Diretrizes Clínicas da ABRAMEDE para o Manejo de Dengue em Pacientes Adultos na Emergência
Diretrizes Clínicas de Dengue na Emergência
DOI:
https://doi.org/10.54143/jbmede.v4i2.199Palavras-chave:
Dengue, Diretrizes clínicas, Síndrome febrilResumo
No Brasil, a dengue é a arbovirose mais significativa e um dos principais motivos de consultas em Departamentos de Emergência (DEs). Em 2024, o país vem enfrentando um número recorde de casos, exacerbando a superlotação das emergências. Diante da grave epidemia, é crucial aprimorar o manejo clínico para evitar a evolução para formas graves da doença e reduzir a mortalidade. Esta diretriz clínica é dedicada ao manejo de pacientes adultos com suspeita ou quadro confirmado de dengue na emergência, seja em DEs hospitalares ou unidades de pronto atendimento. A elaboração desta diretriz ocorreu entre fevereiro, março e abril de 2024, por um painel de 16 especialistas. Adotou-se a metodologia GRADE, que segue um processo envolvendo: (1) o desenvolvimento de revisões sistemáticas para as questões priorizadas; (2) a avaliação da certeza das evidências; (3) a formulação de recomendações utilizando o framework GRADE evidence-to-decision (EtD). A metodologia GRADE-ADOLOPMENT também foi utilizada para adotar e/ou adaptar revisões sistemáticas e recomendações de outras diretrizes aplicáveis. Dez perguntas clínicas foram priorizadas e respondidas, sendo geradas recomendações com força e nível de evidência variados. Esta é a primeira diretriz da ABRAMEDE que emprega a metodologia GRADE para fornecer respostas claras e baseadas em evidências às perguntas consideradas mais críticas por especialistas no manejo de pacientes adultos com dengue nas emergências.
Referências
REFERÊNCIAS
Kularatne SAM. Dengue fever. BMJ. 2015;351:h4661. doi:10.1136/bmj.h4661
Simmons CP, Farrar JJ, Nguyen van VC, Wills B. Dengue. N Engl J Med. 2012;366(15):1423-1432. doi:10.1056/NEJMra1110265
Guzman MG, Harris E. Dengue. Lancet Lond Engl. 2015;385(9966):453-465. doi:10.1016/S0140-6736(14)60572-9
Dengue: Diagnóstico e Manejo Clínico Adulto e Pediátrico. Accessed October 3, 2024. http://bvsms.saude.gov.br/bvs/publicacoes/dengue_ diagnostico_manejo_clinico_6ed.pdf
Monitoramento Arboviroses.; 2024. Accessed March 27, 2024. https://www.gov.br/saude/pt-br/assuntos/saude-de-a-a-z/a/aedes-aegypti/monitoramento-das-arboviroses
Dengue Virus and Dengue - Module 2 - Causes of Death. Accessed February 28, 2024. https://www.cdc.gov/dengue/training/cme/ccm/page50639.html
Zhang Y, Akl EA, Schünemann HJ. Using systematic reviews in guideline development: the GRADE approach. Res Synth Methods. Published online July 14, 2018. doi:10.1002/jrsm.1313
Alonso-Coello P, Oxman AD, Moberg J, et al. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines. BMJ. 2016;353:i2089. doi:10.1136/bmj.i2089
World Health Organization. Dengue guidelines for diagnosis, treatment, prevention and control : new edition. 2009;(WHO/HTM/NTD/DEN/2009.1). Accessed December 7, 2016. https://iris.who.int/handle/10665/44188
Guidelines for the Clinical Diagnosis and Treatment of Dengue, Chikungunya, and Zika. Pan American Health Organization; 2022. doi:10.37774/9789275124871
Atkins D, Best D, Briss PA, et al. Grading quality of evidence and strength of recommendations. BMJ. 2004;328(7454):1490. doi:10.1136/bmj.328.7454.1490
Schünemann HJ, Wiercioch W, Brozek J, et al. GRADE Evidence to Decision (EtD) frameworks for adoption, adaptation, and de novo development of trustworthy recommendations: GRADE-ADOLOPMENT. J Clin Epidemiol. 2017;81:101-110. doi:10.1016/j.jclinepi.2016.09.009
