120 MAPPING INJURIES IN TRAFFIC ACCIDENT VICTIMS: A LITERATURE REVIEW Ana Maria Calil1 ...

120


MAPPING INJURIES IN TRAFFIC ACCIDENT VICTIMS: A LITERATURE REVIEW


Ana Maria Calil1


Elias Aissar Sallum2


Cristiane de Alencar Domingues3


Lilia de Souza Nogueira3


Calil AM, Sallum EA, Domingues CA, Nogueira LS. Mapping injuries in traffic accident victims: a literature


review. Rev Latino-am Enfermagem 2009 janeiro-fevereiro; 17(1):120-125.


The objective of this study was to identify the body regions most affected in traffic accident victims and to map


the trauma and severity of the lesions. A systematic literature review using key words related to traffic accidents,


transportation accidents, wounds and injuries found a total of 248 articles. The electronic bases LILACS, MEDLINE,


and PAHO were surveyed between the years 1990 and December 2006. This review emphasized a series of


conclusive studies about the most frequent body regions involved and the major injuries occurring in these


situations. It also indicated information gaps in the Brazilian literature. We believe that these findings are


valuable for pre-hospital and intra-hospital teams and point the way to new investigations.


DESCRIPTORS: accidents, traffic; wounds and injuries; epidemiology


IDENTIFICACIÓN DE LESIONES EN VÍCTIMAS DE ACCIDENTES DE TRÁNSITO: REVISIÓN
SISTEMÁTICA DE LA LITERATURA


El objetivo del estudio fue identificar las regiones corpóreas más afectadas en víctimas de accidentes de


transporte e identificar la gravedad de las lesiones y del trauma. Fue realizada una revisión sistemática de la


literatura, utilizándose descriptores relacionados a los accidentes de tránsito, accidentes de transporte, heridas


y lesiones, totalizando 248 artículos. Las bases electrónicas investigadas fueron LILACS, MEDLINE y PAHO,


entre 1990 y diciembre de 2006. Esta revisión destacó una serie de estudios conclusivos sobre las regiones


corpóreas más frecuentes y aquellas de mayor gravedad afectadas en esos eventos y apuntó lagunas de


conocimiento en la literatura nacional. Pensamos que lo encontrado puede ser de gran importancia para los


equipos en los escenarios de prehospitalario e intrahospitalario y apuntan caminos en dirección de nuevas


investigaciones.


DESCRIPTORES: accidentes de tránsito; heridas y lesiones; epidemiología


MAPEAMENTO DAS LESÕES EM VÍTIMAS DE ACIDENTES DE TRÂNSITO: REVISÃO
SISTEMÁTICA DA LITERATURA


O objetivo do estudo foi identificar as regiões corpóreas mais atingidas em vítimas de acidentes de transporte


e mapear a gravidade das lesões e do trauma. Foi realizada revisão sistemática da literatura, utilizando-se


descritores relacionados aos acidentes de trânsito, acidentes de transporte, ferimentos e lesões, totalizando


248 artigos. As bases eletrônicas pesquisadas foram LILACS, MEDLINE e PAHO, entre 1990 e dezembro de


2006. Essa revisão destacou uma série de estudos conclusivos sobre as regiões corpóreas mais freqüentes e


aquelas de maior gravidade atingidas nesses eventos e apontou lacunas de conhecimento na literatura nacional.


Acredita-se que esses achados possam ser de grande valia para as equipes nos cenários de pré-hospitalar e


intra-hospitalar e apontem caminhos na direção de novas pesquisas.


DESCRITORES: acidentes de trânsito; ferimentos e lesões; epidemiologia


1RN, Ph.D. in Nursing, Collaborating Professor at Centro Universitário São Camilo, Brazil, e-mail: easallum.fnr@terra.com.br; 2Physician, Ph.D. in Medicine,
Assistant Physician at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, e-mail: easallum.fnr@terra.com.br;
3RN, M.Sc. in Nursing, e-mail: crismingues@usp.br, lilianogueira@usp.br.


Artigo de Revisão
Rev Latino-am Enfermagem 2009 janeiro-fevereiro; 17(1):120-125


www.eerp.usp.br/rlae


Disponible en castellano/Disponível em língua portuguesa
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121


INTRODUCTION


External causes are among the main causes
of morbidity and mortality in the world, and the


number of deaths as a result of traffic accidents in


2005 in Brazil was 35,763, which corresponds to an


average of 98 deaths per day(1).


