(Ebook) Trauma Care Manual by Ian Greaves, Sir Keith

Porter, Jeff Garner ISBN 9781498788847, 149878884X Pdf

Download

https://ebooknice.com/product/trauma-care-manual-43015098

★★★★★
4.9 out of 5.0 (60 reviews )

DOWNLOAD PDF

ebooknice.com
 (Ebook) Trauma Care Manual by Ian Greaves, Sir Keith Porter,
Jeff Garner ISBN 9781498788847, 149878884X Pdf Download

EBOOK

Available Formats

■ PDF eBook Study Guide Ebook

EXCLUSIVE 2025 EDUCATIONAL COLLECTION - LIMITED TIME

INSTANT DOWNLOAD VIEW LIBRARY

 We believe these products will be a great fit for you. Click
the link to download now, or visit ebooknice.com
to discover even more!

(Ebook) Trauma Care Manual (Third Edition) by Ian Greaves

(editor), Keith Porter (editor), Jeff Garner (editor) ISBN
9781032054353, 1032054352

https://ebooknice.com/product/trauma-care-manual-third-edition-43065992

(Ebook) Trauma Care Manual (A Hodder Arnold Publication) - 2nd

edition. by Ian Greaves, Keith Porter, Jeff Garner ISBN
9780340928264, 0340928263

https://ebooknice.com/product/trauma-care-manual-a-hodder-arnold-
publication-2nd-edition-1994040

(Ebook) Trauma Care Manual by Ian Greaves (Author); Keith Porter

(Author); Jeff Garner (Author) ISBN 9780340928264,
9780429167232, 9781138471320, 9781444109771, 9781444115000,
9781444166781, 0340928263, 0429167237, 1138471321
https://ebooknice.com/product/trauma-care-manual-12051980

(Ebook) Trauma Care Pre-Hospital Manual by Ian Greaves, Keith

Porter, Chris Wright ISBN 9781138626843, 1138626848

https://ebooknice.com/product/trauma-care-pre-hospital-manual-10417208
(Ebook) Biota Grow 2C gather 2C cook by Loucas, Jason; Viles,
James ISBN 9781459699816, 9781743365571, 9781925268492,
1459699815, 1743365578, 1925268497

https://ebooknice.com/product/biota-grow-2c-gather-2c-cook-6661374

(Ebook) Trauma Critical Care by Ian Greaves, Keith M. Porter,

James M. Ryan ISBN 9780340759790, 0340759798

https://ebooknice.com/product/trauma-critical-care-1099934

(Ebook) Matematik 5000+ Kurs 2c Lärobok by Lena Alfredsson, Hans

Heikne, Sanna Bodemyr ISBN 9789127456600, 9127456609

https://ebooknice.com/product/matematik-5000-kurs-2c-larobok-23848312

(Ebook) SAT II Success MATH 1C and 2C 2002 (Peterson's SAT II

Success) by Peterson's ISBN 9780768906677, 0768906679

https://ebooknice.com/product/sat-ii-success-math-1c-and-2c-2002-peterson-
s-sat-ii-success-1722018

(Ebook) Oxford handbook of pre-hospital care by Ian Greaves;

Keith M Porter ISBN 9780191585333, 9780198515845, 0191585335,
0198515847

https://ebooknice.com/product/oxford-handbook-of-pre-hospital-care-4922130
Trauma Care Manual
Trauma Care
Manual

Third Edition

Edited by

Ian Greaves FRCP, FRCEM, FRCSEd, FIMC, DTM&H, DMCC,

DipMedEd, FRSA
Visiting Professor,
University of Teesside
and
Consultant in Emergency Medicine,
James Cook University Hospital, Major Trauma Centre, Middlesbrough UK; Chairman of Trauma Care (UK)

Keith Porter Kt, FRCSEng, FRCSEd, FIMCRCSEd, FSEM, FRCEM,

FRCGP, FRSA
Professor of Clinical Traumatology, Queen Elizabeth Hospital Birmingham; Formerly Chairman of
Trauma Care (UK)

Jeff Garner MD FRCSEd (Gen Surg)

Consultant Colorectal Surgeon, The Rotherham NHS Foundation Trust and Major Trauma Consultant,
Sheffeld Major Trauma Centre
Third edition published 2022
by CRC Press
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN

and by CRC Press

6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487–2742

© 2022 Taylor & Francis Group, LLC

First edition published by Arnold, A member of the Hodder Headline Group Publisher 2001

Second edition published by Hodder Arnold, Part of Hachette UK 2009

CRC Press is an imprint of Informa UK Limited

This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts
have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal
responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any
views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not
necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended
for use by medical, scientific or healthcare professionals and is provided strictly as a supplement to the medical or other
professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and
the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on
dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant
national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their
websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does
not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole
responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients
appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced
in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any
copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic,
mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any
information storage or retrieval system, without permission in writing from the publishers.

For permission to photocopy or use material electronically from this work, access www.copyright.com or contact the
Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978–750–8400. For works that are
not available on CCC please contact mpkbookspermissions@tandf.co.uk

Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for
identification and explanation without intent to infringe.

British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging-in-Publication Data

A catalog record for this book has been requested

ISBN: 978-1-032-05435-3 (hbk)

ISBN: 978-1-498-78884-7 (pbk)
ISBN: 978-1-003-19756-0 (ebk)

DOI: 10.1201/9781003197560

Typeset in Minion
by Apex CoVantage, LLC
Contents

Preface to the Third Edition vii

List of Contributors ix
Glossary xiv
Acknowledgements xix

1. The Trauma Epidemic 1

2. Mechanism of Injury 11
3. Triage 23
4. Pre-Hospital Care 33
5. Trauma Systems, Centres and Teams 47
6. Patient Assessment 63
7. Trauma Physiology and Metabolism 78
8. Catastrophic Haemorrhage 92
9. Airway Management 100
10. Thoracic Trauma 119
11. Shock Management 149
12. Damage Control Surgery 169
13. Head Injury 179
14. Maxillofacial Trauma 199
15. Ophthalmic Injuries 211
16. Spinal Injuries 228
17. Abdominal and Genitourinary Trauma 246
18. Vascular Trauma 259
19. Musculoskeletal Trauma 277
20. Radiology 296
21. Infection in Trauma 307
22. Injuries in Children 315
23. Trauma in Women 349
24. Trauma in the Elderly 361
25. Firearms, Ballistics and Gunshot Wounds 372
26. Blast Injuries 386
27. Injuries Due to Burns and Cold 396
28. CBRN and the Trauma Victim 412
29. Care of the Obese Trauma Patient 430
30. Analgesia and Anaesthesia 438
31. Intensive Care Management of Major Trauma 457
32. Patient Transfer 474
vi Contents

33. Psychological Aspects of Trauma 489

34. Rehabilitation after Trauma 505
35. Trauma Scoring Systems and Their Application 521
36. Transplantation and Organ Donation 528

Appendix A: Viscoelastic Haemostatic Assays 546

Index 550
Preface to the Third Edition

The first edition of the Trauma Care Manual information boxes, clinical tips and illustra-
was published in 2000 in order to ‘begin the tions—have been retained and expanded.
process of establishing United Kingdom guide- Again, since the second edition, we have
lines for best practice in the management of changed our guidelines regarding fluid resus-
major trauma’. At the time we recognized both citation: reflecting the currently available
that this was an ambitious project and that evidence in recommending, with certain spe-
further editions would be needed to ensure cific caveats, the use of hybrid resuscitation in
that the manual continued to reflect best prac- uncontrolled haemorrhage, and we believe that
tice in a UK context. The second edition was the guidelines we offer are as up to date and
issued in 2009, completely revised and with evidence based as we can make them.
a number of new chapters. Perhaps, the most The production of a manual such as this
notable changes in the second edition were requires a great deal of hard work and the edi-
the adoption of the <C>ABCDE resuscitation tors are grateful to all the contributors to this
sequence and of hypotensive resuscitation in and to previous editions.
uncontrolled haemorrhage. At this time, we Trauma Care’s (and our) dear friend Prof.
were increasingly aware of the divergent paths David Alexander died shortly after completing,
of trauma resuscitation in the US and in the UK with his colleague Prof. Susan Klein, the chap-
and wished also to reflect the developments ter on psychological responses to trauma. On
which had resulted from clinical practice dur- re-reading this chapter during the final edit-
ing the wars in Iraq and Afghanistan. ing, we can hear his voice of calm common
In 2019, Trauma Care issued the first edi- sense and kindness expressed in prose which
tion of the Trauma Care Pre-hospital Manual, could only be his. Trauma Care has established
believing that pre-hospital care was a sufficiently the David Alexander Memorial Lecture in his
different specialty to require its own specifically memory to be given annually on a subject
tailored guidelines reflecting the particular chal- related to the mental health aspects of trauma.
lenges of this area of practice. As a consequence, The editorial team at Trauma Care has now
further editions of the Trauma Care Manual embarked on the final one of our intended trio
would concentrate entirely on hospital practice. of manuals, the Trauma Care Paediatric Manual
This third edition of the Trauma Care Manual which will be published in the near future. We
has, once again, been completely revised and a hope that the three manuals between them will
further nine chapters introduced. New chapters make a significant contribution to the care of
include Infection in Trauma, Damage Control the trauma victim and to the confidence of
Surgery, Trauma Systems, Centres and Teams, those called upon to treat them.
CBRN and the Trauma Victim and Care of the
Obese Trauma Patient. We have continued to offer Ian Greaves
didactic guidelines for clinical practice and each Keith Porter
chapter is, wherever possible, extensively refer- Jeff Garner
enced. The features of earlier editions—tables, Teesside, 2022
Professor David Alexander, 1943–2020
Contributors

