Pediatric Wound Care and Management in the Emergency Department | EB Medicine

Pediatric Wound Care and Management in the Emergency Department

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Table of Contents
About This Issue

Although wounds and lacerations are some of the most common presenting complaints to EDs, recommendations for proper wound management can be contradictory and are often not supported by the literature. In this issue, you will learn:

Risk factors that affect wound healing and infection rates

Solutions that can safely and effectively irrigate wounds

Techniques and treatments to prevent pain and anxiety during wound closure

Methods for primary wound closure and how to use them appropriately

When antibiotic prophylaxis is necessary

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
  6. Differential Diagnosis
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
  9. Diagnostic Studies
    1. Laboratory Studies
    2. Imaging Studies
  10. Treatment
    1. Timing of Wound Closure
    2. Wound Irrigation and Cleansing
      1. Wound Irrigation Solutions
      2. Wound Irrigation Volume and Pressure
    3. Anesthesia
      1. Topical Anesthesia
      2. Intradermal Anesthesia
      3. Nerve Blocks
    4. Anxiolysis/Sedation
    5. Wound Closure
    6. Sutures
      1. Suture Materials
      2. Suturing Techniques
        • Simple Interrupted Suture
        • Running Suture and Locked Running Suture
        • Running Subcuticular Suture
        • Mattress Suture
        • Corner Stitch
    7. Tissue Adhesive
    8. Staples
    9. Hair Apposition
    10. Adhesive Strips
    11. Antibiotic Prophylaxis
    12. Tetanus Prophylaxis
    13. Post-Repair Wound Care
  11. Special Circumstances
    1. Specialist Consultation
    2. Bite Wounds
      1. History and Physical Examination for Bite Wounds
      2. Treatment of Bite Wounds
      3. Human Bites
    3. Surgical Site Infections
  12. Controversies and Cutting Edge
    1. Honey
    2. Scar Management
  13. Disposition
  14. Key Points
  15. Summary
  16. Risk Management Pitfalls in the Management of Wounds in Pediatric Patients
  17. Time- and Cost-Effective Strategies
  18. Case Conclusions
  19. Clinical Pathway for Management of Wounds in Pediatric Patients
  20. Tables and Figures
    1. Table 1. Irrigation Methods and Delivered Pressure
    2. Table 2. Maximum Lidocaine Dosage
    3. Table 3. Types and Properties of Suture Materials
    4. Table 4. Recommended Suture Material Sizes and Duration, Based on Location
    5. Table 5. High-Risk Wound Characteristics
    6. Table 6. Post Wound Tetanus Vaccination Guidelines
    7. Figure 1. Simple Interrupted Suture
    8. Figure 2. Locked Running Suture
    9. Figure 3. Running Subcuticular Suture
    10. Figure 4. Vertical Mattress Suture
    11. Figure 5. Horizontal Mattress Suture
    12. Figure 6. Corner Stitch
    13. Figure 7. Hair Apposition Technique
    14. Figure 8. Zig-Zag Technique
  21. References


Traumatic wounds and lacerations are common pediatric presenting complaints to emergency departments. Although there is a large body of literature on wound care, many emergency clinicians base management of wounds on theories and techniques that have been passed down over time. Therefore, controversial, conflicting, and unfounded recommendations are prevalent. This issue reviews evidence-based recommendations for wound care and management, including wound cleansing and irrigation, anxiolysis/sedation techniques, closure methods, and post-repair wound care.

Case Presentations

A 2-year-old boy presents with a chin laceration that occurred when he ran into a wall 23 hours ago. The family cleaned the wound with water and applied a bandage. The boy is very upset and screams and runs away when you try to remove the bandage. The resident you are working with asks if the wound should be closed primarily or if it should be allowed to heal via secondary intention. He also asks you what the best way is to handle toddlers who require local wound care.

A 12-month-old girl presents with 2 C-shaped lacerations on her upper arm with some surrounding bruising. The family reports that she fell. After evaluating the child and the wound, you have some concerns that this wound may have been inflicted. The medical student shadowing you asks why you think that.


