Publications by authors named "Guillermo Kohn Loncarica"

17 Publications

  • Page 1 of 1

[Consensus on treatment of multisystemic inflammatory syndrome associated with COVID-19].

Arch Argent Pediatr 2021 08;119(4):S198-S211

Hospital de Pediatría "Prof. Dr. Juan P. Garrahan", Buenos Aires.

The pandemic caused by the SARS-CoV-2 virus declared by the WHO in March 11th 2020, affects a small number of pediatric patients, who mostly present mild respiratory compromise and favorable evolution. However began to be observed in previously healthy children, an increase in cases defined as "Multisystemic Inflammatory Syndrome" (MIS-C) or "Kawasaki-like" post-COVID 19 (KLC) that evolve to shock and require hospitalization in the Pediatric Intensive Care Unit. MIS-C and KL-C are characterized by fever; signs of inflammation, gastrointestinal symptoms, and cardiovascular dysfunction, associated with sever forms of presentation with higher incidence of hypotension and/or shock. In the laboratory, markers of inflammation, hypercoagulability and myocardial damage are observed. Firstline drug treatment consists of intravenous immunoglobulin plus oral acetylsalicylic acid. A multidisciplinary approach is recommended for an accurate diagnosis and an early and effective treatment, in order to reduce morbidity and mortality.
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http://dx.doi.org/10.5546/aap.2021.S198DOI Listing
August 2021

The Pediatric Emergency Research Network (PERN): A decade of global research cooperation in paediatric emergency care.

Emerg Med Australas 2021 Oct 3;33(5):900-910. Epub 2021 Jul 3.

Pediatric Emergency Care Applied Research Network (PECARN).

Objectives: The Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in paediatric emergency care to organise globally for the conduct of collaborative research across networks.

Methods: PERN has grown from five to eight member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children.

Results: Beginning as a pandemic response studying H1N1 influenza risk factors in children, PERN research has progressed to multiple observational studies and ongoing global randomised controlled trials (RCTs). As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current COVID-19 pandemic.

Conclusions: Following its success with developing global research, the PERN goal now is to promote the implementation of scientific advances into everyday clinical practice by: (i) expanding the capacity for global RCTs; (ii) deepening the focus on implementation science; (iii) increasing attention to healthcare disparities; and (iv) expanding PERN's reach into resource-restricted regions. Through these actions, PERN aims to meet the needs of acutely ill and injured children throughout the world.
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http://dx.doi.org/10.1111/1742-6723.13801DOI Listing
October 2021

The Pediatric Emergency Research Network: A Decade of Global Research Cooperation in Pediatric Emergency Care.

Pediatr Emerg Care 2021 07;37(7):389-396

Objectives: The Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in pediatric emergency care to organize globally for the conduct of collaborative research across networks.

Methods: The Pediatric Emergency Research Network has grown from 5- to 8-member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed, and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children.

Results: Beginning as a pandemic response with a high-quality retrospective case-controlled study of H1N1 influenza risk factors, PERN research has progressed to multiple observational studies and ongoing global randomized controlled trials. As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current coronavirus disease 2019 pandemic. In light of the ongoing need for translation of research knowledge into equitable clinical practice and to promote health equity, PERN is committed to a coordinated international effort to increase the uptake of evidence-based management of common and treatable acute conditions in all emergency department settings.

Conclusions: The Pediatric Emergency Research Network's successes with global research, measured by prospective observational and interventional studies, mean that the network can now move to improve its ability to promote the implementation of scientific advances into everyday clinical practice. Achieving this goal will involve focus in 4 areas: (1) expanding the capacity for global randomized controlled trials; (2) deepening the focus on implementation science; (3) increasing attention to healthcare disparities and their origins, with growing momentum toward equity; and (4) expanding PERN's global reach through addition of sites and networks from resource-restricted regions. Through these actions, PERN will be able to build on successes to face the challenges ahead and meet the needs of acutely ill and injured children throughout the world.
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http://dx.doi.org/10.1097/PEC.0000000000002466DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8244934PMC
July 2021

Clinical outcome of children with fluid-refractory septic shock treated with dopamine or epinephrine. A retrospective study at a pediatric emergency department in Argentina.

Rev Bras Ter Intensiva 2020 Oct-Dec;32(4):551-556

Red Colaborativa Pediátrica de Latinoamérica (LARed Network) - Montevideo, Uruguay.

Objective: To analyze the clinical outcome of children with fluid-refractory septic shock initially treated with dopamine or epinephrine.