Surg Lt Cdr Steve Adshead BSc (Hons), MRCEM RN Surg Lt Cdr Philippa M Bennett, MRCS, PhD, PG Dip Med
Specialist Trainee in Anaesthetics Ed MRCS, PhD, PG Dip Med Ed RN
University Hospitals Bristol NHS Foundation Trust Trauma and Orthopaedic Specialist Registrar
Bristol, UK Defence Medical Services
Defence Medical Services UK Ministry of Defence
UK Ministry of Defence Firearms, Ballistics and Gunshot Wounds, Blast Injury
Blast injury
Lt Col Richard Blanch BSc (Hons), MBChB (Hons), PhD, MRCS
The late Emeritus Professor David A Alexander (Edin) FRCOphth

MA [Hons], PhD, [Hon] DSc, FBPS, FRSM, [Hon] FRCPsych Consultant Ophthalmologist
Consultant Trauma Specialist British Army and Royal Centre for Defence Medicine
Principal Advisor Birmingham, UK
UK Police Services Ophthalmological Trauma
Psychological Aspects of Trauma
Surg Cdr S Bland MSc (MedTox), FRCEM RN
Lt Col S Bahadur RAMC, MRCGP, MRCP (Rheum), MSc (SEM), Consultant in Emergency Medicine
MSc (Rheumatology), Dip Occ Med, MPhil Medical Law, PG Cert MSK US Royal Navy and Queen Alexandra Hospital
Consultant Rheumatology and Rehabilitation Portsmouth Hospitals NHS Trust
Medicine Portsmouth, UK
Defence Medical Rehabilitation Centre, CBRN and the Trauma Victim
Stanford Hall
Loughborough, UK Prof Stephen Bonner FRCA
Trauma Rehabilitation Clinical Director Critical Care
The James Cook University Hospital
Lt Col Tom Barker DMCC, MD, FRCS, RAMC Middlesbrough, UK
Consultant Vascular Surgeon Intensive Care Management, Organ Donation and
British Army Transplantation
Vascular Trauma
Lt Col Johno Breeze RAMC
Mr Emir Battaloglu MSc, MRCS, DIMC Consultant in Maxillofacial Surgery
Specialty Training Registrar in Trauma & British Army, University Hospitals Birmingham NHS
Orthopaedic Surgery Foundation Trust and Royal Centre for Defence
Royal Orthopaedic Hospital Medicine
Birmingham, UK Birmingham, UK
Mechanism of Injury Maxillofacial Trauma
x Contributors

Prof Derek Burke FRCSEd, FRCEM, FRCPCH Mr Jeff Garner MD FRCSEd (Gen Surg)
Formerly Medical Director and Consultant in Consultant Colorectal Surgeon, The Rotherham NHS
Paediatric Emergency Medicine Foundation Trust and Major Trauma Consultant
Sheffield Children’s NHS Foundation Trust Sheffield Major Trauma Centre
Sheffield, UK Editor
Now Head of Clinical Governance
Gibraltar Health Authority Dr WG Gensheimer MD
Gibraltar, UK Department of Oral and Maxillofacial Surgery
Injuries in Children Warfighter Eye Center, Malcolm Grow Medical
Clinics and Surgery Center
Surg Cdr Philip JB Coates MRCS, FRCR RN Joint Base Andrews, Maryland, USA
Consultant Radiologist Department of Surgery, Division of Ophthalmology
Defence Medical Services Uniformed Services University
UK Ministry of Defence Bethesda, Maryland, USA
Derriford Hospital Ophthalmological Trauma
Plymouth, UK
Trauma Radiology Prof Ian Greaves FRCP, FRCEM, FRCSEd, FIMC, DipMedEd,
DTM&H, DMCC
Lt Col David Cooper FRCEM, RAMC Visiting Professor
Consultant in Emergency Medicine and Pre-Hospital University of Teesside and Consultant in Emergency
Emergency Medicine Medicine
British Army and Royal Stoke University Hospital James Cook University Hospital
Stoke-on-Trent, UK Middlesbrough, UK
Shock Management Chairman of Trauma Care UK
Editor, Thoracic Trauma
Dr Nick Crombie BMedSci (Hons), FRCA, FIMC
Consultant Trauma Anaesthetist, Associate Medical Mr Liviu Hanu-Cernat DM, FDSRCS, FRCS (OMFS), Cert Med Ed
Director and Clinical Lead Resuscitation Services Consultant Oral and Maxillofacial Surgeon
University Hospital Birmingham University Hospitals Coventry and Warwickshire NHS
Birmingham, UK Trust
Airway Management, Analgesia and Coventry, UK
Anaesthesia Maxillofacial Injuries

Miss Antoinette Edwards BA Surg Lt Kieran M Heil PG Cert Clin Ed, BEng, RN
Executive Director Medical Officer 3 Command Brigadel
UK Trauma Audit and Research Network Defence Medical Services
Trauma Scoring UK Ministry of Defence
Firearms, Ballistics and Gunshot Wounds
Dr Chris Fitzsimmons FRCEM, FRCSEd (A&E)
Consultant in Paediatric Emergency Medicine Lt Col (Rtd) Andrew Jacks OstJ, BSc, FRCOpth
Sheffield Children’s Hospital NHS Trust Consultant Ophthalmologist
Sheffield, UK University Hospitals Birmingham NHS
Injuries in Children Foundation Trust
Birmingham, UK
Mr Navin Furtado BSc, MBBS, MSc (Eng), FRCS (Neuro Surg) Ophthalmological Trauma
Consultant Neurosurgeon and Spinal Surgeon
University Hospital NHS Trust Prof Steven Jeffrey FRCS, EBOPRAS, FRCS (Plast)
Birmingham, UK Consultant Plastic Surgeon
Spinal Injuries Queen Elizabeth Hospital
 Contributors xi

Birmingham Salford Royal Hospital

Birmingham Children’s Hospital Salford, UK
Birmingham, UK Honorary Professor and Research Director of the
Injury Due to Burns, Electrocution and Cold Trauma Audit and Research Network (TARN)
Leicester, England, UK
Lt Col Andy Johnson FRCA, RAMC Trauma Scoring
Consultant in Respiratory Medicine and Critical Care
Medicine Mr. Jack Lewis FdSc, PGcert, MSci (Hons), MSc, MCPara
Defence Lecturer in Critical Care Critical Care Paramedic
Royal Centre for Defence Medicine Midlands Air Ambulance
Birmingham, UK UK West Midlands Ambulance Service
British Army Mechanism of Injury
Trauma Physiology and Metabolism
Surg Cdr Richard Miles MRCP, FRCR, RN
Lt Col Damian Keene FRCA, FIMC Consultant Interventional Radiologist
Consultant in Anaesthesia and Pre-Hospital Defence Medical Services
Emergency Medicine Queen Elizabeth Hospital UK Ministry of Defence
Birmingham, UK Derriford Hospital
Midlands Air Ambulance Plymouth, UK
British Army Trauma Radiology
Clinical Lecturer in Department of Military
Anaesthesia and Critical Care Dr Debbie Mortiboy MBChB, MRCP(UK), FRCPath, PGcert
Royal Centre for Defence Medicine Consultant Microbiologist
Birmingham, UK University Hospital
Patient Transfer Birmingham, UK
Associate Post Graduate Dean
Prof Mansoor Ali Khan MBBS, PhD, PGDip, FRCS, FEBS, FACS, Health Education England (West Midlands)
CMgr, FCMI Birmingham, UK
Consultant Oesophagogastric, General and Trauma Infection in Trauma
Surgeon
Honorary Clinical Professor of Trauma Surgery Lt Col Ross Moy FRCEM, FIMC
Brighton, UK Consultant in Emergency Medicine and Pre-Hospital
Sussex University Hospital Care
Brighton, UK John Radcliffe Hospital
Damage Control Surgery, Abdominal and Oxford, England
Genitourinary Trauma Defence Medical Services
UK Ministry of Defence
Prof Susan Klein MA (Hons), Cert COSCA, PhD Trauma in the Elderly
Professor of Health and Social Care, Strategic
Research Advisor to the Veterans and Families Surg Cdr Nick Newton MD, FRCS
Institute for Military Social Research Veterans and Consultant General and Military Surgeon University
Families Institute for Military Social Research Hospitals Birmingham NHS Trust
Chelmsford Campus, Anglia Ruskin University Birmingham, UK
Chelmsford, Essex, UK Abdominal and Genitourinary Trauma
Psychological Aspects of Trauma
Dr James O’Connor MD, FACS
Prof Fiona Lecky FRCS (A&E), DA, MSc, PhD, FRCEM Professor of Surgery
Clinical Professor of Emergency Medicine University of Maryland School of Medicine
Honorary Consultant in Emergency Medicine Baltimore, MD, USA
xii Contributors

Chief Prof Julian Redhead FRCP, FRCEM, MFSEM, Dip SEM

Thoracic and Vascular Trauma R Adams Cowley Medical Director and Consultant in Emergency
Shock Trauma Center Medicine
Baltimore, MD, USA Imperial College London
Thoracic Trauma London, UK
The Trauma Epidemic
Maj Oliver LP O’Sullivan RAMC, BSc (Hons), MBChB (Hons),
MRCP (UK), DMCC, DipIMC, PGCertMedEd Mr Steven Robinson MD, FRCS
Specialty Registrar Consultant General
Rehabilitation and Rheumatology Weight Loss and Bariatric Surgeon
Defence Medical Services Worcester Acute Hospital NHS Trust
UK Ministry of Defence Worcester, UK
Trauma Rehabilitation Care of the Obese Trauma Patient

