do you anticipate?
– Heart, lung, vessels
– Trachea
– Esophagus
Visible wound
Object viewed on x-ray
99
Case Study #5 – Operative View
• Impaled object after removal
• Was near pulmonary artery but no damage
• Knife missed all vital structures
100
Case Closure
• What saves lives when impaled/penetrating
objects are involved?
Age and condition of patient
• Younger patients and those in good health can
tolerate the insult better
Rapid identification and transport from the
field
Proper stabilization of the object to prevent
further damage by movement
Rapid OR for direct visualization and repair
101
Bibliography
• Hoover, C. Fluid Resuscitation Controversies. EMS
Magazine. March 2010.
• Proehl, J. Emergency Nursing Procedures, 4th Edition.
Saunders. 2009.
• Region X SOP March 2007; amended January 1, 2008.
• Smith, M. Lecture. “Working Together” EMS Conference
2010.
• Wauconda Fire Department call records
• Olliver.family.gen.nz/launchpad/Head_wound.png
• www.cabelas.com<http://www.cabelas.com>
• www.jems.com<http://www.jems.com>
102
Bibliography cont’d
•
•
•
•
www.remington.com<http://www.remington.com>
www.vidacare.com
www.Wikipedia.org<http://www.Wikipedia.org>
www.winchester.com<http://www.winchester. com>
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