Vasküler Travmaların Epidemiyolojisi
Özet
Travmatik damar hastalıkları her yaştaki hastada karşımıza çıkabilecek hayatı tehdit eden durumlardan biridir. Travmanın şekli, yaralanma bölgesi, hayati organlara ve büyük vasküler yapılara yakınlığı, travma sonrasında hastaneye ulaşıncaya kadar geçen süre gibi faktörler bu hastaların klinik seyirlerini öngörmede önemli unsurlardır. Vasküler travma düşündüğümüz bir hastada yapılacak hızlı bir fizik muayeneden sonra tanıyı kesinleştirmek ve yapılacak girişimlerin şeklini belirlemek için görüntüleme yöntemlerini kullanmak günümüzde hasta değerlendirmenin vazgeçilmez bir parçasıdır. Tecrübeli bir radyoloji uzmanı tarafından yapılan Doppler USG ekstremite vasküler yaralanmaları hakkında önemli bilgiler verebilmektedir. Ancak tanıyı kesinleştirecek ve girişim stratejilerimizi belirleyecek en önemli tetkik BT anjiografi görüntülemesidir. Gelişen teknoloji ile birlikte çok kesitli BT anjiografiler vasküler yapı hakkında detaylı bilgi sunmakta ve damar yaralanmasının ekartasyonu veya tanı koydurması açısından neredeyse zorunlu hale gelmiştir. Vasküler yaralanma tanısı için yapılan arteriografi ve venografi gibi invaziv tetkikler günümüzde çok nadiren gerekmektedir. Görüntülemeler sırasında non-invaziv tetkiklerin kullanılması ile hem hastalar invaziv tetkiklerin getirebileceği komplikasyonların riskinden korunmakta hem de travmanın şüpheli olduğu durumlarda hastaya ek girişim yapılmadan hızlıca tanı konulabilmektedir.
Bu bölümde penetran ve künt travmalarla meydana gelebilecek çeşitli damar yaralanmalarında yapılabilecek ve tercih edilebilecek görüntüntüleme yöntemlerinden bahsedilmiştir.
Traumatic vascular injuries are life-threatening conditions that can occur in patients of any age. Factors such as the mechanism of trauma, the site of injury, proximity to vital organs and major vascular structures, and the time elapsed before reaching the hospital significantly influence the clinical course of these patients. In modern medical practice, imaging techniques have become an indispensable component of patient evaluation following a rapid physical examination in cases where vascular trauma is suspected, to confirm the diagnosis and determine the course of intervention.
Doppler ultrasonography (USG) performed by an experienced radiologist can provide valuable information regarding extremity vascular injuries. However, the most crucial diagnostic tool for confirming the diagnosis and planning intervention strategies is computed tomography (CT) angiography. Advances in technology have made multi-slice CT angiography essential, offering detailed information about vascular structures and becoming nearly indispensable for ruling out or diagnosing vascular injuries.
Invasive investigations such as arteriography and venography, once commonly employed for diagnosing vascular injuries, are now rarely required. The use of non-invasive imaging methods not only spares patients from the risks of complications associated with invasive procedures but also allows for rapid diagnosis in cases of suspected trauma without the need for additional interventions.
This section discusses imaging techniques that can be employed or preferred for evaluating various vascular injuries resulting from penetrating and blunt trauma.
Referanslar
Alberdi, F., García, I., Atutxa, L., & Zabarte, M. (2014). Epidemiology of severe trauma. Medicina Intensiva (English Edition), 38(9), 580-588.
Perkins, Z. B., De'Ath, H. D., Aylwin, C., Brohi, K., Walsh, M., & Tai, N. R. M. (2012). Epidemiology and outcome of vascular trauma at a British Major Trauma Centre. European journal of vascular and endovascular surgery, 44(2), 203-209.
Tai, N. R., & Rasmussen, T. E. (2016). Epidemiology of Vascular Injury. In Rich's Vascular Trauma (pp. 13-20). Elsevier.
Caps MT: The epidemiology of vascular trauma. Semin Vasc Surg 11:227– 231, 1998.
Smith General Sir Rupert: The utility of force, London, 2005, Allen Lane. ISBN 0-7139-9836-9.
Holcomb JB, McMullin NR, Pearse L, et al: Causes of death in U.S. Special Operations forces in the global war on terrorism 2001–2004. Ann Surg 245:986–991, 2007.