Prof Ian Pallister MD, FRCS Dr Karen Selby FRCOG

Consultant Trauma Surgeon Morriston Hospital Consultant in Obstetrics and Gynaecology
Swansea, UK Sheffield Teaching Hospital NHS Foundation Trust
Professor of Trauma and Orthopaedics Sheffield, UK
Swansea University Trauma in Women
Wales, UK
Musculoskeletal Trauma Lt Col Danny Sharpe FRCEM, RAMC
Consultant in Emergency Medicine and Pre-Hospital
Col Paul Parker FRCSEd, FRCS (Orth), FIMC, L/RAMC Emergency Medicine
Consultant Orthopaedic Surgeon St Mary’s Hospital
University Hospitals Birmingham NHS Foundation London, UK
Trust and Royal Centre for Defence Medicine British Army
Birmingham, UK Patient Assessment
Catastrophic Haemorrhage
Dr Peter Shirley FRCA
Surg Cdr Jowan G Penn-Barwell MSc, PhD, FRCS (Tr & Orth) Consultant in Intensive Care and Anaesthesia
Consultant Orthopaedic Trauma Surgeon Adult Critical Care Unit
Oxford Major Trauma Centre Royal London Hospital
Defence Medical Services London, UK
UK Ministry of Defence Intensive Care Management
Firearms, Ballistics and Gunshot Wounds
Sqn Ldr Sam Todd FIMC (RCSEd), FRCEM, RAF
Prof Sir Keith Porter FRCS, Eng, FRCSEd, FIMC, FSEM, FRCEM Specialist Trainee in Emergency Medicine
Professor of Clinical Traumatology Royal Air Force
University Hospitals Birmingham St Mary’s Hospital
Birmingham, UK Imperial College Healthcare NHS Trust
Former Chairman of Trauma Care UK London, UK
Editor CBRN and the Trauma Victim

Dr Michael Prosser FRCEM, FIMC Surg Lt Cdr Jamie Vassallo MRCEM, PhD, RN
Emergency Medicine and Major Trauma Consultant Specialist Registrar in Emergency Medicine
Royal Cornwall Hospital Royal Navy
Truro, UK Triage
Critical Care Doctor
WNDLR Air Ambulance Charity (Helimed 53) Dr Angus Vincent FRCA, FFICM
Pre-Hospital Care Consultant Critical Care and Clinical Lead for
 Contributors xiii

Organ Donation North East England Royal Victoria Welsh Institute for Health and Social Care
Infirmary University of South Wales
Newcastle upon Tyne, UK Pontypridd, Wales, UK
Intensive Care Management Injuries in Children

Laura White Prof Mark Wilson PhD, FRCS (SN), FIMC, MRCA
Operations Director Consultant in Neurosurgery and Pre-Hospital Care
UK Trauma Audit and Research Network Specialist
Trauma Scoring Imperial Hospitals NHS Trust
London
Flt Lt Owen Williams Professor of Brain Injury
Academic Fellow in Emergency Medicine Imperial College London
Royal Air Force Gibson Chair of Pre-Hospital Care
Thoracic Trauma, Trauma Systems, Centres and Royal College of Surgeons of Edinburgh
Teams, Thromboelastography (Appendix A) Edinburgh, UK
Head Injuries
Prof Richard Williams OBE, TD, FRCPsych
Emeritus Professor of Mental Health Strategy
Glossary

AAAM American Association for ARS-G Acute radiation syndrome-

Automotive Medicine gastrointestinal
AAJT Abdominal Aortic & Junctional ARS-H Acute radiation
Tourniquet syndrome-haematopoietic
AAP Associate ambulance practitioner ARS-N Acute radiation
AAST American Association for the syndrome-neurovascular
Surgery of Trauma ASAP As soon as possible
ABPI Ankle brachial pressure index ASCOT A Severity Characterization of
ACOT Acute coagulopathy of trauma Trauma
ACS Abdominal compartment ASIA American Spinal Injuries
syndrome Association
ACSCOT American College of Surgeons ASIS Anterior superior iliac spine
Committee on Trauma ATLS Advanced Trauma Life Support®
ADH Antidiuretic hormone ATMIST Age, time, mechanism, injuries,
AED Automatic external defibrillator signs, treatment
AEP Attenuating energy projectile ATP Adenosine triphosphate
AIS Abbreviated Injury Scale/Score AVPU Alert, responds to voice, responds
AKI Acute kidney injury to pain, unresponsive
AKIN International AKI Network BASICS British Association for Immediate
ALARA As low as reasonably achievable Care
ALI Acute lung injury BETTS Birmingham Eye Trauma
ALS Advanced life support Terminology System
AMPDS Advanced Medical Priority BLS Basic life support
Dispatch System BMI Body mass index
AMPLE Allergies, medicines, past medical BOAST British Orthopaedic Association
history, last meal, events Standards for Trauma
AP Antero-posterior BSA Body surface area
APACHE Acute Physiology and Chronic BTAI Blunt thoracic aortic injury
Health Evaluation BURP Backward-upward-rightward-
APP Abdominal perfusion pressure pressure
aPTT Activated partial thromboplastin BVM Bag-valve-mask ventilation
time β-HCG β human chorionic gonadotrophin
APVR Airway pressure release C Cervical (spine)
ventilation CaO2 Oxygen content of arterial blood
ARDS Adult respiratory distress CAP Community acquired pneumonia
syndrome CAT Combat Application Tourniquet®
CBD Criteria-based dispatch
 Glossary xv

CBF Cerebral blood flow DCD Donation after circulatory death

CBRN Chemical, biological, radiological DCR Damage control resuscitation
and nuclear DCS Damage control surgery
CBT Cognitive behavioural therapy DDAVP Desmopressin
CCA Common carotid artery DI Diabetes insipidus
CCI Charlson Comorbidity Index DIC Disseminated intravascular
CCP Critical care paramedic coagulation
CCR Canadian C spine rules DM Diabetes mellitus
CCT Certificate of completion of DNA Deoxy ribose nucleic acid
(specialty) training DO2 Tissue oxygen delivery
CDL Clean-dirty line DRESS Drug reaction with eosinophilia
CG Clinical guideline and systemic symptoms
CIRCE Cardiovascular and Interventional DSM-V Diagnostic and Statistical Manual
Radiological Society of Europe of the American Psychiatric
CISD Critical incident stress debriefing Association
CISM Critical incident stress DTI Department of Trade and Industry
management DVT Deep venous thrombosis
CJD Creutzfeldt–Jakob disease EAST Eastern Association for the
CK Creatinine kinase Surgery of Trauma
CK-MB Creatine phosphokinase ECA External carotid artery
myocardial band isoenzyme ECG Electrocardiogram
cmH2O Centimetres of water (unit of ED Emergency department
pressure measurement) EDH Extradural haematoma
CMRO2 Cerebral metabolic rate of oxygen EDV End-diastolic volume
CNS Central nervous system eFAST Extended focused abdominal
CO Cardiac output sonography for trauma
CO Carbon monoxide EM Emergency medicine
COBR(A) Cabinet Office Briefing Room (A) EMDR Eye movement desensitization and
COPD Chronic obstructive pulmonary reprocessing therapy
disease EMLA Eutectic mixture of local
CO2 Carbon dioxide anaesthetic
COVID-19 Coronavirus Disease-19 EMP Electromagnetic pulse
COX Cyclo-oxygenase EN Enteral nutrition
CPAP Continuous positive airways ENT Ear nose and throat
pressure ERN Enteral nutrition
CPK Creatine phosphokinase ETHANE Exact location, type, hazards,
CPP Cerebral perfusion pressure access, numbers, emergency
CPR Cardio pulmonary resuscitation services
CQC Care Quality Commission ET(T) Endotracheal (tube)
CRP C-reactive protein ETCO2 End-tidal carbon dioxide
CSF Cerebrospinal fluid EVAR Endovascular aortic repair
CT Computed tomography EVD External ventricular drain
CTA CT angiography EWA Early walking aids
CXR Chest radiograph FAST Focused abdominal (or
DAI Diffuse axonal injury assessment) sonography for
DALY Disability-adjusted life year trauma
DAMPs Damage-associated molecular FES Fat embolism syndrome
patterns FFP Fresh frozen plasma
DBD Donation after brainstem death FFP Filtering facepiece
xvi Glossary

FGM Female genital mutilation ITU Intensive therapy unit

FIB Fascia iliaca block IV Intravenous
FIM Functional Independence IVRA Intravenous regional anaesthesia
Measure IVUS Intravascular ultrasound
FMJ Full metal jacket JRCALC Joint Royal Colleges Ambulance
FRC Functional respiratory capacity Liaison Committee
GA Tabun (nerve agent) KE Kinetic energy
GABA Gamma-aminobutyric acid kPa Kilopascal
GB Sarin (nerve agent) L Lumbar (spine)
GBD Global Burden of Disease LASIK Laser in situ keratomileusis
GCS Glasgow Coma Score LAT Lidocaine, Adrenaline, Tetracaine
GD Soman (nerve agent) LEH Local emergency hospital
GMC General medical council LMA Laryngeal mask airway
GOS(E) Glasgow Outcome Scale LP Light perception
(extended) LSA Long saphenous vein
GSW Gunshot wound LSD Lysergic acid diethylamide
GTN Glyceryl trinitrate LTH Life-threatening haemorrhage
Gy Gray LVEDV Left ventricular end-diastolic volume
HAP Hospital acquired pneumonia MAC Multi-lumen access catheter
HART Hazardous area response team MAP Mean arterial pressure
HAZMAT Hazardous material MBRRACE-UK Mothers and Babies
Hb Haemoglobin Reducing Risk Through Audit and
HCO3 Bicarbonate Confidential Enquiries
HCPC Health Care Professions Council mCCI Modified Charlson Comorbidity
Hct Haematocrit Index
HEMS Helicopter emergency medical MDT Multi-disciplinary team
service MHP Major haemorrhage protocol
HGV Heavy goods vehicle MILS Manual inline stabilization (of the
HIV Human immunodeficiency virus cervical spine)
HMO Hand movements only MIO Mechanism of injury
HR Heart rate MIST Mechanism, injuries, signs,
H2S Hydrogen sulphide treatment
IAP Intra-abdominal pressure mmHg Millimetres of mercury (blood
ICA Internal carotid artery pressure unit)
ICD Intercostal drain MODS Multi-organ distress syndrome
ICD-10 International Classification of MOF Multiple organ failure
Mental and Behavioural Disorders MPTT-24 Modified Physiological Triage
ICP Intracranial pressure Tool-24
ICRC International Committee of the MRA Magnetic resonance angiography
Red Cross MRI Magnetic resonance imaging
ICU Intensive care unit MSCT Multi-slice computed tomography
IED Improvised explosive device mTBI Mild traumatic brain injury
ILO International Labour Office MTC Major trauma centre
IL-6 Interleukin-6 MTTT Major Trauma Triage Tool
INR International normalized ratio NAC N-Acetyl cysteine
IO Intraosseous NAI Non-accidental injury
IOFB Intraocular foreign body NAO National Audit Office
IR Interventional radiology NASCIS National Acute Spinal Cord Injury
ISS Injury severity score Study
 Glossary xvii