Carpenter CR, E Silva LOJ, Upadhye S, Broder JS, Bellolio F. A candle in the dark: The role of indirect evidence in emergency medicine clinical practice guidelines. Acad Emerg Med Off J Soc Acad Emerg Med. 2022;29(5):674-677. doi:10.1111/acem.14494
Setiawan MW, Samsi TK, Pool TN, Sugianto D, Wulur H. Gallbladder wall thickening in dengue hemorrhagic fever: An ultrasonographic study. J Clin Ultrasound. 1995;23(6):357-362. doi:10.1002/jcu.1870230605
Setiawan MW, Samsi TK, Wulur H, Sugianto D, Pool TN. Dengue haemorrhagic fever: ultrasound as an aid to predict the severity of the disease. Pediatr Radiol. 1998;28(1):1-4. doi:10.1007/s002470050281
Gleeson T, Pagnarith Y, Habsreng E, et al. Dengue Management in Triage using Ultrasound in children from Cambodia: a prospective cohort study. Lancet Reg Health - West Pac. 2022;19:100371. doi:10.1016/j.lanwpc.2021.100371
Chacko B, Subramanian G. Clinical, Laboratory and Radiological Parameters in Children with Dengue Fever and Predictive Factors for Dengue Shock Syndrome. J Trop Pediatr. 2007;54(2):137-140. doi:10.1093/tropej/fmm084
Pothapregada S, Kullu P, Kamalakannan B, Thulasingam M. Is Ultrasound a Useful Tool to Predict Severe Dengue Infection? Indian J Pediatr. 2016;83(6):500-504. doi:10.1007/s12098-015-2013-y
Bharath Kumar Reddy KR, Laksmana RR, Veerappa BG, Shivananda. Ultrasonography as a tool in predicting the severity of dengue fever in children--a useful aid in a developing country. Pediatr Radiol. 2013;43(8):971-977. doi:10.1007/s00247-013-2642-0
Colbert JA, Gordon A, Roxelin R, et al. Ultrasound measurement of gallbladder wall thickening as a diagnostic test and prognostic indicator for severe dengue in pediatric patients. Pediatr Infect Dis J. 2007;26(9):850-852. doi:10.1097/INF.0b013e3180619692
Raman R, Lakshmi M. Correlation of inferior vena cava ultrasound with packed cell volume and clinical condition in children with dengue fever. J Emerg Med Trauma Acute Care. 2016;2016(3). doi:https://doi.org/10.5339/jemtac.2016.6
Srikiatkhachorn A, Krautrachue A, Ratanaprakarn W, et al. Natural history of plasma leakage in dengue hemorrhagic fever: a serial ultrasonographic study. Pediatr Infect Dis J. 2007;26(4):283-290; discussion 291-292. doi:10.1097/01.inf.0000258612.26743.10
Yousaf KR, Atiq S, Sheikh QS, Nisar MS, Khalid S. Sonographic features of polyserositis as an adjunct to clinico-pathological parameters in diagnosing and predicting the severity of dengue fever.
Khurram M, Qayyum W, Umar M, Jawad M, Mumtaz S, Khaar HTB. Ultrasonographic pattern of plasma leak in dengue haemorrhagic fever. J Pak Med Assoc. 2016;66(3).
Adil B, Rabbani A, Ahmed S, Arshad IS, Khalid MA. Gall Bladder Wall Thickening in Dengue Fever - Aid in Labelling Dengue Hemorrhagic Fever and a Marker of Severity. Cureus. 2020;12(11):e11331. doi:10.7759/cureus.11331
Tavares MDA, João GAP, Bastos MS, et al. Clinical relevance of gallbladder wall thickening for dengue severity: A cross-sectional study. Schildgen O, ed. PLOS ONE. 2019;14(8):e0218939. doi:10.1371/journal.pone.0218939
Ibrahim MA, Hamzah SS, Md Noor J, et al. The association of ultrasound assessment of gallbladder wall thickness with dengue fever severity. Ultrasound J. 2022;14(1):13. doi:10.1186/s13089-022-00262-w
Chai XT. Ultrasound findings of plasma leakage as imaging adjunct in clinical management of dengue fever without warning signs. 2020;75(6).