Champion HR, Bellamy RF, Roberts CP, et al: A profile of combat injury. J Trauma 54:S13–S19, 2003.
Kelly JF, Ritenour AE, McLaughlin DF, et al: Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003–2004 versus 2006. J Trauma 64:S21–S26, 2008.
Bellamy RF: The cause of death in conventional land warfare: implications for combat casualty care research. Mil Med 149:55–62, 1984.
Bowlby A, Wallace C: The development of British surgery at the front. Brit Med J 1:705–721, 1917.
DeBakey ME, Simeone FA: Battle injuries of the arteries in World War II: an analysis of 2471 cases. Ann Surg 123:534–579, 1946.
Hughes CW: Arterial repair during the Korean War. Ann Surg 147:555– 561, 1958.
Rich NM, Hughes CW: Vietnam vascular registry: a preliminary report. Surgery 65:218–226, 1969.
White JM, Stannard A, Burkhardt GE, et al: The epidemiology of vascular injury in the Wars in Iraq and Afghanistan. Ann Surg 253:1184–1189, 2011.
Fox CJ, Gillespie DL, O’Donnell SD, et al: Contemporary management of wartime vascular trauma. J Vasc Surg 41:638–644, 2005.
Sohn VY, Arthurs ZM, Herbert GS, et al: Demographics, treatment, and early outcomes in penetrating vascular combat trauma. Arch Surg 143: 783–787, 2008.
Stannard A, Brown K, Benson C, et al: Outcome after vascular trauma in a deployed military trauma system. British Journal of Surgery 98:228– 234, 2011.
AAP-6, NATO Glossary of terms and definitions 2010. North Atlantic Treaty Organisation NATO Standardisation Agency, 2010.
Peck M, Clouse D, Cox M, et al: The complete management of extremity vascular injury in a local population: a wartime report from the 332nd Expeditionary Medical Group/Air Force Theater Hospital, Balad Air Base. J Vasc Surg 45:1197–1205, 2007.
Sfeir, R. E., Khoury, G. S., & Kenaan, M. K. (1995). Vascular trauma to the lower extremity: the Lebanese war experience. Cardiovascular Surgery, 3(6), 653-657.
Barmparas, G., Inaba, K., Talving, P., David, J. S., Lam, L., Plurad, D., ... & Demetriades, D. (2010). Pediatric vs adult vascular trauma: a National Trauma Databank review. Journal of pediatric surgery, 45(7), 1404-1412.
http://www.unodc.org/unodc/en/data-and-analysis/homicide.html. Accessed November 2011.
http://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2010/crime-in -the-u.s.-2010/tables/10tbl17.xls. Accessed November 2011.
Recorded crime victims. 4510.0. Australian Bureau of statistics 2009.
Loh S, Rockman C, Chung C, et al: Existing trauma and critical care scoring systems underestimate mortality among vascular trauma patients. J Vasc Surg 53:359–366, 2011.
Galindo RM, Workman CR: Vascular trauma at a military level II trauma center. Curr Surg 57:615–618, 2000.
Mattox K, Feliciano DV, Burch J, et al: Five thousand seven hundred sixty cardiovascular injuries in 4459 patients: epidemiologic evolution 1958 to 1987. Ann Surg 209:698–705, 1989
Bongard F, Dubrow T, Klein S: Vascular injuries in the urban battleground: experience at a metropolitan trauma center. Ann Vasc Surg 4: 415–418, 1990.
Gupta R, Rao S, Sieunarine K: An epidemiological view of vascular trauma in Western Australia. Aust NZ J Surg 71:461–466, 2001.
Sugrue M, Caldwell E, D’Amours S, et al: Vascular injury in Australia. Surg Clin N Am, 82:211–219, 2002.
Magee TR, Collin J, Hands LJ, et al: A ten year audit of surgery for vascular trauma in a British teaching hospital. Eur J Vasc Endovasc Surg 12:424– 427, 1996.
De’Ath HD, Galland RB: Iatrogenic and non-iatrogenic vascular trauma in a district general hospital: a 21-year review. World J Surg 34(10):2363– 2367, 2010 Oct.
Stannard A, Brohi K, Tai N: Vascular injury in the United Kingdom. Perspect Vasc Surg Endovasc Ther 23:27–33, 2011.