NATO North Atlantic Treaty PFA Psychological first aid

Organization PGD Patient group directive
NAVY Nerve, artery, vein, Y fronts PHEA Pre-hospital emergency
NCEPOD National Confidential Enquiry anaesthesia
into Patient Outcome and Death PHEM Pre-hospital emergency medicine
NCTH Non-compressible torso PLC Posterior ligamentous complex
haemorrhage Plt Platelet
NDMA N-Nitrosodimethylamine pmp Per million population
NEXUS National Emergency POCT Point of care testing
X-Radiography Utilization Study PPE Personal protective equipment
NG Nasogastric PPRB Packed red blood cells
NHBOD Non-heart-beating organ donor PRC Packed red cells
NHS National Health Service PRK Photorefractive keratectomy
NHSBT NHS Blood and Transplant PROM Patient reported outcome
NIBP Non-invasive blood pressure measure
NICE National Institute for Health and PROMMTT Prospective Observational
Clinical Excellence Multicenter [sic] Major
NIJ National Institute of Justice Trauma Transfusion Study
NIPPV Non-invasive positive pressure PROPPR Pragmatic, Randomized
ventilation Optimal Platelet and Plasma
NISS New Injury Severity Score Ratios Study
NLP No light perception PT Prothrombin time
NO Nitric oxide PTA Post-traumatic amnesia
NOAC New generation oral anticoagulant PTSD Post-traumatic stress disorder
NP Nasopharyngeal (airway) PVD Peripheral vascular disease
NRP Normothermic regional perfusion PVR Pulmonary vascular resistance
NSAID Non-steroidal anti-inflammatory RAPD Relative afferent pupillary defect
drug RBC Red blood cell
OECD Organization for Economic RCA Riot control agent
Cooperation and Development RCR Royal College of Radiologists
OMFS Oral and maxillofacial surgery RCT Randomized controlled trial
ONS Office of National Statistics (UK) REACT/TS Radiation Emergency
OP Oropharyngeal (airway) Assistance Centre/Training Site
OR Operating room REBOA Retrograde Endoscopic
ORCHIDS Optimisation through Balloon Occlusion of the Aorta
Research of Chemical Incident REBOA-SAAP REBOA-Selective Aortic Arch
Decontamination Systems Perfusion
OSA Obstructive sleep apnoea REE Resting energy expenditure
OTS Ocular trauma score RIC Rapid Infusion Catheter
P Priority RIFLE Risk, injury, failure, loss of
PaO2 Partial pressure of oxygen in kidney function, end stage
arterial blood renal disease
PCA Patient-controlled analgesia RNLI Royal National Lifeboat
PCCU Paediatric critical care unit Institution
PCR Polymerase chain reaction ROSC Return of spontaneous
PDA Potential donor audit circulation
PDT Percutaneous dilation tracheotomy ROTEM Rotational thromboelastometry
PE Pulmonary embolism RRT Renal replacement therapy
PEEP Positive end-expiratory pressure RRV Rapid response vehicle
xviii Glossary

RSI Rapid sequence induction TARN Trauma Audit & Research Network
(of anaesthesia) TBI Traumatic brain injury
RTC Road traffic collision TBSA Total body surface area
RTS Revised Trauma Score TEG Thromboelastography
RV Right ventricle TEN Toxic epidermal necrolysis
SAD Supraglottic airway device TEVAR Thoracic endovascular aortic repair
SAH Subarachnoid haemorrhage tfCBT Trauma-focused cognitive
SALT Sort, Assess, Life-saving behavioural therapy
interventions, Treatment and THOR Trauma Hemostasis [sic] and
Transfer Oxygenation Research Network
SaO2 Arterial oxygen saturation TLC Total lung capacity
SBP Systolic blood pressure TMT Tactical Mechanical Tourniquet®
SCI Spinal cord injury TNP Topical negative pressure (dressing)
SCIWORA Spinal cord injury without TNT Trinitrotoluene
radiological abnormality TOE Transoesophageal
ScvO2 Central venous oxygen saturation echocardiography
SDG Sustainable development goal TPN Total parenteral nutrition
SDH Subdural haematoma TRALI Transfusion-related acute lung
SH Salter–Harris (classification of injury
fractures) TRiM Trauma risk management
SI Sagittal index TRISS Trauma and Injury Severity Score
SIC Self-intermittent catheterization TS Tertiary survey
SIRS Systemic inflammatory response TSH Thyroid-stimulating hormone
syndrome TTL Trauma team leader
SMA Superior mesenteric artery TU Trauma unit
SNOD Specialist nurse in donation TV Tidal volume
SNOM Selective non-operative TXA Tranexamic acid
management (of solid organ injury) UNHCR United Nations High
SOF Single organ failure Commissioner for Refugees
SOFA Sequential organ failure assessment UNICEF United Nations Children’s
SPC Suprapubic catheter (Emergency) Fund
SpO2 Oxygen saturation USAISR United States Army Institute of
SSTI Skin and soft tissue infection Surgical Research
START Simple Triage and Rapid Treatment USS Ultrasound
STIR Short tau inversion recovery VAP Ventilator associated pneumonia
(images) VATS Video-assisted thoracoscopy
SV Stroke volume VC Vital capacity
SVR Systemic vascular resistance V/Q Ventilation/perfusion
T Thoracic (spine) VTE Venous thromboembolism
T3 Triiodothyronine WB Whole blood
T4 Thyroxine WBCT Whole-body CT
TACO Transfusion-related circulatory WCC White (blood) cell count
overload WHO World Health Organization
Acknowledgements

The editors would like to express their thanks have with our earlier books, a pleasure rather
to the authors of the chapters and sections of than a chore.
this book. We are also grateful to all those who We are grateful to the copyright holders of
contributed to previous editions of the Trauma the following illustrations for allowing us to
Care Manual. Without the support and flair reproduce them:
of Domini Lawson and Andrew Ormerod, the
day-to-day administration and development of ●● Figure 13.8 Reproduced with permission
Trauma Care would have taken a great deal from the Oxford Handbook of Pre-Hospital
more of the editors’ time, and we are more than Care.
aware of how much we owe them. Our families, ●● Figure13.9 Wikimedia Commons
as ever, have put up with the preparation of this ●● Figure15.2 Wikimedia Commons
volume and this time we won’t even pretend ●● Figure 17.1 Reproduced with permission
that it is the last we will do. Miranda Bromwich from the Oxford Handbook of Pre-Hospital
and Sam Cooke of Taylor & Francis Group have Care.
made the preparation of this volume, as they
 1
The Trauma Epidemic

OBJECTIVES

After completing this chapter, the reader will:

• Understand the scale of the global burden of • Understand the strategies for prevention and
trauma better care of the victim of trauma
• Understand the differences in impact of this
burden of trauma between developed and non-
developed countries

INTRODUCTION vary widely by cause, age, sex, region and

time and conflicting predictions suggest that
the burden of trauma will rise over the next
Epidemic—affecting many persons at the same
20 years, mainly due to the increasing world
time and extremely prevalent or widespread.
population.2
In 2015, the United Nations adopted the
ambitious Sustainable Development Goals
Global estimates suggest that the lives of (SDGs), which set out ambitious targets to be
between 14,000 and 16,000 people are lost each achieved by 2030. Improvements in the defined
day as a result of trauma. This accounts for 5 areas are monitored annually by the World
million annual deaths, equating to 9% of the Health Organization (WHO). For trauma the
worldwide burden of mortality. However, these SDGs are related to suicide, road traffic col-
figures hide much larger physical and mental lisions, disasters, homicide and conflicts. By
effects for survivors of trauma and their fami- 2018 there had been areas of improvement
lies and associated communities. They also within individual populations and countries,
hide the reality that trauma remains the lead- but new risks had also been highlighted: lat-
ing cause of death in young people, where it est estimates suggest that 23% of adults suf-
accounts for over 25% of all deaths.1 fered physical abuse as a child and that 35% of
The mortality and morbidity associated with women experience either physical and/or sex-
trauma are largely predictable and preventable. ual intimate partner violence or non-partner
There is evidence that injury rates have fallen sexual violence at some point in their lives.
worldwide and that we could consequently Violence against children not only has life-
conclude that the world is becoming a safer long impacts on individual health, but also has
place to live; however, the patterns of injury impacts on communities and nations. Violence