Wounds and skin injuries are among the most common presenting complaints to emergency departments (EDs). More than 6 million lacerations are treated each year in United States EDs.1 Most children, at some point, are likely to sustain accidental trauma and minor wounds due to their developmental states, curious nature, and risk-taking behavior.

Despite a large body of literature on wound care, controversial, conflicting, and unfounded recommendations still remain.2 Clinicians may develop their wound care practice based on dogma or word-of-mouth, and there is great variability among emergency clinicians on the preparation and treatment of wounds.3 A widely accepted standard of care does not exist.

Most wounds heal well, which is more likely due to the body’s innate ability for healing than to medical intervention. Nevertheless, it is prudent to know ideal methods and recommendations for wound care. This issue of Pediatric Emergency Medicine Practice reviews major aspects of wound care, including cleansing, repair methods, and post wound care. Evidence-based recommendations are distinguished from unfounded traditional practices.

Critical Appraisal of the Literature

A search was performed in PubMed for articles pertaining to, but not limited to, children using multiple combinations of the search terms woundlacerationtraumatic woundanimal bitehuman bitetissue adhesivecyanoacrylateadhesive stripsstapleshair apposition, and antibiotic prophylaxis. The Cochrane Database of Systematic Reviews was also searched and articles relevant to traumatic wound care were reviewed. Over 300 articles were reviewed, 146 of which were chosen for inclusion, including a number of randomized controlled trials, meta-analyses, and clinical practice guidelines.

Risk Management Pitfalls in the Management of Wounds in Pediatric Patients

1. “I use topical antibiotic ointment on all the wounds I close.”

Topical creams and ointments will dissolve tissue adhesives. Patients and families should be encouraged not to apply ointments over tissue adhesives.

2. “The patient wouldn’t sit still, so I called the plastic surgeon.”

While specialist consultation may be appropriate depending on the wound and the family’s wishes, managing anxiety and pain will be necessary whether the repair is done by a specialist or the emergency clinician.

3. “The family said that no glass got into the wound, so I proceeded with the repair.”

If the index of suspicion for a foreign body is high, the emergency clinician should proceed with appropriate imaging to evaluate whether a foreign body is present. Retained foreign bodies are a risk factor for wound infection.

4. “The bite wound on the child’s hand was small and appeared clean, so I closed it using tissue adhesive.”

Tissue adhesives are not recommended for use on animal-bite repairs, stellate wounds, infected wounds, mucosal surfaces, or areas of high moisture or dense hair.70

5. “I thought the hand wound was trauma from a punch. I did not consider that it might have been a fight bite.”

Clenched-fist injuries occur when a closed fist strikes the teeth of another (ie, fight bite), which can result in a hand infection. A careful history can help to determine whether there was any contact with teeth. Because 10% to 15% of human bites become infected, these patients should be given prophylactic antibiotics. Fight bites may also incur tendon injury that may not be readily apparent on initial examination.

6. “Wound adhesives cause increased infectious complications and have a poorer cosmetic outcome compared to sutures, so I don’t use them”

Recent randomized controlled trials have shown that wound adhesive has no increased rates of infection compared to sutures.71,72,76 Studies have also found similar cosmetic outcomes when comparing wound adhesive to sutures.62,66

7. “Use of an absorbable suture to close a wound will result in a poorer cosmetic outcome, so I always use nonabsorbable sutures.”

Several studies have evaluated the cosmetic outcome and patient satisfaction with absorbable and nonabsorbable sutures, and have found absorbable sutures to be noninferior to nonabsorbable sutures.63 Some studies have found that caregivers prefer absorbable sutures over nonabsorbable sutures.64

8. “I give systemic antibiotics to all of my patients with traumatic lacerations.”

Evidence has not shown benefit in prescribing systemic antibiotics for clean, simple lacerations.