As to the victims that were hospitalized, the


numbers are alarming. Almost 120,000


hospitalizations occurred in 2005, which represents a


rate of 64 hospitalizations for every 100,000


inhabitants(1) by the Sistema Único de Saúde (SUS) -


the Brazilian national public health system. The number


of accidents with victims in 2005 was 383,371, with a


total 513,510 victims, which translates to, on average,


1406 accidents/day and 1369 victims/day (1.30 victim


per accident)(1).


Reports by the World Health Organization


about the Mortality Database, referring to the period


from 1990 to 2003, revealed that external causes were


responsible for about 12% of the deaths in the world,


which corresponds to, approximately, 8 million deaths


per year, and traffic accidents were responsible for a


large proportion of these deaths (3.9 million)(2).


Early in this decade, some 20 to 50 million


people in the world became totally or partially


incapacitated due to injuries caused by traffic


accidents. Injured and trauma victims took 10% of


all hospital beds that year(3).


In Latin America, the approximate cost


associated with incapacities and death due to these


events was 18.9 billion dollars; in highly motorized


countries, it was 453.3 billion(3). In Brazil, in 2004,


traffic accidents caused a total of 117,155


hospitalizations. This means that 15.5% of


hospitalizations were due to injuries, which shows the


impact of these injuries(4).


A large number of patients remain for weeks,


months, or even years in rehabilitation programs and


physiotherapy, losing salaries and their jobs due to


these events. This points to the economic-social


dimension of the problem(5).


The inquietudes in view of this sad situation,


showing external causes as the third highest cause of


unclear deaths, as well as the urgency and necessity


of measures to help better understand the


consequences of trauma and implement assistance


programs to individuals involved in these occurrences,


led to the present inquiry about whether there are


similarities in the injuries of traffic accident victims.


To organize these possibilities and inquiries,


systematic reviews can be useful in their identification.


Within this context, the purpose of this study was to


identify the existence of specific and common


characteristic between the body regions and injuries


in traffic accident victims, considering their frequency


and severity.


METHODOLOGY


This is a systematic review. Systematic


reviews aim to synthesize the knowledge in a certain


area by formulating a question and then identifying,


selecting, and evaluating studies, critically seeking a


consensus about some practice or concept in which


the available knowledge is insufficient or


controversial(6). The research question was: what body


regions are most frequently and most severely injured


in traffic accident victims? With this question, the task


was to identify similarities and differences in the


frequency and severity of traffic accident victim injuries.


The search for articles included a survey in


electronic databases, and a manual search of


statements in the initially identified publications. The


electronic databases included in the survey were


LILACS (Latin-American and Caribbean Health


Sciences), COMPREHENSIVE MEDLINE (Medical


Literature end Retrieval System on Line), and PAHO


(Pan American Health Organization Database). In


MEDLINE, only English keywords were used, while in


the others, the keywords used were in Portuguese,


Spanish, and English. The research period was


between 1990 and December 2006.


The article search was performed using


descriptors standardized by the Medical Subject


Heading (MESH) and Descritores em Ciências da Saúde


– Health Science Descriptors (DeCS), as follows: traffic


accidents, transportation accidents, wounds and


injuries, trauma severity indices, and epidemiology.


To refine the search, the terms classification,


prevention, control, and evaluation were added to


these combinations. In the end, there were 1236


combinations between the descriptors to obtain a


maximum possible number of references.


The titles and abstracts of each article


identified in the electronic search were reviewed.


Where possible, the studies that seemed to meet the


inclusion criteria were obtained in full. A list was made,


containing the articles to be included in the study.


Mapping injuries in traffic accident victims…
Calil AM, Sallum EA, domingues CA, Nogueira LS


Rev Latino-am Enfermagem 2009 janeiro-fevereiro; 17(1):120-125
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122


The inclusion criteria were study articles


published in periodicals about traffic or transportation


accidents (pedestrians, motorcycle, or automobile),


containing data about the characterization of the


frequency, injury and/or trauma severity, or that


addressed the affected body regions. The period


considered in the survey was from 1990 to December


2006, and studies could be published in Portuguese,


Spanish, and English.