Methods: A retrospective cohort study was conducted at a pediatric emergency department of a tertiary hospital. Population: children admitted because of fluid-refractory septic shock. Clinical outcome was compared between two groups: Dopamine and Epinephrine. Variables evaluated were use of invasive mechanical ventilation, days of inotropic therapy, length of hospital stay, intensive care stay, and mortality. For numerical and categorical variables, we used measures of central tendency. They were compared by the Mann-Whitney U-test and the (2 test.

Results: We included 118 patients. A total of 58.5% received dopamine and 41.5% received epinephrine. The rate of invasive mechanical ventilation was 38.8% for epinephrine versus 40.6% for dopamine (p = 0.84), with a median of 4 days for the Epinephrine Group and 5.5 for the Dopamine Group (p = 0.104). Median time of inotropic therapy was 2 days for both groups (p = 0.714). Median hospital stay was 11 and 13 days for the Epinephrine and Dopamine groups, respectively (p = 0.554), and median stay in intensive care was 4 days (0 - 81 days) in both groups (p = 0.748). Mortality was 5% for the Epinephrine Group versus 9% for the Dopamine Group (p = 0.64).

Conclusions: At our center, no differences in use of invasive mechanical ventilation, time of inotropic therapy, length of hospital stay, length of intensive care unit stay, or mortality were observed in children admitted to the pediatric emergency department with a diagnosis of fluid-refractory septic shock initially treated with dopamine versus epinephrine.
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http://dx.doi.org/10.5935/0103-507X.20200092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853679PMC
October 2019

Exposure and confidence across critical airway procedures in pediatric emergency medicine: An international survey study.

Am J Emerg Med 2021 04 31;42:70-77. Epub 2020 Dec 31.

Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand; Paediatric Emergency Department, Monash Medical Centre, Melbourne, Australia; Department of Paediatrics, School of Clinical Sciences at Monash Health, Monash University, Australia.

Background: Airway management procedures are critical for emergency medicine (EM) physicians, but rarely performed skills in pediatric patients. Worldwide experience with respect to frequency and confidence in performing airway management skills has not been previously described.

Objectives: Our aims were 1) to determine the frequency with which emergency medicine physicians perform airway procedures including: bag-mask ventilation (BMV), endotracheal intubation (ETI), laryngeal mask airway (LMA) insertion, tracheostomy tube change (TTC), and surgical airways, and 2) to investigate predictors of procedural confidence regarding advanced airway management in children.

Methods: A web-based survey of senior emergency physicians was distributed through the six research networks associated with Pediatric Emergency Research Network (PERN). Senior physician was defined as anyone working without direct supervision at any point in a 24-h cycle. Physicians were queried regarding their most recent clinical experience performing or supervising airway procedures, as well as with hands on practice time or procedural teaching. Reponses were dichotomized to within the last year, or ≥ 1 year. Confidence was assessed using a Likert scale for each procedure, with results for ETI and LMA stratified by age. Response levels were dichotomized to "not confident" or "confident." Multivariate regression models were used to assess relevant associations.

Results: 1602 of 2446 (65%) eligible clinicians at 96 PERN sites responded. In the previous year, 1297 (85%) physicians reported having performed bag-mask ventilation, 900 (59%) had performed intubation, 248 (17%) had placed a laryngeal mask airway, 348 (23%) had changed a tracheostomy tube, and 18 (1%) had performed a surgical airway. Of respondents, 13% of physicians reported the opportunity to supervise but not provide ETI, 5% for LMA and 5% for BMV. The percentage of physicians reporting "confidence" in performing each procedure was: BMV (95%) TTC (43%), and surgical airway (16%). Clinician confidence in ETT and LMA varied by patient age. Supervision of an airway procedure was the strongest predictor of procedural confidence across airway procedures.

Conclusion: BMV and ETI were the most commonly performed pediatric airway procedures by emergency medicine physicians, and surgical airways are very infrequent. Supervising airway procedures may serve to maintain procedural confidence for physicians despite infrequent opportunities as the primary proceduralist.
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http://dx.doi.org/10.1016/j.ajem.2020.12.075DOI Listing
April 2021

Recommendations for the initial management of multisystem inflammatory syndrome temporally related to COVID-19, in children and adolescents.

Arch Argent Pediatr 2020 12;118(6):e514-e526

Facultad de Medicina, Universidad Nacional del Nordeste, Corrientes, Argentina. Red Colaborativa Pediátrica de Latinoamérica (LARed Network).