9. “The wound looked dirty, so I squirted some povidone-iodine in the wound to clean it.”

Many antiseptics have been found to have detrimental effects on wound healing at the cellular level,19,130,131 with no significant difference in infection rates.132 Wounds that appear dirty or contaminated should be thoroughly irrigated to remove debris.

10. “My patient had a simple chin laceration, so I didn’t take a thorough medical history.”

Obtaining a thorough past medical history can reveal conditions that may cause poor wound healing. Patients and families should be made aware that wounds may not heal as quickly or as well if there are pre-existing conditions that affect wound healing.

Tables and Figures

Table 1. Irrigation Methods and Delivered Pressure


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, are noted by an asterisk (*) next to the number of the reference.

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  2. Berk WA, Welch RD, Bock BF. Controversial issues in clinical management of the simple wound. Ann Emerg Med. 1992;21(1):72-80. (Review)
  3. Howell JM, Chisholm CD. Outpatient wound preparation and care: a national survey. Ann Emerg Med. 1992;21(8):976-981. (Survey; 151 responses)
  4. Childs DR, Murthy AS. Overview of wound healing and management. Surg Clin North Am. 2017;97(1):189-207. (Review)
  5. Nicks BA, Ayello EA, Woo K, et al. Acute wound management: revisiting the approach to assessment, irrigation, and closure considerations. Int J Emerg Med. 2010;3(4):399-407. (Review)
  6. * Berk WA, Osbourne DD, Taylor DD. Evaluation of the ‘golden period’ for wound repair: 204 cases from a Third World emergency department. Ann Emerg Med. 1988;17(5):496-500. (Prospective study; 372 patients)
  7. van den Baar MT, van der Palen J, Vroon MI, et al. Is time to closure a factor in the occurrence of infection in traumatic wounds? A prospective cohort study in a Dutch Level 1 trauma centre. Emerg Med J. 2010;27(7):540-543. (Prospective study; 425 patients)
  8. Waseem M, Lakdawala V, Patel R, et al. Is there a relationship between wound infections and laceration closure times? Int J Emerg Med. 2012;5(1):32. (Prospective study; 297 patients)
  9. Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: what are the risks for infection and has the ‘golden period’ of laceration care disappeared? Emerg Med J. 2014;31(2):96-100. (Prospective study; 2663 patients)
  10. Stevenson TR, Thacker JG, Rodeheaver GT, et al. Cleansing the traumatic wound by high pressure syringe irrigation. JACEP. 1976;5(1):17-21. (Comparative study)
  11. Block L, King TW, Gosain A. Debridement techniques in pediatric trauma and burn-related wounds. Adv Wound Care (New Rochelle). 2015;4(10):596-606. (Review)
  12. Angeras MH, Brandberg A, Falk A, et al. Comparison between sterile saline and tap water for the cleaning of acute traumatic soft tissue wounds. Eur J Surg. 1992;158(6-7):347-350. (Randomized controlled trial; 705 patients)
  13. Thompson S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Wound cleaning methods. J Accid Emerg Med. 1999;16(1):63-64. (Review)
  14. Weiss EA, Oldham G, Lin M, et al. Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial. BMJ Open. 2013;3(1):1-6. (Randomized controlled trial; 663 patients)
  15. * Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012(2):CD003861. (Meta-analysis; 11 trials)
  16. Valente JH, Forti RJ, Freundlich LF, et al. Wound irrigation in children: saline solution or tap water? Ann Emerg Med. 2003;41(5):609-616. (Prospective study; 271 patients)