Studies were chosen if they identified the


injury severity using the Abbreviated Injury Scale


(AIS) index, of anatomical basis, presented as a


manual in which hundreds of injuries are listed


according to their type, location, and severity,


composing over 1300 injury descriptions. The


severity of each injury ranges from AIS1 to AIS6, of


which scores were defined by trauma specialists


according to life risk, i.e. score 1 indicates light injury


and 6 indicates maximum severity of injury(7).


Trauma severity was observed using the New


Injury Severity Score (NISS). The body regions,


according to the instructions in these severity


manuals, are divided into six categories: head/neck,


face, thorax, abdomen or pelvic contents, upper/


lower limbs, and external surface.


Studies using the Maximum Abbreviated


Injury Scale (MAIS), which refers to the major injury


identified by the AIS in a patient, were also included.


Reading was limited to articles that


addressed injury severity, trauma severity, and


analyzed the body regions or common aspects of


these variables.


RESULTS


In the MEDLINE database, considering the


period between 1990 and 2006, 2743 articles were


located and 178 were included. Of the total of 208


articles found in the LILACS database, 52 were


included, and only 18 of the 150 articles found in the


PAHO database were included. In total, 248 articles


met the inclusion criteria.


The main reasons for excluding articles were:


it was an update article, case study, or did not


describe the injuries in terms of their severity and


frequency or affected body region. The manual


search did not add any new articles. Some articles


were included in more than one database and, when


this occurred, the oldest article was included.


Of the 248 analyzed articles, 226 were cross-


sectional studies using a quantitative approach, 18


were cohort studies, and 4 were systematic reviews.


It is noted that, among the selected studies,


120 addressed injury severity, 55 also included trauma


severity, and only 73 addressed the most affected


body regions.


The survey found original studies from five


continents, highlighting North-American, Australian,


and Asian publications. Regarding Brazil, 34 studies


were located.


As to the patients’ characteristics, the studies


were unanimous in pointing out men aged 40 years


or less as the most common victims, especially those


aged 19 to 29 years. It was observed that children


and elderly individuals comprised the majority of those


involved in pedestrian-vs-auto accidents.


As to the type of victim, i.e., motorcycle user,


automobile user, and pedestrian (struck by vehicle),


there was a variation in the findings according to the


period the study was performed (before 1999) and


the country or location where the event took place.


In Asian countries, motorcycle and bicycle accidents


prevail in a uniform manner over the analyzed years,


due to the large number of these used as the main


mode of transportation.


In terms of auto and pedestrian accidents,


auto injury patients were found in greater numbers.


This finding was expected since there can be more


passengers in a vehicle, and also because of the great


number of cars in countries like the United States of


America (USA), Canada and Brazil.


Adopting preventive measures, such as


increasing the crossing time for pedestrians in streets


and avenues in European and North-American


countries, was identified as an effective measure to


reduce pedestrian-vs-auto accidents in some


countries. Nevertheless, the type of victim was found


with less homogeneity among the studies.


Specifically concerning Brazil, most studies


reported automobile users as the most frequent


victims until the year 2000, when motorcycle users


became the most frequent victims of injury. It should


be emphasized that accidents involving being struck


by an automobile are generally regarded as the most


lethal of accidents.


As to the most frequently injured body region,


upper and lower limbs are highlighted, followed by


the head region. The thorax region, external surface


and face alternated in the studies in terms of


Mapping injuries in traffic accident victims…
Calil AM, Sallum EA, domingues CA, Nogueira LS


Rev Latino-am Enfermagem 2009 janeiro-fevereiro; 17(1):120-125
www.eerp.usp.br/rlae




123


frequency, and the thorax, abdomen, and limbs in


terms of severity.


As to severity, there is no doubt it can be


affirmed that injuries to the head region, referred to


as craniocerebral trauma (CCT), rank first in terms


of injury severity. It is important to emphasize that


numerous studies report the head region as the one


with most injuries IS≥4.
In terms of trauma severity, most studies state


that between 58% and 60% of people involved in


traffic accidents have trauma severity ≤16, considered
to be moderate to light, and around 35% to 40% have


serious or life-threatening trauma.


DISCUSSION


A great number of patients are transported


to the emergency ward due to traffic accident injuries.


These cases are a daily challenge for the teams


working in pre and intra-hospital settings, especially


due to the severity of the injuries and to the time it


takes to reach the hospital and forward patients to


surgery(8).