Koivunen D, Nichols WK, Silver D: Vascular trauma in a rural population. Surgery 91:723–727, 1982.
Stannard A, Brohi K, Tai N: Vascular injury in the United Kingdom. Perspect Vasc Surg Endovasc Ther 23:27–33, 2011
Oller D, Rutledge R, Thomas C, et al: Vascular injuries in a rural state: a review of 978 patients from a state trauma registry. Journal of Trauma 32:740–746, 1992.
Whitehouse WM, Coran AG, Stanley JC, et al: Pediatric vascular trauma: manifestations, management, and sequelae of extremity arterial injury in patients undergoing surgical treatment. Arch Surg 111:1269–1275, 1976.
Meagher DP, Jr, Defore WW, Mattox KL: Vascular trauma in infants and children. J Trauma 19:532–536, 1979. 42. Myers SI, Reed MK, Black CT, et al: Noniatrogenic pediatric vascular trauma. J Vasc Surg 10:258–265, 1989.
De Virgilio C, Mercado PD: Noniatrogenic pediatric vascular trauma: a ten-year experience at a level I trauma center. Am Surg 63:781–784, 1997.
Linda M, Harris MD, Hordines John: Major vascular injuries in the pediatric population. Ann Vast Surg 17:266–269, 2003.
Klinkner DB, Arca MJ, Lewis BD, et al: Pediatric vascular injuries: patterns of injury, morbidity, and mortality. J Pediatr Surg 42(1):178–182, discussion 182–3, 2007.
Fingerhut A, Leppaniemi AK, Androulakis G, et al: The European experience with vascular injuries. Surg Clin North Am 82:175–188, 2002.
Igun GO, Nwadiaro HC, Sule AZ: Ramyil VM, Dakum NK. Surgical experience with management of vascular injuries. West Afr J Med 20:102– 106, 2001.
Rudström H, Bergqvist D, Ogren M, et al: Iatrogenic vascular injuries in Sweden. A nationwide study 1987–2005. Eur J Vasc Endovasc Surg 35: 131–138, 2008.
Simmons JD, Duchesne JC, Ahmed N, et al: The weight of obesity in patients with lower extremity vascular injuries. Injury 2010. doi: 10.1016/j. injury.2010.04.025.
Rosen H, Saleh F, Lipsitz S, et al: Downwardly mobile: the accidental cost of being uninsured. Arch Surg 144:1006–1011, 2009.
Dozier KC, Miranda MA, Jr, Kwan RO, et al: Insurance coverage is associated with mortality after gunshot trauma. J Am Coll Surg 210:280–285, 2010.
Maybury RS, Bolorunduro OB, Villegas C, et al: Pedestrians struck by motor vehicles further worsen race- and insurance-based disparities in trauma outcomes: the case for inner-city pedestrian injury prevention programs. Surgery 148:202–208, 2010.
Crandall M, Sharp D, Brasel K, et al: Lower extremity vascular injuries: increased mortality for minorities and the uninsured? Surgery 150:656– 664, 2011.
Fansa, İ., Atay, M., Altınay, L., Saydam, O., Karatepe, C., Acıpayam, M., & Lale, C. (2016). Analysis of vascular trauma in terror-related civilian attacks within South-Eastern Turkey.
Akça, B. (2019). Management of war-related vascular injuries: A civilian surgeon experience in the treatment of war casualties at a secondary care hospital. RJMM, 122(3), 29.
Açıksarı, K., Koçak, M., Solakoğlu, G. A., Turan, Ö., Erinc, S., Ekinci, Ö., & Aydın, E. (2020). The characteristics of the patients in mass public shootings among coup attempt in Turkey: A single-center hospital response. Turkish Journal of Trauma & Emergency Surgery/Ulusal Travma ve Acil Cerrahi Dergisi, 26(1).
Günday, M., Durusu, M., Yıldızhan, A., Karpuzoğlu, E., Depboylu, B., & Eryılmaz, M. (2012). Vasküler yaralanmalı 41 olgunun analizi. Türk Göğüs Kalp Damar Cerrahisi Dergisi, 20(1), 65-68.
Demirkiliç, U., Kuralay, E., Yilmaz, A. T., Özal, E., Tatar, H., & Öztürk, Ö. Y. (1998). Surgical approach to military vascular injuries. Cardiovascular Surgery, 6(4), 342-346.