Michels M, Sumardi U, De Mast Q, et al. The Predictive Diagnostic Value of Serial Daily Bedside Ultrasonography for Severe Dengue in Indonesian Adults. Lopes Da Fonseca BA, ed. PLoS Negl Trop Dis. 2013;7(6):e2277. doi:10.1371/journal.pntd.0002277
Sigera PC, Weeratunga P, Deepika Fernando S, Lakshitha De Silva N, Rodrigo C, Rajapakse S. Rational use of ultrasonography with triaging of patients to detect dengue plasma leakage in resource limited settings: a prospective cohort study. Trop Med Int Health. 2021;26(8):993-1001. doi:10.1111/tmi.13594
Quiroz-Moreno R. Utilidad clínica del ultrasonido en la identificación de dengue hemorrágico. Rev Med Inst Mex Seguro Soc.
Lakshman A, Balasubramanian P, Nampoothiri RV, Vijayvergiya R, Bhalla A, Varma SC. Elevated cardiac biomarkers and echocardiographic left ventricular dysfunction at admission in patients with dengue fever: report from a tertiary care center in Northwest India. Trop Doct. 2018;48(4):261-265. doi:10.1177/0049475518785315
Thulkar S, Sharma S, Srivastava DN, Sharma SK, Berry M, Pandey RM. Sonographic findings in grade III dengue hemorrhagic fever in adults. J Clin Ultrasound JCU. 2000;28(1):34-37. doi:10.1002/(sici)1097-0096(200001)28:1<34::aid-jcu5>3.0.co;2-d
Sharma N, Mahi S, Bhalla A, Singh V, Varma S, Ratho RK. Dengue fever related acalculous cholecystitis in a North Indian tertiary care hospital. J Gastroenterol Hepatol. 2006;21(4):664-667. doi:10.1111/j.1440-1746.2006.04295.x
Wu K, Changchien C, Kuo C, et al. Early abdominal sonographic findings in patients with dengue fever. J Clin Ultrasound. 2004;32(8):386-388. doi:10.1002/jcu.20060
Ultrasound Guidelines: Emergency, Point-of-Care and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med. 2017;69(5):e27-e54. doi:10.1016/j.annemergmed.2016.08.457
Sorensen B, Hunskaar S. Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations. Ultrasound J. 2019;11(1):31. doi:10.1186/s13089-019-0145-4
Dupriez F, Geukens P, Penaloza A, Vanpee D, Bekkering G, Bobbia X. Agreement of emergency physician-performed ultrasound versus RADiology-performed UltraSound for cholelithiasis or cholecystitis: a systematic review. Eur J Emerg Med. 2021;28(5). https://journals.lww.com/euro-emergencymed/fulltext/2021/09000/agreement_of_emergency_physician_performed.9.aspx
Zaki HA, Albaroudi B, Shaban EE, et al. Advancement in pleura effusion diagnosis: a systematic review and meta-analysis of point-of-care ultrasound versus radiographic thoracic imaging. Ultrasound J. 2024;16(1):3. doi:10.1186/s13089-023-00356-z
Huffman JL, Schenker S. Acute acalculous cholecystitis: a review. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2010;8(1):15-22. doi:10.1016/j.cgh.2009.08.034
Whiting PF. QUADAS-2: A Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies. Ann Intern Med. 2011;155(8):529. doi:10.7326/0003-4819-155-8-201110180-00009
Pellegrini JAS, Cordioli RL, Grumann ACB, Ziegelmann PK, Taniguchi LU. Point-of-care ultrasonography in Brazilian intensive care units: a national survey. Ann Intensive Care. 2018;8(1):50. doi:10.1186/s13613-018-0397-3
Gracias VH, Frankel HL, Gupta R, et al. Defining the learning curve for the Focused Abdominal Sonogram for Trauma (FAST) examination: implications for credentialing. Am Surg. 2001;67(4):364-368.