The variety and possible severity of the clinical


conditions that occur in a trauma make it essential to


reach a fast and precise diagnosis of the nature of


the injuries. The differentiation between the injuries


and the severity potential that risk life (CCT, thoracic


and abdominal injuries) is critical in order to start


treatment immediately and discharge or admit patients


to hospital(8).


Although the clinical presentation of patients


with traffic accident injuries can vary immensely,


especially because of the organic responses from shock


and changes in hemodynamic and respiratory


parameters, about 50% of patients present limb injuries


and about 40% present more than one injury(3,9).


A national study analyzed the distribution of


injuries per body region in traffic accident victims, and


found that motorcycle users had a significantly higher


number of injuries to the upper limbs, lower limbs,


and pelvis compared to other victims, while there were


more head/neck and face injuries in run-over and


automobile accidents(10).


Another study verified the injuries in 3594


hospital admissions in 28 North American trauma


centers and identified that the most affected body


regions were the upper limbs, lower limbs, and pelvis


in 51% of cases(11).


The analysis regarding the location of injuries


in 6099 victims of this event in the South of Brazil


identified that the most affected body regions were


the lower and upper limbs (69.7%), the head (49.6%),


and the thorax (19.9%)(12).


The distribution found in the analyzed studies


often shows the upper/lower limbs and pelvis, and


head/neck regions as the two most affected body


regions in traffic accidents, with variations for the other


affected regions.


Isolated upper or lower limb injuries are rarely


fatal, but often require reparative and corrective


surgeries and amputations, which have a direct


influence on the quality of life of patients and their


family.


Only one national study evaluated the most


common injuries in automobile users, motorcycle


users and pedestrians, using the proposed severity


indices, and found that the most common injuries for


the limb region were: wrist contusion, torsion of the


clavicle, elbow contusion, finger fracture (AIS=1),


lower and upper limb bone fracture, elbow luxation,


tendon laceration, hand laceration (AIS=2), multi-


fragmentary pelvis fracture, femur fracture, knee joint


rupture, femoral and axillary artery laceration


(AIS=3), and traumatic amputation above the knee


(AIS=4). Injuries with greater severity, like AIS=5


and AIS=6, were not identified.


As to the most severely affected body region,


the head/neck had a percentage a lot higher than the


other regions; these injuries scored AISe”4 in most


studies. This finding is extremely important, due to


the high prognostic value determined by injuries in


this body segment(13).


CCT in traffic accident victims is the most


common isolated injury in severe and fatal cases,


and it causes the highest number of sequelae,


incapacities and deficiencies. The overall analysis of


the studies highlights pedestrians as the victim in cases


that are most likely to evolve to death when this body


segment is injured(5,10).


The most common head injuries, according


to the severity classification, were: post-CCE


amnesia, post-trauma headache, and cervical spine


torsion (AIS=1), simple skull fracture, cervical spine


luxation (AIS=2), cerebral contusion (AIS=3),


intracranial hematoma, depressed skull base fracture


(AIS=4). Injuries of greater severity (AIS=5 and


AIS=6) were not identified(10).


Mapping injuries in traffic accident victims…
Calil AM, Sallum EA, domingues CA, Nogueira LS


Rev Latino-am Enfermagem 2009 janeiro-fevereiro; 17(1):120-125
www.eerp.usp.br/rlae




124


The thoracic region appears as the second


most severely injured region in most studies. Recent


studies about trauma report it is a body segment


with high risk to patients, since it contains organs


like the heart and lungs(10). The injuries most


frequently found in this body segment were: rib


fracture (AIS=2), lung, hemo or pneumothorax


contusion (AIS=3), and bilateral hemopneumothorax,


hemopneumomediastinum (AIS=4). One pedestrian


had an injury of severity = 5 (bronchi rupture) and


another pedestrian had a maximum severity injury


=6 (total aorta dissection)(10).


As to the abdomen, the main injuries found


were: stomach laceration, liver contusion, spleen


contusion (AIS=2), retroperitoneum hematoma,


important contusion involving liver/spleen veins


(AIS=3), important liver laceration (AIS=4). There


was one automobile user with an injury AIS=5


(complex liver rupture)(10).