Buyurgan, Ç. S., Babuş, S. B., Yarkaç, A., Köse, A., Usluer, H. O., Ayrık, C., ... & Temel, G. O. (2023). Demographic and clinical characteristics of earthquake victims presented to the emergency department with and without crush injury upon the 2023 Kahramanmaraş (Turkey) Earthquake. Prehospital and disaster medicine, 38(6), 707-715.
Asirdizer, M., Yavuz, M. S., Buken, E., Daglar, S., & Uzun, I. (2004). Medicolegal evaluation of vascular injuries of limbs in Turkey. Journal of clinical forensic medicine, 11(2), 59-64.
Kayalar, N., Boyacıoğlu, K., Ketenciler, S., Kuplay, H., Mert, B., Yücel, C., ... & Erentuğ, V. (2017). Emergency vascular injuries: patient profile, management strategies and risk factors for mortality. Turk Gogus Kalp Dama, 25(1), 74-81.
Er, Z. C., & Atılgan, K. (2020). Evaluation of peripheral vascular injuries treated with surgery: A retrospective cohort study. Journal of Surgery and Medicine, 4(5), 371-373.
World Health Organization: Decade of Decade of Action for Road Safety 2011–2020: saving millions of lives. http://www.who.int/violence_injury_ prevention/publications/road_traffic/saving_millions_lives_en.pdf. Accessed 6th Nov 2011.
Geneva Declaration Secretariat: Global Burden of Armed Violence: Lethal Encounters http://www.genevadeclaration.org/measurability/ global-burden-of-armed-violence/global-burden-of-armed-violence -2011.html. Accessed 6th Nov 2011.
Referanslar
Alberdi, F., García, I., Atutxa, L., & Zabarte, M. (2014). Epidemiology of severe trauma. Medicina Intensiva (English Edition), 38(9), 580-588.
Perkins, Z. B., De'Ath, H. D., Aylwin, C., Brohi, K., Walsh, M., & Tai, N. R. M. (2012). Epidemiology and outcome of vascular trauma at a British Major Trauma Centre. European journal of vascular and endovascular surgery, 44(2), 203-209.
Tai, N. R., & Rasmussen, T. E. (2016). Epidemiology of Vascular Injury. In Rich's Vascular Trauma (pp. 13-20). Elsevier.
Caps MT: The epidemiology of vascular trauma. Semin Vasc Surg 11:227– 231, 1998.
Smith General Sir Rupert: The utility of force, London, 2005, Allen Lane. ISBN 0-7139-9836-9.
Holcomb JB, McMullin NR, Pearse L, et al: Causes of death in U.S. Special Operations forces in the global war on terrorism 2001–2004. Ann Surg 245:986–991, 2007.
Champion HR, Bellamy RF, Roberts CP, et al: A profile of combat injury. J Trauma 54:S13–S19, 2003.
Kelly JF, Ritenour AE, McLaughlin DF, et al: Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003–2004 versus 2006. J Trauma 64:S21–S26, 2008.
Bellamy RF: The cause of death in conventional land warfare: implications for combat casualty care research. Mil Med 149:55–62, 1984.
Bowlby A, Wallace C: The development of British surgery at the front. Brit Med J 1:705–721, 1917.
DeBakey ME, Simeone FA: Battle injuries of the arteries in World War II: an analysis of 2471 cases. Ann Surg 123:534–579, 1946.
Hughes CW: Arterial repair during the Korean War. Ann Surg 147:555– 561, 1958.
Rich NM, Hughes CW: Vietnam vascular registry: a preliminary report. Surgery 65:218–226, 1969.
White JM, Stannard A, Burkhardt GE, et al: The epidemiology of vascular injury in the Wars in Iraq and Afghanistan. Ann Surg 253:1184–1189, 2011.
Fox CJ, Gillespie DL, O’Donnell SD, et al: Contemporary management of wartime vascular trauma. J Vasc Surg 41:638–644, 2005.
Sohn VY, Arthurs ZM, Herbert GS, et al: Demographics, treatment, and early outcomes in penetrating vascular combat trauma. Arch Surg 143: 783–787, 2008.
Stannard A, Brown K, Benson C, et al: Outcome after vascular trauma in a deployed military trauma system. British Journal of Surgery 98:228– 234, 2011.