  17. Roberts AH, Roberts FE, Hall RI, et al. A prospective trial of prophylactic povidone iodine in lacerations of the hand. J Hand Surg Br. 1985;10(3):370-374. (Randomized controlled trial; 418 patients)
  18. Gravett A, Sterner S, Clinton JE, et al. A trial of povidone-iodine in the prevention of infection in sutured lacerations. Ann Emerg Med. 1987;16(2):167-171. (Randomized controlled trial; 500 patients)
  19. Brennan SS, Leaper DJ. The effect of antiseptics on the healing wound: a study using the rabbit ear chamber. Br J Surg. 1985;72(10):780-782. (In vivo rabbit study; 10 rabbit ears)
  20. Van den Broek PJ, Buys LF, Van Furth R. Interaction of povidone-iodine compounds, phagocytic cells, and microorganisms. Antimicrob Agents Chemother. 1982;22(4):593-597. (In vivo study)
  21. Bennett LL, Rosenblum RS, Perlov C, et al. An in vivo comparison of topical agents on wound repair. Plast Reconstr Surg. 2001;108(3):675-687. (Comparative study)
  22. Liu JX, Werner JA, Buza JA 3rd, et al. Povidone-iodine solutions inhibit cell migration and survival of osteoblasts, fibroblasts, and myoblasts. Spine (Phila Pa 1976). 2017. (In vitro study)
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  24. Wilson JR, Mills JG, Prather ID, et al. A toxicity index of skin and wound cleansers used on in vitro fibroblasts and keratinocytes. Adv Skin Wound Care. 2005;18(7):373-378. (Prospective in vitro study)
  25. Chisholm CD, Cordell WH, Rogers K, et al. Comparison of a new pressurized saline canister versus syringe irrigation for laceration cleansing in the emergency department. Ann Emerg Med. 1992;21(11):1364-1367. (Randomized controlled trial; 550 patients)
  26. Lammers RL, Hudson DL, Seaman ME. Prediction of traumatic wound infection with a neural network-derived decision model. Am J Emerg Med. 2003;21(1):1-7. (Prospective study; 1142 wounds)
  27. Chatterjee JS. A critical review of irrigation techniques in acute wounds. Int Wound J. 2005;2(3):258-265. (Review)
  28. Longmire AW, Broom LA, Burch J. Wound infection following high-pressure syringe and needle irrigation. Am J Emerg Med. 1987;5(2):179-181. (Letter to the Editor)
  29. Edlich RF, Rodeheaver GT, Morgan RF, et al. Principles of emergency wound management. Ann Emerg Med. 1988;17(12):1284-1302. (Review)
  30. Brown LL, Shelton HT, Bornside GH, et al. Evaluation of wound irrigation by pulsatile jet and conventional methods. Ann Surg. 1978;187(2):170-173. (Prospective study; 234 rats)
  31. Wheeler CB, Rodeheaver GT, Thacker JG, et al. Side-effects of high pressure irrigation. Surg Gynecol Obstet. 1976;143(5):775-778. (In vivo study)
  32. Rodeheaver GT, Smith SL, Thacker JG, et al. Mechanical cleansing of contaminated wounds with a surfactant. Am J Surg. 1975;129(3):241-245. (Animal study)
  33. Singer AJ, Hollander JE, Subramanian S, et al. Pressure dynamics of various irrigation techniques commonly used in the emergency department. Ann Emerg Med. 1994;24(1):36-40. (Matched experimental trial; 10 patients)
  34. Morse JW, Babson T, Camasso C, et al. Wound infection rate and irrigation pressure of two potential new wound irrigation devices: the port and the cap. Am J Emerg Med. 1998;16(1):37-42. (Randomized controlled trial; 208 patients)
  35. Moscati RM, Reardon RF, Lerner EB, et al. Wound irrigation with tap water. Acad Emerg Med. 1998;5(11):1076-1080. (Randomized blinded crossover study; 10 animals)
  36. Hollander JE, Singer AJ, Valentine SM, et al. Risk factors for infection in patients with traumatic lacerations. Acad Emerg Med. 2001;8(7):716-720. (Cross-sectional study; 5521 patients)
  37. Gross A, Cutright DE, Bhaskar SN. Effectiveness of pulsating water jet lavage in treatment of contaminated crushed wounds. Am J Surg. 1972;124(3):373-377. (Comparative study; 200 rats)