As to the face region, commonly injured in all


kinds of traffic accidents, the following injuries are


highlighted: nose and tooth fracture (AIS=1),


cheekbone or mandible fracture, cornea laceration


(AIS=2), and optic nerve laceration and Lefort II


fracture (AIS=3). On the external surface, there are


mostly contusions, abrasions, and superficial lacerations


that do not have a severity index above AIS=2.


It should be emphasized that victims with


injuries equal to or above 5 died and, of the total


studied patients (220), 45 died, of which 30 (66.6%)


were pedestrians. This type of victim had more CCE


(48.5%) than the others(10). These findings are in


agreement with the literature(3, 8-9).


Approximately 40% of the injuries are


multiple and occur in the following body regions: head/


neck, face, abdomen/pelvic content, and more than


50% occur on upper limbs, lower limbs and pelvis.


Traffic accident victims are often characterized as


polytrauma patients or as having multiple injuries in


the same body segment. This situation worsens the


prognosis and, therefore, requires emergency


evaluation from the surgery teams(14).


It is observed that, in most traffic accidents,


the severity rates equal to or below 15 correspond to


around 58%-60% of all events, but an important


percentage of traffic accident victims present trauma


severity ISS ≥16(15-17).
Studies involving trauma severity highlight


pedestrians as the most frequent fatal victims. This


situation is easy to understand because it is a case of


hundreds of kilos of steel against a far smaller number


of kilos of weight, and it is the most mortal type of


traffic accident in the world(10,15).


There is a difference in Brazil in terms of the


type of accidents, with collisions prevailing in


approximately 50% of cases. The proportion of events


varies considerably; for instance, pedestrian-vs-


automobile accidents in Roraima were responsible for


7.1% of all accidents, while they account for 39.5%


and 43.3% in Rio de Janeiro and Amazonas,


respectively(1).


This distinct panorama found in the country


should serve as a guide for preventive and educational


measures in each region.


It is important to emphasize that the mortality


rate for motorcycle users showed the highest increase


from 1996 to 2005: 540%, rising from 0.5 to 3.2 per


100,000 inhabitants. This rapid climb can be


understood due to the increase in the current fleet


(65.3% between 2001 and 2005), whereas the


automobile fleet increased from 142.5 to 165.5 (a


16.1% increase)(1,13).


After this broad review, points of agreement


and disagreement were found regarding the universe


of traffic accident victims. It was found that the national


literature presents a solid body of knowledge about


the epidemiology of external causes in terms of traffic


accidents. Nevertheless, there is a scarcity of studies


that describe the injuries affecting these victims with


greater detail.


The knowledge of this traffic accident reality,


and facts regarding the most frequently affected body


regions, as well as their severity, could contribute to


implement, set up and develop assistance programs


for individuals involved in these accidents, in addition


to providing an analysis of the situation and appoint


the need to perform other studies that would serve


as a reference for the teams working in pre- and intra-


hospital environment, to establish conducts, assign


priority of care, develop protocols, direct human/


material resources, and plan care.


CONCLUSIONS


The analysis of the studies showed that the


most commonly affected body regions in traffic


accident victims are upper/lower limbs, followed by


the head/neck region. In terms of severity, the head/


neck region is highlighted in studies related to severity


Mapping injuries in traffic accident victims…
Calil AM, Sallum EA, domingues CA, Nogueira LS


Rev Latino-am Enfermagem 2009 janeiro-fevereiro; 17(1):120-125
www.eerp.usp.br/rlae




125


and mortality. It is important to emphasize that


numerous studies report the head region as the area


most affected by injuries with AIS equal to or above 4.


Regarding the third most affected body region, studies


differ in identifying the face, thorax, and external


surface regions; in terms of severity, the thoracic


region is highlighted as second. Several studies


emphasize that health teams should double their


attention in accidents in which the thorax and


abdomen regions have been injured or, due to the


trauma mechanism, present potential for injuries in


these body segments, because of their relation to


serious cases of hemorrhage and respiratory arrest.


As to the type of victim, there was no homogeneity


among the studies, varying in terms of the location of


the accident (country) and the analyzed period.


In Brazil, accidents and mortality involving


motorcyclists increased significantly as of 1999,


although the literature reports pedestrians as the most


vulnerable victims. Studies that analyze traffic


accident injury frequency, type and particularities are


scarce in our environment or extremely circumscribed


to a location/municipality, and most choose to focus


on only one type of victim, which makes comparisons


difficult. Further broader (multicentric) studies should


be encouraged.