Multisystem inflammatory syndrome temporally related to COVID-19 in children and adolescents is a clinical presentation of SARS-CoV-2 infection. It shares some features with Kawasaki disease, toxic shock, sepsis, macrophage activation syndrome, and myocarditis. Few publications have addressed its initial management, which is similar to that proposed for septic shock. This review analyzes such approach based on the characteristics typical of multisystem inflammatory syndrome related to COVID-19 in accordance with the paradigm of an "institutional practice guideline" and suggests therapeutic approach strategies, including early detection, stabilization, referral, specific treatment, and process analysis.
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http://dx.doi.org/10.5546/aap.2020.eng.e514DOI Listing
December 2020

Use of Inotropics by Peripheral Vascular Line in the First Hour of Treatment of Pediatric Septic Shock: Experience at an Emergency Department.

Pediatr Emerg Care 2020 Nov 18. Epub 2020 Nov 18.

From the Unidad Emergencias, Hospital de Pediatría "Juan P. Garrahan".

Objective: Mortality in pediatric septic shock remains unacceptably high. Delays in vasopressor administration have been associated with an increased risk of mortality. Current treatment guidelines suggest the use of a peripheral vascular line (PVL) for inotropic administration in fluid-refractory septic shock when a central vascular line is not already in place. The aim of this study was to report local adverse effects associated with inotropic drug administration through a PVL at a pediatric emergency department setting in the first hour of treatment of septic shock.

Methods: A prospective, descriptive, observational cohort study of patients with septic shock requiring PVL inotropic administration was conducted at the pediatric emergency department of a tertiary care pediatric hospital. For the infusion and postplacement care of the PVL for vasoactive drugs, an institutional nursing protocol was used.

Results: We included 49 patients; 51% had an underlying disease. Eighty-four percent of the children included had a clinical "cold shock." The most frequently used vasoactive drug was epinephrine (72%). One patient presented with local complications.

Conclusions: At our center, infusion of vasoactive drugs through a PVL was shown to be safe and allowed for adherence to the current guidelines for pediatric septic shock.
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http://dx.doi.org/10.1097/PEC.0000000000002295DOI Listing
November 2020

Exposure and Confidence With Critical Nonairway Procedures: A Global Survey of Pediatric Emergency Medicine Physicians.

Pediatr Emerg Care 2021 Sep;37(9):e551-e559

School of Clinical Sciences at Monash Health, Monash University Melbourne, Australia.

Background: Children rarely experience critical illness, resulting in low exposure of emergency physicians (EPs) to critical procedures. Our primary objective was to describe senior EP confidence, most recent performance, and/or supervision of critical nonairway procedures. Secondary objectives were to compare responses between those who work exclusively in PEM and those who do not and to determine whether confidence changed for selected procedures according to increasing patient age.

Methods: Survey of senior EPs working in 96 emergency departments (EDs) affiliated with the Pediatric Emergency Research Networks. Questions assessed training, performance, supervision, and confidence in 11 nonairway critical procedures, including cardiopulmonary resuscitation (CPR), vascular access, chest decompression, and cardiac procedures.

Results: Of 2446 physicians, 1503 (61%) responded to the survey. Within the previous year, only CPR and insertion of an intraosseous needle had been performed by at least 50% of respondents: over 20% had performed defibrillation/direct current cardioversion. More than 50% of respondents had never performed or supervised ED thoracotomy, pericardiocentesis, venous cutdown, or transcutaneous pacing. Self-reported confidence was high for all patient age groups for CPR, needle thoracocentesis, tube thoracostomy, intraosseous needle insertion, and defibrillation/DC cardioversion. Confidence levels increased with increasing patient age for central venous and arterial line insertion. Respondents working exclusively in PEM were more likely to report being at least somewhat confident in defibrillation/DC cardioversion, intraosseous needle insertion, and central venous line insertion in particular age groups; however, they were less likely to be at least somewhat confident in ED thoracotomy and transcutaneous pacing.

Conclusions: Cardiopulmonary resuscitation and intraosseous needle insertion were the only critical nonairway procedures performed by at least half of EPs within the previous year. Confidence was higher for these procedures, and needle and tube thoracostomy. These data may inform the development of continuing medical education activities to maintain pediatric procedural skills for emergency physicians.
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http://dx.doi.org/10.1097/PEC.0000000000002092DOI Listing
September 2021

Detection and management of Anaphylaxis in children.

Rev Chil Pediatr 2019 2;90(1):44-51. Epub 2019 Jan 2.

Unidad de Emergencias, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Argentina.

Introduction: Anaphylaxis is an emergency condition. According to the latest international guide lines, early recognition and treatment with intramuscular epinephrine are associated with increased survival.

Objective: To determine the level of knowledge of pediatricians in a tertiary Pediatric Hos pital about the diagnostic criteria and treatment of anaphylaxis.