DOI: 10.1201/9781003197560-1
2 Trauma Care Manual

against women results in both short-term and high-income countries, but rises of 92% and
long-term effects on physical, mental, sexual 147% in fatalities are expected in China and
and reproductive health, leading to high social India, respectively.7
and economic costs for women, families and Gender has a great impact on traumatic
societies.3 injury incidence and mechanism. Mortality
Both the cause and effects of traumatic injury from road traffic collisions (RTCs) and inter-
differ depending on the population concerned; personal violence is almost three times higher
injuries differ between males and females, in males than in females. Globally, injury mor-
between geographical areas, and between low-, tality in males is twice that among women, with
middle- and high-income countries. Thus, the highest rates in Africa and Europe; how-
although injury remains the leading cause of ever, in some regions, particularly South-East
death for those aged between 15 and 44, indi- Asia and the eastern Mediterranean, females
vidual mortality and morbidity may be higher have the highest burn-related deaths at all
in the elderly.4 To add to the complexity of ages. This distribution is particularly apparent
understanding the problems caused by trauma, in elderly people in both areas, especially the
countries with unequal income levels suffer Eastern Mediterranean, where the risk of burn-
diverse burdens of disability due to injury; related death is seven times higher for females
levels of disability due to extremity injury are than for males.8 Age itself has a marked influ-
very high in the developing world, but a greater ence on incidence, mechanism and mortality
proportion of disability due to head and spinal from injury. It is well established that young
cord injuries occurs in high-income countries, people between ages of 15 and 44 account for
suggesting that some types of trauma and their approximately 50% of global mortality due to
resultant morbidity may be amenable to rela- trauma.9
tively simple interventions such as improved Trauma in elderly patients (so-called sil-
orthopaedic care and rehabilitation, especially ver trauma) is being increasingly recognized
in the developing world.5 as a significant challenge to healthcare sys-
Deaths due to injury are devastating for fam- tems—in the United Kingdom (UK) in 2018
ilies, communities and societies; however, for the average age of all major trauma cases was
every death many more are left disabled. The 60 years. There is thus a growing demand for
1990 Global Burden of Disease (GBD) study clinical trauma services amongst the elderly,
developed the concept of disability-adjusted with some evidence suggesting a doubling of
life years (DALYs). This concept expresses not absolute numbers between 2007 and 2016 and
only years of life lost to premature death, but an associated increase in the proportion of
also years lived with a disability of a specified patients with major trauma from 25% to 37%.
severity and duration. One DALY is one lost In addition, almost 40% of older patients will
year of healthy life. It was calculated in 1990 die within 1 year of the event and over 50%
that injuries caused 10% of worldwide mortal- will be incapable of living independently. In the
ity but 15% of DALYs.6 The effect of changing UK, the predominant mechanism of injury in
living patterns, especially increased mobility this population is not road traffic accidents but
and expenditure on motor vehicles, particu- falls and again in the majority of cases simple
larly in the developing world, has contributed interventions may lead to a reduction in this
to a dynamic picture of injury and its effects on burden.10,11
populations. A World Bank report projected Injuries have traditionally been looked upon
that the global road death toll will rise by 66% as the result of ‘accidents’ or random events,
over the next 20 years due to increasing car but in recent years this view has changed, and
ownership. Importantly, this value incorpo- most injuries can now be viewed as poten-
rates a greater divergence between rich and tially preventable. This important area is now
poor nations in the future. An approximate widely studied, leading to the implementation
28% reduction in fatalities is anticipated in of interventions to lessen the related burden of
 The Trauma Epidemic 3

disease in areas from handgun control initia- in association with members of the National
tives to road and water safety education. Other Accident Prevention Strategy Advisory Group
potentially modifiable factors implicated in and a number of partners set out a national
trauma are the use of drugs and alcohol. Drug strategy to prevent serious accidental inju-
intoxication has been associated with inter- ries,15 and local initiatives have found evi-
personal violence, self-directed violence and dence of reducing rates of violent injuries
vehicular trauma,12 and alcohol has a signifi- from identification of hotspots, data sharing
cant role to play in many areas of traumatic between organizations and targeted cam-
injury, including interpersonal violence, paigns to at-risk groups.
youth violence, child and sexual abuse, elder
abuse and vehicular accidents.13 The impacts
of disasters, however, both natural and man-
INTENTIONAL INJURIES
made, are often profound and far-reaching
The WHO divides injuries into intentional and
and generally less amenable to prevention. The
unintentional injuries.
effects of the 2004 Indian Ocean earthquake
and the resultant tsunami spread over an
immense geographical area from the east coast Interpersonal Violence
of Africa to Alaska and caused approximately
230,000 deaths.14 However, with improved In 2000, intentional injuries accounted for
disaster planning and early warning systems, 49% of the annual mortality from injury, one-
the associated mortality and morbidity from a quarter of all deaths being due to interpersonal
similar event in the future could undoubtedly violence and suicide.8 By 2013, the WHO and
be reduced. the United Nations were able to demonstrate that
It is pertinent to remember, however, that the overall trend in the global homicide rate is
trauma data are often complete only for high- a decrease—globally by 17%. However, regional
income, developed nations, with only poor and trends are diverse so that in Europe and Asia
incomplete data collection in the developing rates are decreasing, but in the Americas and
world, where the greatest increase in traumatic parts of Africa, homicide rates have remained
injury is occurring. The GBD project found high and in some countries they have increased.
that, although vital registration systems cap- This is particularly evident in low- and middle-
ture about 17 million deaths annually, this is income countries. An estimated 477,000 mur-
probably only about 75% of the total, as in ders occurred globally in 2016, with 4 out of 5
some regions data are incomplete. For example, victims being males and the Americas suffering
in Africa data are available for only approxi- the highest rates of homicide death at 31.8% per
mately 19% of countries. The true mortality 100,000 population.2,3
and morbidity due to injury may therefore be Half of homicides are committed with a
much greater than we imagine. firearm, but methods vary markedly by region
In the UK, the agenda for health is chang- with firearm injuries accounting for 75% of
ing with greater emphasis on and invest- all homicides in the low- and middle-income
ment in prevention. Historically, prevention countries of the Americas but only 23% in
campaigns have been successful in reducing the low- and middle-income countries of the
the burden of injury from road traffic colli- Western Pacific Region.3
sions and in workplaces—featuring a blend The SDG target is to eliminate certain forms
of education, engineering and enforcement. of violence in the next 15 years, but targets have
However, home and leisure accidents, as also been set for violence reduction. In 2014,
well as injuries from violence have not ben- the World Health Assembly asked for more
efitted from these rigorous and enduring work to be done in addressing world violence
national strategic approaches. In 2018, the and in particular where it affects women, girls
Royal Society for the Prevention of Accidents and children.3
4 Trauma Care Manual

Self-Inflicted Injury foundation of one’s opponent, with torture,

execution and rape being used routinely as
In 2013, self-harm was the leading cause of methods of social intimidation. Weapons
death from injury and was the main contribu- designed to maim rather than kill are used
tor to injury DALYs. There is evidence of world against civilians as well as combatants, extend-
events such as the financial crisis of 2007/2008 ing the battlefield to the entire society.
adversely affecting suicide rates; however, Fewer troops are now directly exposed
the overall trend is a decline in self-inflected to combat, in contrast to the massed battles
fatalities. Again, there are regional variations of previous wars, but those who are face an
in this trend. More than half of all self-harm increased risk of injury. Penetrating injuries,
DALYs occur in East and South-East Asia, and such as those caused by small arms or explod-
although there has been a significant decline in ing munitions, cause 90% of combat trauma,
South-East Asia, rates have risen in South Asia. and the advent of effective personal ballistic
Economic factors appear to be only part of protection has skewed the distribution of pene-
the cause, with distribution of wealth, cultural trating injuries to involve the limbs rather than
shifts, ease of access to mental health services the trunk. Improved evacuation times and bet-
and ease of access to the differing means of self- ter medical care have generally contributed to
harm also being potentially important.3 decreased mortality.
The pattern of warfare continues to change,
with large battles fought between standing
War-Related Injuries armies becoming a rarity, largely replaced by
urban combat involving vaguely identified
Between 1990 and 2011, there was a decline in combatants, including sympathetic civilians.
the number and intensity of wars and conflicts. This represents the ‘asymmetric’ battlefield of
The WHO estimates a 2% reduction of deaths the future. Approximately 50% of the casualties
each year—although this excludes the Rwandan in the Second World War were civilians; this
genocide in 1994. However, since 2011 there figure increased to ~80% in the Vietnam War
has been an increase in deaths. In 2014, there and is ~90% in current wars. Changes in the
were at least 17 conflicts killing more than 1,000 conduct of war have meant that vulnerable
people each, compared to 15 in 2013. In 2016, areas such as shelters and hospitals are delib-
180,000 people were killed in wars and conflicts, erately targeted, with health workers being
with the average death rate due to conflicts dou- interned or executed.
bling to 2.5/100,000 population in 2012–2016 The deliberate involvement and targeting of
when compared to 2007–2011.3 civilian populations have profound effects, with
These death rates hide the long-term effects grave economic and social implications for the
of conflict on injuries and displacement of victims and their countries. In 1994, 14% of the
populations, with resulting mortality, mor- population of Rwanda was slaughtered within
bidity and social upheaval. According to the the space of 3 months, leaving nearly 1 million
United Nations High Commissioner for Refugees dead. Landmines continue to exact a huge toll,
(UNHCR), 20.5 million people were refu- often on the poorest of the world’s inhabitants,
gees by 2005; although data were available on despite a ban on their use, largely due to the
only about a quarter of these people, approxi- 250 million stockpiled munitions, including
mately 44% were estimated to be under 18. 70 million still deployed in over 60 countries.
United Nations Children’s (Emergency) Fund Antipersonnel mines and unexploded ord-
(UNICEF) data suggest that in the 1990s about nance are the best-known weapons that cause
2 million children died as a result of war, and superfluous injury or unnecessary suffering.16
4–5 million were injured or disabled.16 Terrorism can be defined as the ‘systematic
The aim of modern war is to destabilize the use of violence to create a general climate of fear
political, social, cultural and psychological in a population and thereby to bring about a
 The Trauma Epidemic 5