  38. Fry DE. Pressure irrigation of surgical incisions and traumatic wounds. Surg Infect (Larchmt). 2017;18(4):424-430. (Review)
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  40. Pryor GJ, Kilpatrick WR, Opp DR. Local anesthesia in minor lacerations: topical TAC vs lidocaine infiltration. Ann Emerg Med. 1980;9(11):568-571. (Randomized controlled trial; 158 patients)
  41. Grant SA, Hoffman RS. Use of tetracaine, epinephrine, and cocaine as a topical anesthetic in the emergency department. Ann Emerg Med. 1992;21(8):987-997. (Review)
  42. Ernst AA, Marvez-Valls E, Nick TG, et al. LAT (lidocaine-adrenaline-tetracaine) versus TAC (tetracaine-adrenaline-cocaine) for topical anesthesia in face and scalp lacerations. Am J Emerg Med. 1995;13(2):151-154. (Randomized controlled trial; 95 patients)
  43. Schilling CG, Bank DE, Borchert BA, et al. Tetracaine, epinephrine (adrenalin), and cocaine (TAC) versus lidocaine, epinephrine, and tetracaine (LET) for anesthesia of lacerations in children. Ann Emerg Med. 1995;25(2):203-208. (Randomized controlled trial; 171 patients)
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  45. Ernst AA, Marvez E, Nick TG, et al. Lidocaine adrenaline tetracaine gel versus tetracaine adrenaline cocaine gel for topical anesthesia in linear scalp and facial lacerations in children aged 5 to 17 years. Pediatrics. 1995;95(2):255-258. (Randomized controlled trial; 95 patients)
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  63. * Xu B, Xu B, Wang L, et al. Absorbable versus nonabsorbable for skin closure: a meta-analysis of randomized controlled trials. Ann Plast Surg. 2016;76(5):598-606. (Meta-analysis; 19 trials)
  64. * Luck R, Tredway T, Gerard J, et al. Comparison of cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations. Pediatr Emerg Care. 2013;29(6):691-695. (Randomized controlled trial; 89 patients)
  65. Hochberg J MK, Marion MD. Suture choice and other methods of skin closure. Surg Clin North Am. 2009(89):627-641. (Review)
  66. Quinn J, Wells G, Sutcliffe T, et al. A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. JAMA. 1997;277(19):1527-1530. (Randomized controlled trial; 130 patients)
  67. Bruns TB, Worthington JM. Using tissue adhesive for wound repair: a practical guide to dermabond. Am Fam Physician. 2000;61(5):1383-1388. (Review)
  68. Mattick A, Clegg G, Beattie T, et al. A randomised, controlled trial comparing a tissue adhesive (2-octylcyanoacrylate) with adhesive strips (Steristrips) for paediatric laceration repair. Emerg Med J. 2002;19(5):405-407. (Randomized controlled trial; 44 patients)
  69. Leahey AB, Gottsch JD, Stark WJ. Clinical experience with N-butyl cyanoacrylate (Nexacryl) tissue adhesive. Ophthalmology. 1993;100(2):173-180. (Prospective, 44 patients)
  70. Beam JW. Tissue adhesives for simple traumatic lacerations. J Athl Train. 2008;43(2):222-224. (Meta-analysis; 11 studies)
  71. Singer AJ, Hollander JE, Valentine SM, et al. Prospective, randomized, controlled trial of tissue adhesive (2-octylcyanoacrylate) vs standard wound closure techniques for laceration repair. Acad Emerg Med. 1998;5(2):94-99. (Prospective randomized controlled trial; 124 patients)
  72. Bruns TB, Robinson BS, Smith RJ, et al. A new tissue adhesive for laceration repair in children. J Pediatrics. 1998;132(6):1067-1070. (Randomized controlled trial; 83 patients)
  73. Quinn JV, Drzewiecki A, Li MM, et al. A randomized, controlled trial comparing a tissue adhesive with suturing in the repair of pediatric facial lacerations. Ann Emerg Med. 1993;22(7):1130-1135. (Randomized controlled trial; 81 patients)