AAP-6, NATO Glossary of terms and definitions 2010. North Atlantic Treaty Organisation NATO Standardisation Agency, 2010.
Peck M, Clouse D, Cox M, et al: The complete management of extremity vascular injury in a local population: a wartime report from the 332nd Expeditionary Medical Group/Air Force Theater Hospital, Balad Air Base. J Vasc Surg 45:1197–1205, 2007.
Sfeir, R. E., Khoury, G. S., & Kenaan, M. K. (1995). Vascular trauma to the lower extremity: the Lebanese war experience. Cardiovascular Surgery, 3(6), 653-657.
Barmparas, G., Inaba, K., Talving, P., David, J. S., Lam, L., Plurad, D., ... & Demetriades, D. (2010). Pediatric vs adult vascular trauma: a National Trauma Databank review. Journal of pediatric surgery, 45(7), 1404-1412.
http://www.unodc.org/unodc/en/data-and-analysis/homicide.html. Accessed November 2011.
http://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2010/crime-in -the-u.s.-2010/tables/10tbl17.xls. Accessed November 2011.
Recorded crime victims. 4510.0. Australian Bureau of statistics 2009.
Loh S, Rockman C, Chung C, et al: Existing trauma and critical care scoring systems underestimate mortality among vascular trauma patients. J Vasc Surg 53:359–366, 2011.
Galindo RM, Workman CR: Vascular trauma at a military level II trauma center. Curr Surg 57:615–618, 2000.
Mattox K, Feliciano DV, Burch J, et al: Five thousand seven hundred sixty cardiovascular injuries in 4459 patients: epidemiologic evolution 1958 to 1987. Ann Surg 209:698–705, 1989
Bongard F, Dubrow T, Klein S: Vascular injuries in the urban battleground: experience at a metropolitan trauma center. Ann Vasc Surg 4: 415–418, 1990.
Gupta R, Rao S, Sieunarine K: An epidemiological view of vascular trauma in Western Australia. Aust NZ J Surg 71:461–466, 2001.
Sugrue M, Caldwell E, D’Amours S, et al: Vascular injury in Australia. Surg Clin N Am, 82:211–219, 2002.
Magee TR, Collin J, Hands LJ, et al: A ten year audit of surgery for vascular trauma in a British teaching hospital. Eur J Vasc Endovasc Surg 12:424– 427, 1996.
De’Ath HD, Galland RB: Iatrogenic and non-iatrogenic vascular trauma in a district general hospital: a 21-year review. World J Surg 34(10):2363– 2367, 2010 Oct.
Stannard A, Brohi K, Tai N: Vascular injury in the United Kingdom. Perspect Vasc Surg Endovasc Ther 23:27–33, 2011.
Koivunen D, Nichols WK, Silver D: Vascular trauma in a rural population. Surgery 91:723–727, 1982.
Stannard A, Brohi K, Tai N: Vascular injury in the United Kingdom. Perspect Vasc Surg Endovasc Ther 23:27–33, 2011
Oller D, Rutledge R, Thomas C, et al: Vascular injuries in a rural state: a review of 978 patients from a state trauma registry. Journal of Trauma 32:740–746, 1992.
Whitehouse WM, Coran AG, Stanley JC, et al: Pediatric vascular trauma: manifestations, management, and sequelae of extremity arterial injury in patients undergoing surgical treatment. Arch Surg 111:1269–1275, 1976.
Meagher DP, Jr, Defore WW, Mattox KL: Vascular trauma in infants and children. J Trauma 19:532–536, 1979. 42. Myers SI, Reed MK, Black CT, et al: Noniatrogenic pediatric vascular trauma. J Vasc Surg 10:258–265, 1989.
De Virgilio C, Mercado PD: Noniatrogenic pediatric vascular trauma: a ten-year experience at a level I trauma center. Am Surg 63:781–784, 1997.
Linda M, Harris MD, Hordines John: Major vascular injuries in the pediatric population. Ann Vast Surg 17:266–269, 2003.
Klinkner DB, Arca MJ, Lewis BD, et al: Pediatric vascular injuries: patterns of injury, morbidity, and mortality. J Pediatr Surg 42(1):178–182, discussion 182–3, 2007.
Fingerhut A, Leppaniemi AK, Androulakis G, et al: The European experience with vascular injuries. Surg Clin North Am 82:175–188, 2002.