Augusto Tambelli R, Sylvana Martins da Silva P, Ujakow Correa Schubert D, et al. Extended Focused Assessment Sonography in Dengue (E-FASD):: protocolo de ultrassom point of care para avaliação de pacientes com dengue. JBMEDE - J Bras Med Emergência. 2024;4(1):e24005. doi:10.54143/jbmede.v4i1.186
Hernández G, Ospina-Tascón GA, Damiani LP, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019;321(7):654-664. doi:10.1001/jama.2019.0071
World Health Organization, ed. Dengue Haemorrhagic Fever: Diagnosis, Treatment, Prevention, and Control. 2nd ed. World Health Organization; 1997.
Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract. 2012;120(4):c179-184. doi:10.1159/000339789
Lauque D, Khalemsky A, Boudi Z, et al. Length-of-Stay in the Emergency Department and In-Hospital Mortality: A Systematic Review and Meta-Analysis. J Clin Med. 2022;12(1). doi:10.3390/jcm12010032
Relator: Mauro Luiz de Britto Ribeiro. Resolução Conselho Federal de Medicina no 2.077/14. Accessed March 18, 2024. https://portal.cfm.org.br/images/PDF/resolucao2077.pdf
Borghi D, Canetti MD, Braz W, Cortes L, Vasconcellos RC. Field hospital for fluid intake: The solution for the decrease mortality in dengue fever. Int J Infect Dis. 2010;14:e45. doi:10.1016/j.ijid.2010.02.1587
Marra AR, de Matos GFJ, Janeri RD, Machado PS, Schvartsman C, dos Santos OFP. Managing patients with dengue fever during an epidemic: the importance of a hydration tent and of a multidisciplinary approach. BMC Res Notes. 2011;4(1):335. doi:10.1186/1756-0500-4-335
Ahmad MH, Ibrahim MI, Mohamed Z, et al. The Sensitivity, Specificity and Accuracy of Warning Signs in Predicting Severe Dengue, the Severe Dengue Prevalence and Its Associated Factors. Int J Environ Res Public Health. 2018;15(9). doi:10.3390/ijerph15092018
Rosenberger KD, Lum L, Alexander N, et al. Vascular leakage in dengue – clinical spectrum and influence of parenteral fluid therapy. Trop Med Int Health. 2016;21(3):445-453. doi:https://doi.org/10.1111/tmi.12666
Kattan E, Castro R, Miralles-Aguiar F, Hernández G, Rola P. The emerging concept of fluid tolerance: A position paper. J Crit Care. 2022;71:154070. doi:10.1016/j.jcrc.2022.154070
Prasetyo RV, Azis AL, Soegijanto S. Comparison of the efficacy and safety of hydroxyethyl starch 130/0.4 and Ringer’s lactate in children with grade III dengue hemorrhagic fever. Paediatr Indones. 2009;49(2):97. doi:10.14238/pi49.2.2009.97-103
Dung NM, Day NPJ, Tam DTH, et al. Fluid Replacement in Dengue Shock Syndrome: A Randomized, Double-Blind Comparison of Four Intravenous-Fluid Regimens. Clin Infect Dis. 1999;29(4):787-794. doi:10.1086/520435
Nhan NT, Phuong CXT, Kneen R, et al. Acute Management of Dengue Shock Syndrome: A Randomized Double-Blind Comparison of 4 Intravenous Fluid Regimens in the First Hour. Clin Infect Dis. 2001;32(2):204-213. doi:10.1086/318479
Wills BA, Dung NM, Loan HT, et al. Comparison of Three Fluid Solutions for Resuscitation in Dengue Shock Syndrome. N Engl J Med. 2005;353(9):877-889. doi:10.1056/NEJMoa044057
Lewis SR, Pritchard, MW, Evans, DJW, Butler, AR, Alderson, P, Smith, AF, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill people. Cochrane Database Syst Rev. 2018;(8). doi:10.1002/14651858.CD000567.pub7
Zampieri FG, Cavalcanti AB, Di Tanna GL, et al. Balanced crystalloids versus saline for critically ill patients (BEST-Living): a systematic review and individual patient data meta-analysis. Lancet Respir Med. 2024;12(3):237-246. doi:10.1016/S2213-2600(23)00417-4