  74. Applebaum JS, Zalut T, Applebaum D. The use of tissue adhesion for traumatic laceration repair in the emergency department. Ann Emerg Med. 1993;22(7):1190-1192. (Prospective study; 143 patients)
  75. Farion KJ, Osmond MH, Hartling L, et al. Tissue adhesives for traumatic lacerations: a systematic review of randomized controlled trials. Acad Emerg Med. 2003;10(2):110-118. (Review)
  76. * Farion K, Osmond M, Hartling L, et al. Tissue adhesives for traumatic lacerations in children and adults. Cochrane Database Syst Rev. 2002(3):CD003326. (Meta-analysis; 8 studies)
  77. Bruns TB, Simon HK, McLario DJ, et al. Laceration repair using a tissue adhesive in a children’s emergency department. Pediatrics. 1996;98(4 Pt 1):673-675. (Randomized controlled trial; 61 patients)
  78. * Karounis H, Gouin S, Eisman H, et al. A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures. Acad Emerg Med. 2004;11(7):730-735. (Randomized controlled trial; 95 patients)
  79. Osmond MH, Klassen TP, Quinn JV. Economic comparison of a tissue adhesive and suturing in the repair of pediatric facial lacerations. J Pediatr. 1995;126(6):892-895. (Comparative study)
  80. Kanegaye JT, Vance CW, Chan L, et al. Comparison of skin stapling devices and standard sutures for pediatric scalp lacerations: a randomized study of cost and time benefits. J Pediatr. 1997;130(5):808-813. (Randomized controlled trial; 45 children)
  81. Khan AN, Dayan PS, Miller S, et al. Cosmetic outcome of scalp wound closure with staples in the pediatric emergency department: a prospective, randomized trial. Pediatr Emerg Care. 2002;18(3):171-173. (Randomized controlled trial; 42 patients)
  82. Hock MO, Ooi SB, Saw SM, et al. A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study). Ann Emerg Med. 2002;40(1):19-26. (Randomized controlled trial; 189 patients)
  83. Karaduman S, Yuruktumen A, Guryay SM, et al. Modified hair apposition technique as the primary closure method for scalp lacerations. Am J Emerg Med. 2009;27(9):1050-1055. (Prospective study; 102 patients)
  84. Ozturk D, Sonmez BM, Altinbilek E, et al. A retrospective observational study comparing hair apposition technique, suturing and stapling for scalp lacerations. World J Emerg Surg. 2013;8:27. (Retrospective observational study; 134 patients)
  85. Katz KH, Desciak EB, Maloney ME. The optimal application of surgical adhesive tape strips. Dermatol Surg. 1999;25(9):686-688. (Prospective study; 12 patients)
  86. Rodeheaver GT, McLane M, West L, et al. Evaluation of surgical tapes for wound closure. J Surg Res. 1985;39(3):251-257. (Prospective study; 4 surgical tapes)
  87. D’Ettorre M, Bracaglia R, Gentileschi S, et al. A trick in steri-strips application: the zig-zag pattern. Int Wound J. 2015;12(2):233. (Letter)
  88. * Andreana L, Isgro G, Metaxa V. Wound care of pretibial thin-skin lacerations with the combined use of sterile adhesive strips and sutures. J Emerg Med. 2015;49(3):345-346. (Techniques and procedures report)
  89. Davis M, Nakhdjevani A, Lidder S. Suture/steri-strip combination for the management of lacerations in thin-skinned individuals. J Emerg Med. 2011;40(3):322-323. (Techniques and procedures)
  90. Zempsky WT, Zehrer CL, Lyle CT, et al. Economic comparison of methods of wound closure: wound closure strips vs. sutures and wound adhesives. Int Wound J. 2005;2(3):272-281. (Comparative study)
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Jennifer E. Sanders, MD

Publication Date

October 2, 2017

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