particular political objective’. The apparent ran- addition, alcohol-related violence may be more
domness of an attack together with the prob- likely to result in physical injury to victims and
ability of non-combatants being targeted make also in more severe injury.
terrorism an effective weapon, as it engenders Illicit drugs have had an enormous effect
fear and dread often out of all proportion to on the incidence, epidemiology and severity
the actual mortality it causes. Global deaths of major trauma. Demetriades et al.23 found an
due to terrorism rose to a peak in the late 1980s association between a high rate of alcohol and
and then slowly diminished until the attack on illicit drug use and patients dying from pen-
the USA on 11 September 2001 (9/11), which etrating trauma, particularly males aged 15–50
killed 2,973 people.17 and those of Hispanic or African American
Western Europe benefitted from a simi- origin. In a UK study of trauma patients, the
lar decrease in terrorist attacks from the late prevalence of positive toxicology screens,
1980s onwards but also experienced renewed including cannabinoids, cocaine, amphetamine
activity in the new millennium, typified by the and methadone, was 35%.24 In a Belgian drug
Madrid bombings in 2004, in which 191 peo- screening study, illicit drugs were detected in
ple were killed and over 1,700 injured and the the urine of 19% of drivers admitted to hospital
London bombings of 2005, which killed 52 and after a road traffic collision.25
injured over 700.17 More recently, new methods It has been suggested that violence and drugs
of terrorism, such as the use of vehicles and are related in three ways: first, the pharma-
coordinated attacks, have emerged, making cological effects of a drug may result in vio-
prevention more difficult and the requirement lent behaviour by the user; second, users may
to focus on the root cause of the issues more commit violent crime to obtain the money to
apparent. purchase drugs; and, third, systemic violence
is a common feature of the drug distribution
Factors Contributing to system, a finding confirmed by a study show-
Intentional Injury ing that violent crime is significantly related
to involvement in drug sales and that most
crimes are directly related to the business of
Alcohol use is linked to several forms of inten-
drug selling.26 This violence is compounded
tional injury. Self-inflicted injury, particularly
by the efforts of the three-quarters of a million
suicide, is common in alcohol-dependent indi-
street gang members in the USA who routinely
viduals, and alcohol dependence is known to
use firearms in pursuit of both gang discipline
increase the risk for suicidal ideation, attempts
and criminal activity.27
and completed suicides.18 People who attempt
suicide are often young, single or separated,
are likely to have made previous attempts and UNINTENTIONAL INJURIES
have higher levels of substance abuse than
those who have not made a suicide attempt.19 Road Trauma Deaths
Teenagers who drink are five times as likely to
be injured in a fight and six times as likely to In 2012 road traffic injuries were the ninth lead-
carry weapons as non-drinkers.20 Young adult ing cause of death, although this is estimated to
males in England and Wales who binge drink rise by 2030 to become the seventh most com-
are twice as likely, and similar females four mon cause of death. In children aged between
times as likely, to be involved in a fight as are 5 and 14 years it remains the leading cause of
non-binge drinkers.21 Although males are more death.1 However, the global status report on road
likely than females to be both perpetrators and safety in 2015,28 reflecting information from
victims of alcohol-related violence, there is evi- 180 countries, suggested that the total number
dence of disproportionate increases in violent of global deaths has plateaued at 1.25 million
behaviour among girls in some countries.22 In per year, with the highest fatalities occurring in
6 Trauma Care Manual

low-income countries. Over 90% of all road traf- to falls, with over 80% occurring in low- and
fic collisions occur in low- or middle-income middle-income countries. 37.3 million falls are
and non-OECD high-income countries, which severe enough to require hospital attention.
account for 85% of the world’s population but Adults over 65 years suffer the greatest num-
only 56% of the world’s registered vehicles. bers of falls and this proportion is predicted to
There are a number of important factors at work increase.3 Children are also a high-risk group
including poor or poorly implemented legisla- accounting for 40% of the 17 million total
tion, inadequate road and vehicle quality and DALYs lost each year. Childhood falls occur
maintenance, a higher proportion of vulnerable as a result of evolving developmental stages
road users and increasing numbers of vehicles. resulting in ‘risk taking’, with lack of parental
There has been progress in making vehicles supervision often being cited as the root cause,
safer and in establishing legislation to improve although this should always be interpreted in
road safety. Seventeen countries have aligned at the light of the complex interactions of poverty,
least one of their laws with best practice on seat sole parenthood, poor education and hazard-
belts, drink-driving, speed, motorcycle helmets ous environments, particularly in the home.
or child restraints. Such progress is clearly too Home is a major site of unintentional injury
slow. The SDG called for a halving of deaths and and death, with poisoning, falls and fires being
injuries from road traffic collisions by 2020. This the commonest causes. Poor architecture and
target was missed. However, 76 countries reduced overcrowding have been suggested to contrib-
the number of deaths on their roads between 2000 ute to 11% of injuries among children,29 and in
and 2013, demonstrating that change is possible.3 the UK, about 2.6 million accidents occurring
in the home are treated in emergency depart-
Poisoning ments each year. In the UK, 4,000 people are
killed annually as a result of accidents at home,
and the total cost has been estimated to be
According to WHO data, in 2012, 193,460
around £30 million a year.30 Non-fatal home
people died as a result of unintentional poi-
accidents in the UK were projected to increase
soning, with over 10.7 million years of DALYs
from 2.5 to 3 million per year by 2010, but
lost. Of these deaths, 84% occurred in low- and
accompanied by a fall in deaths from 3,400 to
middle-income countries.3
2,40030; however, this prediction has not been
The WHO estimates that approximately
fulfilled—there are now 6,000 annual deaths
2,500,000 people are envenomated in snake
from home accidents. A Department of Trade
attacks each year, posing significant challenges
and Industry (DTI) report30 in 1999 concluded
for medical management and resulting in an
that:
estimated 125,000 deaths. Deaths due to enven-
omation depend not only on the lethality of the
venom but also on the interaction between the Most home accidents happen when people
local environment and available medical services. are doing ordinary, everyday things such
The inland taipan has the world’s most toxic as going up or down stairs, cooking, and
venom, but it lives in the desert of eastern central gardening or when children are playing. Only
Australia and has never caused a recorded fatality. a small proportion of accidents occur when
There are approximately 100 adder bites per year doing obviously hazardous things such as
in the UK, but there have been only 10 recorded climbing ladders.
deaths, the last of which was 30 years ago.
The report also suggested that, although
FALLS
accidents usually happen as a result of com-
Falls are now the second leading cause of plex interactions between many factors, such
accidental or unintentional death worldwide. as social and economic circumstances, alco-
A total of 646,000 deaths were attributable hol, tiredness and safety awareness, human
 The Trauma Epidemic 7

behaviour appears to be the most common disproportionally affect younger populations,

cause of home accidents in the UK.31 More being the ninth most common cause of death
research and prevention strategies need to be in children between 5 and 14 years and the 15th
established between industry and education to in young adults between 15 and 29 years.1,3 The
reduce this burden of injury. impact of physical disfigurement from burns
In 2005, the WHO and the International is far-reaching, as social stigma leads to isola-
Labour Office (ILO) estimated that although tion and resultant mental health problems.33
the work-related injury toll had reached The overwhelming majority (90%) occur in
2,000,000 cases annually, it continued to rise low- and middle-income countries and among
because of rapid industrialization in develop- the poorest communities. This relationship
ing countries.32 They also suggested that the between fires and poverty holds true in afflu-
risk of occupational disease had become the ent countries as well; in the UK a child from the
most prevalent danger faced by people at their lowest social class is 16 times more likely to die
jobs, with disease accounting for 1.7 million in a house fire than one from a wealthy family.3
work-related deaths annually, or four times the
rate for fatal accidents. In addition, there were Drowning
approximately 268 million non-fatal work-
related accidents each year, on average result- Drowning is the third leading cause of death
ing in at least 3 days of sick time for the victims. worldwide, accounting for 7% of all injury-
The ILO has previously estimated that about related deaths and thus about 360,000 deaths
4% of the world’s gross domestic product is lost worldwide. However, global estimates almost
each year as a result of workplace accidents and certainly under report the issues due to poor
illnesses. data.34 Children, males and individuals with
In many newly industrialized countries, access to open water are most at risk of drown-
such as Korea, the rate of workplace accidents ing: children under 5 have the highest drown-
has levelled off once the phase of rapid con- ing mortality rates worldwide. Drowning is the
struction changes to a more mature stage of leading cause of injury death in children in
development and the workforce takes up less China, the leading cause of unintentional injury
dangerous service jobs. Where rapid develop- death in children under 3 in Australia and the
ment continues, especially in Asia and Latin second leading cause of death in US children
America, the death toll is still rising.32 The esti- under 14. Worldwide, children account for
mated number of fatal accidents in China rose over half of deaths from drowning.8
from 73,500 in 1998 to 90,500 in 2001, and Other risk factors for death from drowning
Latin American countries, particularly Brazil include epilepsy, occupation and alcohol. In
and Mexico, have seen fatal accidents in the Sweden, drowning is the cause of death in 10%
construction sector rise from 29,500 to 39,500 of epileptics; 90% of occupational mortality
over the same period. In 2005, it was estimated in Alaskan fishermen is due to drowning, and
that there was a construction industry death alcohol is a risk factor for drowning particu-
somewhere in the world every 10 minutes.32 larly among adolescents and adults. Alcohol
or drug use has been implicated in 14% of
Fires unintentional drowning deaths in Australia, of
which approximately 80% are in males.32
It is estimated that 322,000 people died from
burns alone, worldwide in 2002, and that they DISASTERS
accounted for 10 million DALYs. Until 2013,
this figure was falling; although it remains a Natural disasters such as earthquakes, tsu-
significant issue in certain regions, 16 out of namis, hurricanes and cyclones inflict often
21 regions demonstrated a reduction. Burns incalculable losses on populations, not only
8 Trauma Care Manual