Astapenko D, Navratil P, Pouska J, Cerny V. Clinical physiology aspects of chloremia in fluid therapy: a systematic review. Perioper Med. 2020;9(1):40. doi:10.1186/s13741-020-00171-3
Soff G, Leader A, Al-Samkari H, et al. Management of chemotherapy-induced thrombocytopenia: guidance from the ISTH Subcommittee on Hemostasis and Malignancy. J Thromb Haemost JTH. 2024;22(1):53-60. doi:10.1016/j.jtha.2023.09.031
Sellahewa K, Samaraweera N, Thusita K, Fernando J. Is fresh frozen plasma effective for thrombocytopenia in adults with dengue fever? A prospective randomised double blind controlled study. Ceylon Med J. 2008;53(2):36. doi:10.4038/cmj.v53i2.229
Assir MZK, Kamran U, Ahmad HI, et al. Effectiveness of Platelet Transfusion in Dengue Fever: A Randomized Controlled Trial. Transfus Med Hemotherapy. 2013;40(5):362-368. doi:10.1159/000354837
Lye DC, Archuleta S, Syed-Omar SF, et al. Prophylactic platelet transfusion plus supportive care versus supportive care alone in adults with dengue and thrombocytopenia: a multicentre, open-label, randomised, superiority trial. Lancet Lond Engl. 2017;389(10079):1611-1618. doi:10.1016/S0140-6736(17)30269-6
Lee TH, Wong JGX, Leo YS, et al. Potential Harm of Prophylactic Platelet Transfusion in Adult Dengue Patients. PLoS Negl Trop Dis. 2016;10(3):1-10. doi:10.1371/journal.pntd.0004576
Anthon CT, Granholm A, Sivapalan P, et al. Prophylactic platelet transfusions versus no prophylaxis in hospitalized patients with thrombocytopenia: A systematic review with meta-analysis. Transfusion (Paris). 2022;62(10):2117-2136. doi:10.1111/trf.17064
van Baarle FLF, van de Weerdt EK, van der Velden WJFM, et al. Platelet Transfusion before CVC Placement in Patients with Thrombocytopenia. N Engl J Med. 2023;388(21):1956-1965. doi:10.1056/NEJMoa2214322
Melgarejo-Ortuño A, Ribed-Sánchez A, Giménez-Manzorro Á, Zorrila-Ortúzar J, Sanjurjo-Saez M. Are we overdosing parenteral metamizole? Cir Esp Engl Ed. 2021;99(1):68-70. doi:10.1016/j.cireng.2020.02.013
Bhaskar E, Sowmya G, Moorthy S, Sundar V. Prevalence, patterns, and factors associated with bleeding tendencies in dengue. J Infect Dev Ctries. 2015;9(01):105-110. doi:10.3855/jidc.5031
WANG JY, TSENG CC, LEE CS, CHENG KP. Clinical and upper gastroendoscopic features of patients with dengue virus infection. J Gastroenterol Hepatol. 1990;5(6):664-668. doi:https://doi.org/10.1111/j.1440-1746.1990.tb01122.x
Wijewickrama A. Dengue, bleeding and non-steroidal anti-inflammatory drugs. J Ceylon Coll Physicians. Published online December 2017. doi:10.4038/jccp.v48i2.7824
Díaz-Quijano FA, Villar-Centeno LÁ, Martínez-Vega RA. Efecto de la administración temprana de dipirona sobre la gravedad del dengue en una cohorte prospectiva. Enfermedades Infecc Microbiol Clínica. 2005;23(10):593-597. doi:https://doi.org/10.1157/13081567
Diaz-Quijano FA, Villar-Centeno LA, Martinez-Vega RA. Predictors of spontaneous bleeding in patients with acute febrile syndrome from a dengue endemic area. J Clin Virol. 2010;49(1):11-15. doi:https://doi.org/10.1016/j.jcv.2010.06.011
Management of Acute Pain From Non–Low Back, Musculoskeletal Injuries. Ann Intern Med. 2020;173(9):730-738. doi:10.7326/M19-3601
Lesczinsky DMC, Gutiérrez SP, Torrico A, Paz FT. Efectos de la administración de dipirona en niños tratados por dengue con signos de alarma.