Igun GO, Nwadiaro HC, Sule AZ: Ramyil VM, Dakum NK. Surgical experience with management of vascular injuries. West Afr J Med 20:102– 106, 2001.
Rudström H, Bergqvist D, Ogren M, et al: Iatrogenic vascular injuries in Sweden. A nationwide study 1987–2005. Eur J Vasc Endovasc Surg 35: 131–138, 2008.
Simmons JD, Duchesne JC, Ahmed N, et al: The weight of obesity in patients with lower extremity vascular injuries. Injury 2010. doi: 10.1016/j. injury.2010.04.025.
Rosen H, Saleh F, Lipsitz S, et al: Downwardly mobile: the accidental cost of being uninsured. Arch Surg 144:1006–1011, 2009.
Dozier KC, Miranda MA, Jr, Kwan RO, et al: Insurance coverage is associated with mortality after gunshot trauma. J Am Coll Surg 210:280–285, 2010.
Maybury RS, Bolorunduro OB, Villegas C, et al: Pedestrians struck by motor vehicles further worsen race- and insurance-based disparities in trauma outcomes: the case for inner-city pedestrian injury prevention programs. Surgery 148:202–208, 2010.
Crandall M, Sharp D, Brasel K, et al: Lower extremity vascular injuries: increased mortality for minorities and the uninsured? Surgery 150:656– 664, 2011.
Fansa, İ., Atay, M., Altınay, L., Saydam, O., Karatepe, C., Acıpayam, M., & Lale, C. (2016). Analysis of vascular trauma in terror-related civilian attacks within South-Eastern Turkey.
Akça, B. (2019). Management of war-related vascular injuries: A civilian surgeon experience in the treatment of war casualties at a secondary care hospital. RJMM, 122(3), 29.
Açıksarı, K., Koçak, M., Solakoğlu, G. A., Turan, Ö., Erinc, S., Ekinci, Ö., & Aydın, E. (2020). The characteristics of the patients in mass public shootings among coup attempt in Turkey: A single-center hospital response. Turkish Journal of Trauma & Emergency Surgery/Ulusal Travma ve Acil Cerrahi Dergisi, 26(1).
Günday, M., Durusu, M., Yıldızhan, A., Karpuzoğlu, E., Depboylu, B., & Eryılmaz, M. (2012). Vasküler yaralanmalı 41 olgunun analizi. Türk Göğüs Kalp Damar Cerrahisi Dergisi, 20(1), 65-68.
Demirkiliç, U., Kuralay, E., Yilmaz, A. T., Özal, E., Tatar, H., & Öztürk, Ö. Y. (1998). Surgical approach to military vascular injuries. Cardiovascular Surgery, 6(4), 342-346.
Buyurgan, Ç. S., Babuş, S. B., Yarkaç, A., Köse, A., Usluer, H. O., Ayrık, C., ... & Temel, G. O. (2023). Demographic and clinical characteristics of earthquake victims presented to the emergency department with and without crush injury upon the 2023 Kahramanmaraş (Turkey) Earthquake. Prehospital and disaster medicine, 38(6), 707-715.
Asirdizer, M., Yavuz, M. S., Buken, E., Daglar, S., & Uzun, I. (2004). Medicolegal evaluation of vascular injuries of limbs in Turkey. Journal of clinical forensic medicine, 11(2), 59-64.
Kayalar, N., Boyacıoğlu, K., Ketenciler, S., Kuplay, H., Mert, B., Yücel, C., ... & Erentuğ, V. (2017). Emergency vascular injuries: patient profile, management strategies and risk factors for mortality. Turk Gogus Kalp Dama, 25(1), 74-81.
Er, Z. C., & Atılgan, K. (2020). Evaluation of peripheral vascular injuries treated with surgery: A retrospective cohort study. Journal of Surgery and Medicine, 4(5), 371-373.
World Health Organization: Decade of Decade of Action for Road Safety 2011–2020: saving millions of lives. http://www.who.int/violence_injury_ prevention/publications/road_traffic/saving_millions_lives_en.pdf. Accessed 6th Nov 2011.
Geneva Declaration Secretariat: Global Burden of Armed Violence: Lethal Encounters http://www.genevadeclaration.org/measurability/ global-burden-of-armed-violence/global-burden-of-armed-violence -2011.html. Accessed 6th Nov 2011.