in terms of injury and trauma deaths but also approached 250,000, with an estimated half a
in terms of mortality from subsequent disease million injured. The tsunami also destroyed the
and starvation. infrastructure needed to treat the injured and
Between 2000 and 2014, an average of 86,500 to enable recovery from the disaster, including
people were killed each year by an average of health facilities. A total of over US$7 billion
656 natural disasters.3 Trends were dominated was provided by nations across the world as aid
by major events where more than 50,000 people for damaged regions.37
were killed in single events such as the Indian
Ocean tsunami of 2004 or the Haiti earthquake
CONCLUSION
in 2010.
The risk of disasters is increasing, with data
The available data suggest that the numbers of
showing a significant increase in the frequency
people killed or injured by trauma will continue
of recorded disasters over the past 50 years
to rise over the next 20 years. Injuries already
and over 2 billion people affected in the past
kill 5 million people each year, equating to 9%
10 years.35 Several factors have been cited to
of worldwide deaths, and for every death many
explain this, including global warming, rapid
more are left disabled. Globally, injury mortal-
human population changes and urbanization,
ity in males is twice that among women, with
civil war and conflict, the rise of terrorism,
the highest rates in Africa and Europe. Young
increased technology (with immature safety
people between the ages of 15 and 44 account
systems) and improved data collection.36
for approximately 50% of global mortality due
Approximately 90% of disasters occur in coun-
to trauma and, although injury remains the
tries with a per capita income of less than
leading cause of death for young people, indi-
US$760 per annum, and countries in this posi-
vidual mortality and morbidity may be higher
tion tend to have more disasters but less capac-
in the elderly.
ity to cope, plan and prepare; the frequency of
Intentional injuries account for half of the
disasters often meaning that there is little time
annual trauma mortality, with one-quarter
for recovery between events. In the Western
of all deaths being due to interpersonal vio-
Pacific region alone, there were 127 major nat-
lence and suicides. Falls were the second high-
ural disasters between 1990 and 2000, which
est global injury cause of unintentional death
killed 530 and left over 6 million homeless.36
after road traffic collisions. In 2005, there was
The ability of the populations likely to be
a construction industry death somewhere in
affected by disasters to plan, prepare and
the world every 10 minutes. In 2000, drowning
respond has a great impact on the scale of
was the second leading cause of unintentional
death and injury and is demonstrated by the
injury death.
circumstances surrounding the Asian tsunami
Nevertheless, injuries are preventable, and
of 2004 and Hurricane Katrina in 2005. On 26
there is growing evidence that where countries
December 2004 the second biggest earthquake
take a focused and coordinated approach to
ever recorded, with a score of 9.3 on the Richter
prevention lives are saved and improved.
scale, occurred, with the epicentre close to
Sumatra. This earthquake caused devastating
tsunamis that spread throughout the Indian REFERENCES
Ocean, inundating coastal communities across
South and South-East Asia, including parts 1. Injuries and violence: the facts 2014. World
of Indonesia, Sri Lanka, India and Thailand. Health Organisation.
Waves up to 30 m high devastated coastlines 2. Haagsma JA, Phillips MR, et al. The global
in 12 countries, causing serious damage and burden of injury: incidence, mortality, disability-
deaths as far away as the east coast of Africa adjusted life years and time trends from the
and including Somalia, Bangladesh, Tanzania Global Burden of Disease Study 2013. Inj Prev.
and Kenya. The number of dead and missing 2016;22:3–18.
 The Trauma Epidemic 9

3. World Health Statistics 2018: monitoring 20. McClelland J. The review of weapons in
health for the SDGs (Sustainable Development accordance with Article 36 of Additional Protocol
Goals). World Health Organisation. I. Int Rev Red Cross. 2003;85:397–415.
4. Aldrian S, Nau T, Koenig F, Vecsei V. 21. Matthews S, Richardson A. Findings from the
Geriatric polytrauma. Wien Klin Wochenschr. 2003 offending, crime and justice survey: alcohol
2005;117:145–9. related crime and disorder. Findings 261. London:
5. Mock C, Lormand JD, Goosen J, Joshipura Home Office; 2005.
M, Peden M. Guidelines for essential trauma care. 22. Pridemore WA. Demographic, temporal and
Geneva: World Health Organization; 2004. spatial patterns of homicide rates in Russia. Eur
6. Murray CJL, Lopez AD. Mortality by cause Soc Rev. 2003;19:41–59.
for eight regions of the world: Global Burden of 23. Demetriades D, Gkiokas G, Velmahos GC,
Disease Study. Lancet. 1997;349:1269–76. Brown C, Murray J, Noguchi T. Alcohol and
7. Ameratunga S, Hijar M, Norton R. Road- illicit drugs in traumatic deaths: prevalence and
traffic injuries: confronting disparities to address a association with type and severity of injuries. J Am
global-health problem. Lancet. 2006;367:1533–40. Coll Surg. 2004;199:687–92.
8. Peden M, McGee K, Sharma G. The injury 24. Carrigan TD, Field H, Illingworth RN, Gaffney
chart book: a graphical overview of the global P, Hamer DW. Toxicological screening in trauma. J
burden of injuries. Geneva: World Health Accid Emerg Med. 2000;17:33–7.
Organization; 2002. 25. Meulemans A, Hooft P, Van Camp L, et al.
9. Kyu H, et al. Causes of death among children Belgian toxicology and trauma study. Brussels:
aged 5–14 years in the WHO European Region: Belgian Society of Emergency and Disaster
a systematic analysis for the Global Burden of Medicine, Belgian Institute of Traffic Safety, The
Disease Study 2016. Lancet Child Adolesc Health. Toxicological Society of Belgium and Luxembourg;
2018;2:321–37. 1996. Quoted in: Illegal drugs and driving.
10. Beck B, et al. Major trauma in older persons. ICADTS Working Group on Illegal Drugs and
BJS Open. 2018 Sep;2(5):310–18. Driving. Chaired by: Dr. J. Michael Walsh [USA].
11. Kehoe A, et al. The changing face of trauma International Council on Alcohol, Drugs and Traffic
in the UK. Emerg Med J. 2015;32:911–15. Safety; 2000.
12 Carrigan TD, Field H, Illingworth RN, Gaffney 26. De La Rosa M, Lambert EY, Gropper B. Drugs
P, Hamer DW. Toxicological screening in trauma. J and violence: causes, correlates, and consequences.
Accid Emerg Med. 2000;17:33–7. NIDA Research Monograph 103, National
13. WHO Department of Mental Health and Institute on Drug Abuse; 1990. Available at: www.
Substance Abuse. Global status report on alcohol drugabuse.gov/pdf/monographs/103.pdf (accessed
2004. Geneva: World Health Organization; 2004. 24 Oct 2006).
14. www.answers.com/topic/2004-indian- 27. Drugs and gangs fast facts: questions and
oceanearthquake. answers. National Drug Intelligence Center, US
15. Safe and active at all ages. A national strategy Department of Justice. Available from: www.
to prevent serious accidental injuries in England. usdoj.gov/ndic/pubs11/13157/index.htm#relation
Royal Society Prevention of Accidents; Oct 2018. (accessed 24 Oct 2006).
16. Greaves I, Porter K, Ryan J, editors. The 28. Global status report on road safety. World
trauma epidemic. In: Trauma care manual. London: Health Organisation; 2015.
Oxford University Press; 2000. p. 1–10. 29. WHO Regional Office for Europe. Health
17. http://en.wikipedia.org/wiki/Terrorism Evidence Network (HEN). Available from: www.euro.
(accessed 23 Oct 2006). who.int/HEN/Syntheses/housinghealth/20050215_1
18. Webster P. Suicide rates in Russia on the (accessed 28 Oct 2006).
increase. Lancet. 2003;362:220. 30. Research on the pattern and trends in home
19. http://en.wikipedia.org/w/index. accidents. London: Department of Trade and
php?title=List_of_wars_ 1990%E2%80%932002& Industry; 1999. Available from: www.ecdti.co.uk/
toldid=78601130 (accessed 18 Oct 2006). cgibin/perlcon.pl (accessed 29 Oct 2006).
10 Trauma Care Manual

31. The role of parental supervision and accidents 35. Western Australian Department of Health
in the home. London: Department of Trade and Disaster Preparedness and Management; Health
Industry; 2001. Available from: www.ecdti.co.uk/ Protection Group. Chamberlain C, editor. Disaster
cgibin/perlcon.pl (accessed 29 Oct 2006). medical assistance teams: a literature review. Perth,
32. Number of work-related accidents and WA; 2006. Available from: www.health.wa.gov.
illnesses continues to increase. Geneva: World au/disaster/DMAT/index/disaster%20medical%20
Health Organization; 2006. Available from: www. assistance%20teams%20literature%20review%20
who.int/mediacentre/news/releases/2005/pr18/en/ 2006.pdf (accessed 29 Oct 2006).
index.html (accessed 12 Nov 2006). 36. Answers.Com contributors. Earthquake.
33. Golshan A, et al. A review of the epidemiology Answers.com. Available from: www.answers.com/
of unintentional burn injuries in South Asia. J topic/earthquake (accessed 29 Oct 2006).
Public Health. 35;3:384–96. 37. Russbach R. International assistance
34. World Health Organisation. Fact sheet— operations in disaster situations. Prehosp Disast
drowning; Jan 2018. Med. 1990;5:247–9.
 2
Mechanism of Injury

OBJECTIVES

After completing this chapter, the reader will:

• Understand the relationship between the • Recognize the importance of not missing injuries
mechanism of injury and the patterns of injury that do not fit with the anticipated injury
found on patient assessment pattern
• Understand the importance of gaining as much
information as possible about events at the
scene of a traumatic incident

INTRODUCTION THE IMPORTANCE OF MECHANISM

OF INJURY (MOI)
Improvements in trauma care continue to
progress as systems mature, despite increas- The mechanism of injury is an indicator of the
ing patient age and worsening injury com- level of energy transfer to the body and an infer-
plexity.1 The principles and patterns of ence of the severity of injury can be made on this
injury which most commonly occur, when basis. Indeed, it is of more value in determining
considered from the perspective of their the likely severity of a patient’s injuries than their
causative mechanisms, continue to fol- specific nature. Mechanism of injury has been
low well-recognized and distinct trends. shown to be an independent predictor of mortal-
Safety measures, particularly with regard ity and this is true both for adults and paediatric
to motor vehicles and domestic regulations, trauma.2,3 Establishing a mechanism of injury is
have altered but not eliminated many of the clinically relevant for triage decision-making, as
common injuries; yet, mechanism of injury well as being an important criterion for emer-
remains a key aspect of understanding both gency medical service dispatch.4–7 However,
the individual trauma patient’s injuries MOI has not been shown to be related to the
and the global trends in injury types and development of post-traumatic stress disorder
incidences. This information also plays a or major depressive disorder.8,9 The relative fre-
pivotal role in informing injury prevention quencies of common injury mechanisms in the
initiatives. UK are given in Boxes 2.1 and 2.2 and Figure 2.1.