Material And Method: A cross-sec tional descriptive study was conducted, designing, applying, and validating an anonymous survey to physicians with complete residency in pediatrics who are on call at a third level hospital. The statisti cal analysis was made using the SPSS v.21 software, presenting measures of central tendency (median, range, and frequency table) and Chi-square test for comparison. A value of p < 0.05 was considered significant.

Results: 71 physicians completed the survey with a median of three years after the end of residency.35% of them identified all clinical criteria, 99% (70) indicated epinephrine, 73% chose the intramuscular route, and 55% indicated the correct dose. Only 48% of responders chose the dose and administration route correctly. In general, 21% recognized anaphylaxis and used epinephrine correctly. Physicians with less than five years of experience performed better in the intramuscular administration of epinephrine (83% vs 52% p = 0.005) and in the detection of gastrointestinal symp toms (60% vs 35% p = 0.043).

Conclusions: There are difficulties in the identification and proper management of anaphylaxis by pediatricians of a tertiary Pediatric Hospital in a theoretical clinical setting. Although most of pediatricians chose epinephrine as a first-line drug, half of them did not indicate it correctly, and only one-third recognized anaphylaxis in all scenarios.
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http://dx.doi.org/10.32641/rchped.v90i1.839DOI Listing
December 2019

How Are Clinicians Treating Children With Sepsis in Emergency Departments in Latin America?: An International Multicenter Survey.

Pediatr Emerg Care 2019 May 1. Epub 2019 May 1.

Unidad Emergencias, Hospital de Pediatría Prof. Dr. Juan P. Garrahan y Universidad de Buenos Aires, Buenos Aires.

Objective: Guidelines adherence in emergency departments (EDs) relies partly on the availability of resources to improve sepsis care and outcomes. Our objective was to assess the management of pediatric septic shock (PSS) in Latin America's EDs and to determine the impact of treatment coordinated by a pediatric emergency specialist (PEMS) versus nonpediatric emergency specialists (NPEMS) on guidelines adherence.

Methods: Prospective, descriptive, and multicenter study using an electronic survey administered to PEMS and NPEMS who treat PSS in EDs in 14 Latin American countries.

Results: We distributed 2164 surveys with a response rate of 41.5%, of which 22.5% were PEMS. Overall American College of Critical Care Medicine reported guidelines adherence was as follows: vascular access obtained in 5 minutes, 76%; fluid infusion technique, 60%; administering 40 to 60 mL/kg within 30 minutes, 32%; inotropic infusion by peripheral route, 61%; dopamine or epinephrine in cold shock, 80%; norepinephrine in warm shock, 57%; and antibiotics within 60 minutes, 82%. Between PEMS and NPEMS, the following differences were found: vascular access in 5 minutes, 87.1% versus 72.7% (P < 0.01); fluid infusion technique, 72.3% versus 55.9% (P < 0.01); administering 40 to 60 mL/kg within 30 minutes, 42% versus 29% (P < 0.01); inotropic infusion by peripheral route, 75.7% versus 56.3% (P < 0.01); dopamine or epinephrine in cold shock, 87.1% versus 77.3% (P < 0.05); norepinephrine in warm shock, 67.8% versus 54% (P < 0.01); and antibiotic administration within first 60 minutes, 90.1% versus 79.3% (P < 0.01), respectively. Good adherence criteria were followed by 24%. The main referred barrier for sepsis care was a failure in its recognition, including the lack of triage tools.

Conclusions: In some Latin American countries, there is variability in self-reported adherence to the evidence-based recommendations for the treatment of PSS during the first hour. The coordination by PEMS support greater adherence to these recommendations.
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http://dx.doi.org/10.1097/PEC.0000000000001838DOI Listing
May 2019

[Recommendations for the management of pediatric septic shock in the first hour (part two)].

Arch Argent Pediatr 2019 02;117(1):e24-e33

Facultad de Medicina, Universidad Nacional del Nordeste, Corrientes, Argentina.

In 2016, the Surviving Sepsis Campaign and the National Institute for Health and Care Excellence (NICE) developed clinical practice guidelines for the management of pediatric septic shock. In 2017, the American College of Critical Care Medicine (ACCM) updated its recommendations for hemodynamic support of pediatric shock. Recognizing septic shock is critical, as well as an optimal, time-sensitive treatment. An adequate consultation with a pediatric specialist and/or a timely referral to a facility with a higher level of care are also critical for an appropriate outcome in the management of this condition. Here we analyze the bundles used in the management of these patients, which are essential to improve the quality of care.
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http://dx.doi.org/10.5546/aap.2019.e24DOI Listing
February 2019

Recommendations for the management of pediatric septic shock in the first hour (part one).