REFERENCES


1. Mello Jorge MHP, Koizumi MS. Acidentes de trânsito no


Brasil: um atlas de sua distribuição. São Paulo (SP):


ABRAMET; 2007.


2. Organização Mundial de Saúde [homepage na Internet].


Base de Dados de Mortalidade, 2005 [Acesso em 2006


setembro 19]. Disponível em: http://www.WHO.int/WHOSIS.


3. Souza ER, Minayo MCS, Franco LG. Avaliação do processo


de implantação e implementação do Programa de Redução da


Morbimortalidade por Acidentes de Trânsito. Epidemiologia e


Serviços de Saúde 2007 janeiro-março; 16(1):19-31.


4. Ministério da Saúde [homepage na Internet] Brasília:


Ministério da Saúde [Acesso em 2007 outubro 13].


Informações de Saúde. Disponível em http:// w3.


datasus.gov.br/ datasus/datasus.php.


5. Boto GR, Gómez PA, De La Cruz, Lobato RR. Severe head


injury and the risk of early death. J. Neurol. Neurosurg.


Psychiatry 2006 September; 77(9): 1054-9.


6. Atallah AN, Castro AA. Revisão sistemática da literatura


e metanálise: a melhor forma de evidência para tomada de


decisão em saúde e a maneira mais rápida de atualização


terapêutica [Acesso em 2005 maio 15]. Disponível em: http:/


/www.epm.br/cochrane.


7. Association for the Advancement of Automotive Medice –


AAAM. Abbreviated Injury Scale (AIS): 2005. Des Plaines,


Illions; 2005.


8. American College of Surgeons-ACS. Committee on Trauma


. Suporte avançado de vida no trauma-SAVT: Programa para


médicos. Tradução do Programa ATLS. São Paulo; 2004.


9. Henriksson E, Ostron M, Eriksson A. Preventability of


vehicle- related fatalities. Accidental Anal Previous 2001;


33(4):467-75.


10. Calil AM. Natureza da lesão e gravidade do trauma


segundo qualidade das vítimas de acidentes de trânsito de


veículo a motor. [dissertação]. São Paulo (SP): Escola de


Enfermagem da Universidade de São Paulo; 1997.


11. Gennarelli TA, Champion HR, Copes WS, Sacco WJ .


Comparison of mortality, morbidity and severity of 58.713


head injury patients with 114.447 patients with extracranial


injuries. J Trauma 1994 December; 37(6): 962-8.


12. Ott EA, Favaretto ALF, Neto AFPR, Zechin, JG, Bordin, R.


Acidentes de trânsito em área metropolitana da região sul do


Brasil: caracterização das vítimas e das lesões. Rev. Saúde


Pública 1993 outubro; 27(5): 350-6.


13. Oliveira NLB. Fatores associados ao risco de lesões e


óbito de motociclistas envolvidos em ocorrências de trânsito.


[tese]. São Paulo (SP): Escola de Enfermagem da Universidade


de São Paulo USP ; 2008.


14. Vanlar W, Yannis G. Perception of road accident causes.


Accidental Anal Previous 2006; 38 (1):17-25.


15. Liberatti CL, Andrade SM, Soares DA. The new Brazilian


traffic code and some characteristics of victims in southern


Brazil. Inj Prev 2001 September; 7(3):190-3.


16. Elliot MA, Baughan CJ, Sexton BF . Errors and violations


in relation to motorcyclists’ crash risk. Accidental Anal


Previous 2007; 39 (3): 491-9.


17. Calil AM , Pimenta CAM . Relação entre o padrão de


analgesia e região corpórea em pacientes de trauma. Rev


Gauch Enferm 2008; 29 (1). No prelo.


Recebido em: 12.10.2007
Aprovado em: 27.10.2008


Mapping injuries in traffic accident victims…
Calil AM, Sallum EA, domingues CA, Nogueira LS


Rev Latino-am Enfermagem 2009 janeiro-fevereiro; 17(1):120-125
www.eerp.usp.br/rlae




120 MAPPING INJURIES IN TRAFFIC ACCIDENT VICTIMS: A LITERATURE REVIEW Ana Maria Calil1 ...
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