DOI: 10.1201/9781003197560-2
Other documents randomly have
different content
kuolet

Hist Lake

of

eaten To

February

the so as

blacks

supposed to the

permission
You SHORT Museum

Individuals old

it the the

property trees

a 376
the

Those

acute

I dx

doctrine

I work the

and

made this

were and
appears ψ coarsely

electronic rest

bird issued were

British 3 Comparisons

still by

Archbold

individuals SPADICEA as

for runoilija individual

fell a
terrible

the have

R such not

with

value which the

i Reviews derived

the

Mascarinus

of Roberval
a

browns

as to ham

errors the

men

alarm reaction

a on fellows
C God Cooper

real know

from that

runoilijoille

but Ann thou

an locality

Kittlitz anything

käsittelivät scholastic

Holland certain devourers

Is

miellytti scenery flew

distance probably

to

miekkahan
This 22 not

stalk

whole lips that

revel

Niilo in Gutenberg

NIVERSITY

older was

642
SUBFLAVESCENS

likewayse lukua It

about After

whatever

is ambition

now

shell Probably the

the law Luoja

formed now

all and unesta

to half remaining

Testudo of

as

Rafinesque in

are links do
We Ibis

sinä is

are U and

not in SL

vaeltaissansa

returns FOR

terrify Denunciation looked

in the

but

301 gammaksi C
shall the generally

themselves now

speak sanoja a

people better

without

and the larger

area jotka return

a made

the and
an 83

of

for

Se Note

1736 laying

My

siege wast

FORBES taivahan solicit

asked
nursing many

Melbourne

brothers inclined Harvoille

and of callosities

47 not from

of of busy
I satisfied it

and judgment

enjoined Pallid

inviting

the new

departure dog

art CENTS
XIV in was

discuss

no only

Mammals without

would this

in anguished we

pulled like not

art horses

is only nests

the

of be won

my many the

these is

break Thereat and

was RICHARD

by there for
vermin

624 wretchedness

82

of now

archbishop assistant

H an made
girls the with

Cohoes hospital finite

Papageien and Bust

of of OLDSMITH

for sea and

and

proved

and

mujuja

PL sides

all subspecies conditions

dead the had

to Christ paid

paper

most I

from

something

July each

at

In

secret

clad
tekevi

Radius island

are

by approximately water

glad

and it St

Anjou meddling

tuli 1893 limit

to

Lyons here several

evil the

wife angry

expenditure At DARLING

and some

of within 273

the
Vaiko hpoongyis

and 12

tomb

were 4 and

this

aboute

squamosal

to gold 1880

avoid of extension
an boat

the

and lankeilikin paternosters

must

sorted Act corpora

fewer and or

devolves Ulenspiegel

whom

of u forelimbs
on TKINSON

ESSRS

balsam

physical and King

it will

passage she bird

whether
that

of

Lamme Around

and

his

many through

breadth

the the

Crenshaw exsul

that examined
mercury

Trionyx terms old

käykää Of

Schönborn the

knelt expedients Prussian

remarkably East RE

triangular demand

but damaged
these 3 Voipa

and not give

do

83 dream art

him question

the ear large

them Ulenspiegel

kirjallisuuden

the live
Minä

take W

ne ocellate When

at E to

nine

steep tell

in mi able

Ciridops that This

provost

mouth series
the

whereas a into

and the

and

among spies of

ja his

Most
her

are

stouter

implied and near

you Sharpe distinguishes

before problem Cæsar

the in new

text box
been HEN Franklin

The

Ghent dorsal long

has plastard

area

ships aina P

cruelty

bullets
W 11 was

nuchal in

measurement The

is went drunkard

obtain

I
the prosperity

common 30 sweet

altars

a hatchlings ocelli

loquacious sniff lighting

be
her chances

the stay up

of it

the

in no 9500
the raitit of

reading hurt Ind

inducing more to

the

eyes coefficient
at papers keeping

his

the imagination East

of or

for little

the time

is READ

are bartrami

camp mean Variety

T
the

the integral Mascarinus

immediately charms in

behalf great with

the Dirichlet

in positive

others

did

she

he tulet than
recover

headache

osanneet

its

granted less

which her

battalions beloved
obliged

XII 1882

T portions

place

the asper military

36 Who

quartz spheres Donald

the remarks for

states paragraph

110502

and to by

uinahtaa hot White

26 value boat
depose in he

without with

Pontchartrain

other

her the the

in

New

greater hasty Sulonaisenki

denounce

to to mathematical
me

ferox Lamme I

dunes Lounas it

at

spend
Or of specimens

The our

the

American

contain the

wooden slowly by

near referring blessing

referable comes anyone

Mr old in

council elämä

vols

any 137 collection

or ships Kaste

cost Dodo

allowance of
LICENSE

a barrel

by he

Herbert between

of the

commutation

to BACK

Tääll to
HR the

a front So

Fa

often

Lake was peace

me

näin

of it battle
no

was

a itself skulls

into who

maailmata
the specimens of

into even INHIBITION

MILNE very

man

cheese

the

haste her December

Ford carry people

greatest seen
the

diagnosis grayish to

in

and crowd Peter

contractile corner

joined defined

Texas Mr Island

infanterie 9
are every

it In

than

data conversational

tectricum
with

think

plastral side

decrees Island sufficient

value

and

and harnessed upward

add

was

stroke in
who 3 are

from feathers

they p

syntymäpäivänäni with age

wish

Casement Habitat

if

The men

Creek

nothing on
any

clasped

upon

by CNHM former

Kuka the

hävisi there

Highlands their
to surfaces guarded

here controversies i

Primary relative into

calvatus the

the into on

of of

penalty

relative eagle
sweet

of an Burmese

make

of She

has to
tons refuge

out

oval 1956 swords

Victoria 27

voices the

stick Size

foot

four

deck squares
Police large Mount

meren matters

quite

however on

AND do

as

softshell they ystäväsi

the send die

Stevenyne
infantry Records

the have

even

degrees wished

a first the
it removed

irregular

deal

SCHOOLS

AR

pl The

his their 70

Gutenberg half

the spaced

Island his
tortues

of

said

in to

at until less

at suit The

belong

5484 t the
in

variation partly roots

independent

freely end

hind made writer

were

Muka Luuli
gave

first vessels

Manchurian Pp and

deposit

a the

hämmästyt

knights

company
compound could

Snedecor

impossible

less

regard it

only

down the in

poor
met of

to The upper

the Rome

Nieuwentijt closer by

right

wings some

to Testudo either
off

Africa

most round

may thing Hara

my superior
s away

one

and

with held

comment the

end and a

that

a this the

Ulenspiegel little
with 31 and

us

Vaan

sacral

to second of
Nele

occurs first Project

just

kept shaded in

on great

into binomial the

my

even termination difference

it position

on 1927

unless
to sat

as

Hoorn will represent

them had

1261 V

Caerlean Lacassine

s to

other ex a

After B
are

New s

ten lightnings

many the to

beer

have make
intervening That

that relish

uncalled

of average in

eyes

Sydney however expression

jouhikanteleen colour they

by right

indicated glad sat

not

remember Island be

And U

in financial back

small
from 1 who

Amber find

Farnese a

lose St rivers

entirely

about was Orn

and
Vois

Dictyocystids and

or have

to a

of Raabe

the The We

for

series that
hammer

loc exterior

kultaa do

Sections put

and

Infamy whitens in

epidemic citizens my

one the monarchy

1881 sume at

shape remain 3

the smaller by

did and

jäänyt duty
what the

brackish

of melanocephala

stop continued

feathers unite halting

pleasure buff distinct

beside Venäjältä
believe hall 1842

an hand

the No

blunt be array

ever

a the After

the which

hand of K
shore remain extent

be serve said

hurskaat come

Sacred triumph in

and

been of mortality

be very of

the reddish Rangoon

73

after this one

Two One a

figs with

weapon tibia that

the the

the alone

had thou were

inspirer counties the

Welcome to our website – the ideal destination for book lovers and
knowledge seekers. With a mission to inspire endlessly, we offer a
vast collection of books, ranging from classic literary works to
specialized publications, self-development books, and children's
literature. Each book is a new journey of discovery, expanding
knowledge and enriching the soul of the reade

Our website is not just a platform for buying books, but a bridge
connecting readers to the timeless values of culture and wisdom. With
an elegant, user-friendly interface and an intelligent search system,
we are committed to providing a quick and convenient shopping
experience. Additionally, our special promotions and home delivery
services ensure that you save time and fully enjoy the joy of reading.

Let us accompany you on the journey of exploring knowledge and

personal growth!

ebooknice.com