Vasikasin V, Rojdumrongrattana T, Chuerboonchai W, et al. Effect of standard dose paracetamol versus placebo as antipyretic therapy on liver injury in adult dengue infection: a multicentre randomised controlled trial. Lancet Glob Health. 2019;7(5):e664-e670. doi:10.1016/S2214-109X(19)30032-4
Pandejpong D, Saengsuri P, Rattarittamrong R, Rujipattanakul T, Chouriyagune C. Is excessive acetaminophen intake associated with transaminitis in adult patients with dengue fever? Intern Med J. 2015;45(6):653-658. doi:10.1111/imj.12756
Syed AA, Aslam F, Hakeem H, Siddiqui F, Nasir N. Frequency of worsening liver function in severe dengue hepatitis patients receiving paracetamol: A retrospective analysis of hospital data. J Pak Med Assoc. 2017;67(3).
Thomas L, Brouste Y, Najioullah F, et al. Predictors of severe manifestations in a cohort of adult dengue patients. J Clin Virol. 2010;48(2):96-99. doi:https://doi.org/10.1016/j.jcv.2010.03.008
Djossou F, Vesin G, Walter G, et al. Incidence and predictive factors of transaminase elevation in patients consulting for dengue fever in Cayenne Hospital, French Guiana. Trans R Soc Trop Med Hyg. 2016;110(2):134-140. doi:10.1093/trstmh/trv117
Gutierrez Lesmes OA, Plata Casas LI, Montaño Contreras SC. Mortalidad en pacientes menores de edad con diagnóstico de dengue y su relación con el uso de Dipirona. Univ Salud. 2016;18(3):550. doi:10.22267/rus.161803.60
Rosaldo AR, Almaraz RT. Indicación del metamizol en pacientes con dengue clásico y dengue hemorrágico. Med Interna México. Published online 2006.
Kötter T, Da Costa BR, Fässler M, et al. Metamizole-Associated Adverse Events: A Systematic Review and Meta-Analysis. Manzoli L, ed. PLOS ONE. 2015;10(4):e0122918. doi:10.1371/journal.pone.0122918
Premaratna R, Ragupathy A, Miththinda JKND, de Silva HJ. Timing, predictors, and progress of third space fluid accumulation during preliminary phase fluid resuscitation in adult patients with dengue. Int J Infect Dis IJID Off Publ Int Soc Infect Dis. 2013;17(7):e505-509. doi:10.1016/j.ijid.2012.12.021
Wongsa A. FLUID AND HEMODYNAMIC MANAGEMENT IN SEVERE DENGUE. Southeast Asian J Trop Med Public Health. 2015;46 Suppl 1:123-127.
Michels M, Djamiatun K, Faradz SMH, Koenders MMJF, de Mast Q, van der Ven AJAM. High plasma mid-regional pro-adrenomedullin levels in children with severe dengue virus infections. J Clin Virol Off Publ Pan Am Soc Clin Virol. 2011;50(1):8-12. doi:10.1016/j.jcv.2010.09.008
Andrews B, Semler MW, Muchemwa L, et al. Effect of an Early Resuscitation Protocol on In-hospital Mortality Among Adults With Sepsis and Hypotension: A Randomized Clinical Trial. JAMA. 2017;318(13):1233-1240. doi:10.1001/jama.2017.10913
Russell JA, Walley KR, Singer J, et al. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med. 2008;358(9):877-887. doi:10.1056/NEJMoa067373
De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362(9):779-789. doi:10.1056/NEJMoa0907118
Jayaweera DK, Subasinghe S, De Silva RF, Sanjeewa WAHP, Jayawickreme KP. Complicated Dengue Fever and Its Treatment Dilemmas: A Single-Center Experience in Sri Lanka. Case Rep Infect Dis. 2021;2021:8854282. doi:10.1155/2021/8854282
Rajapakse S. Dengue shock. J Emerg Trauma Shock. 2011;4(1):120-127. doi:10.4103/0974-2700.76835
Rossaint R, Afshari A, Bouillon B, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care Lond Engl. 2023;27(1):80. doi:10.1186/s13054-023-04327-7
Downloads
Publicado
Como Citar
Edição
Seção
Licença
Copyright (c) 2024 JBMEDE - Jornal Brasileiro de Medicina de Emergência
Este trabalho está licenciado sob uma licença Creative Commons Attribution 4.0 International License.