Arch Argent Pediatr 2019 02;117(1):e14-e23

Facultad de Medicina, Universidad Nacional del Nordeste, Corrientes, Argentina.

In the past two years, different organizations have updated their clinical practice guidelines for hemodynamic support in pediatric septic shock. The studies conducted in adults have questioned the initial management of sepsis in accordance to protocols based on achieving various goals. However, the usefulness of these protocols in children has been demonstrated. The possibility of adhering to guidelines may vary depending on patients and facilities, so it is necessary to update the general aspects of initial care for children with sepsis. The proposal is to shift the paradigm from an "individual practice guideline," which is universal for all, to an "institutional practice guideline" and to assess the factors that should be improved at each facility. This manuscript is divided into two parts. The first part analyzes the bundles for the early detection of septic shock. Part two addresses treatment, stabilization, referral, and process analysis.
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http://dx.doi.org/10.5546/aap.2019.eng.e14DOI Listing
February 2019

Preferred learning modalities and practice for critical skills: a global survey of paediatric emergency medicine clinicians.

Emerg Med J 2019 May 16;36(5):273-280. Epub 2018 Oct 16.

Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia.

Objective: To describe senior paediatric emergency clinician perspectives on the optimal frequency of and preferred modalities for practising critical paediatric procedures.

Methods: Multicentre multicountry cross-sectional survey of senior paediatric emergency clinicians working in 96 EDs affiliated with the Pediatric Emergency Research Network.

Results: 1332/2446 (54%) clinicians provided information on suggested frequency of practice and preferred learning modalities for 18 critical procedures. Yearly practice was recommended for six procedures (bag valve mask ventilation, cardiopulmonary resuscitation (CPR), endotracheal intubation, laryngeal mask airway insertion, defibrillation/direct current (DC) cardioversion and intraosseous needle insertion) by at least 80% of respondents. 16 procedures were recommended for yearly practice by at least 50% of respondents. Two procedures (venous cutdown and ED thoracotomy) had yearly practice recommended by <40% of respondents. Simulation was the preferred learning modality for CPR, bag valve mask ventilation, DC cardioversion and transcutaneous pacing. Practice in alternative clinical settings (eg, the operating room) was the preferred learning modality for endotracheal intubation and laryngeal mask insertion. Use of models/mannequins for isolated procedural training was the preferred learning modality for all other invasive procedures. Free-text responses suggested the utility of cadaver labs and animal labs for more invasive procedures (thoracotomy, intercostal catheter insertion, open surgical airways, venous cutdown and pericardiocentesis).

Conclusions: Paediatric ED clinicians suggest that most paediatric critical procedures should be practised at least annually. The preferred learning modality depends on the skill practised; alternative clinical settings are thought to be most useful for standard airway manoeuvres, while simulation-based experiential learning is applicable for most other procedures.
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http://dx.doi.org/10.1136/emermed-2017-207384DOI Listing
May 2019

[Pediatric emergency medicine specialty: Welcome!]

Arch Argent Pediatr 2018 08;116(4):298-300

Comité de Emergencias y Cuidados Críticos, Sociedad Argentina de Pediatría.

Pediatric Emergency Medicine has developed around the world as a subspecialty of pediatrics. There is plenty of data reflecting a growing need for its services. The subspecialty was initiated in the United States and Argentina, together with other Latin American countries, followed the same path. Nevertheless, there is yet much to be done. It is necessary to strengthen its promotion and to stimulate research and teaching activities in order to continue improving the quality of care delivered to the pediatric population, their families and society as a whole.
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http://dx.doi.org/10.5546/aap.2018.298DOI Listing
August 2018

[Early hemodynamic support in septic shock].

Arch Argent Pediatr 2010 Jun;108(3):249-54

Area de Emergencias, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan.

Sepsis is the most common cause of death in children. Its adequate management has a significant impact on morbidity and mortality. Pediatricians who take initial contact with these patients play a fundamental role in the chain of actions that start at the Emergency Area and finish in the Intensive Care Unit. In recent years, some strategies have been developed to achieve staggered targets: clinical, hemodynamic, biochemical, and oxygenation. The correct interpretation of each affected component will allow the most appropriate intervention. The aggressive management with fluids and the early indication of inotropes are the basis for the management of shock. This paper summarizes primary interventions in the Emergency Department.
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http://dx.doi.org/10.1590/S0325-00752010000300017DOI Listing
June 2010
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