Trauma , 7th edition new medical books

TRAUMA
NOTICE
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mended dose or in the contraindications for administration. This recommendation is of particular
importance in connection with new or infrequently used drugs.
TRAUMA
Seventh Edition
Editors
Kenneth L. Mattox, MD
Distinguished Service Professor
Baylor College of Medicine
Michael E. DeBakey Department of Surgery
Chief of Staff
Chief of Surgery
Ben Taub General Hospital
Houston, Texas
Ernest E. Moore, MD
Professor and Vice Chairman
Department of Surgery

University of Colorado at Denver and Health Sciences Center
Bruce M. Rockwell Distinguished Chair of Trauma Surgery
Rocky Mountain Regional Trauma Center
Chief of Surgery
Denver Health Medical Center
Denver, Colorado
David V. Feliciano, MD
Attending Surgeon, Atlanta Medical Center
Atlanta, Georgia
Attending Surgeon, Medical Center of Central Georgia
Macon, Georgia
Professor of Surgery
Mercer University School of Medicine
Macon, Georgia
Adjunct Professor of Surgery
Uniformed Services University of the Health Sciences
Bethesda, Maryland
New York Chicago San Francisco Lisbon London Madrid Mexico City
Milan New Delhi San Juan Seoul Singapore Sydney Toronto
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DEDICATION
The editors of Trauma, Seventh Edition, gratefully dedicate this edition to our five unique
“families”: our spouses, children, grandchildren, and extended families; our trainees, who now
dot the globe—our lasting legacy; our medical schools and academic anchors; our organizations
and associations; and our patients, who continue to teach us so very much.
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Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xix
CONTENTS
SECTION 1
TRAUMA OVERVIEW
1. Kinematics . . . . . . . . . . . . . . . . . . . . . . . . . 2
John P. Hunt, Alan B. Marr, and Lance E. Stuke
2. Epidemiology . . . . . . . . . . . . . . . . . . . . . 18
Thomas J. Esposito and Karen J. Brasel

3. Injury Prevention. . . . . . . . . . . . . . . . . . . 36
Ronald V. Maier and Charles Mock
4. Trauma Systems, Triage, and Transport . . 54
Raul Coimbra, David B. Hoyt, and Vishal Bansal
5. Injury Severity Scoring and
Outcomes Research . . . . . . . . . . . . . . . . . 77
Robert D. Becher, J. Wayne Meredith,
and Patrick D. Kilgo
6. Acute Care Surgery . . . . . . . . . . . . . . . . . 91
Gregory J. Jurkovich
vii
SECTION 2
GENERALIZED APPROACHES TO
THE TRAUMATIZED PATIENT
7. Prehospital Care . . . . . . . . . . . . . . . . . . 100
Jeffrey P. Salomone and Joseph A. Salomone III
8. Disaster and Mass Casualty . . . . . . . . . . 123
Eric R. Frykberg and William P. Schecter
9. Rural Trauma . . . . . . . . . . . . . . . . . . . . . 140
Charles F. Rinker II and Nels D. Sanddal
10. Initial Assessment and Management . . 154
Panna A. Codner and Karen J. Brasel
11. Airway Management . . . . . . . . . . . . . . 167
Eric A. Toschlog, Scott G. Sagraves,
and Michael F. Rotondo
12. Management of Shock . . . . . . . . . . . . . 189
Louis H. Alarcon, Juan Carlos Puyana,
and Andrew B. Peitzman
13. Postinjury Hemotherapy
and Hemostasis . . . . . . . . . . . . . . . . . . . 216

Fredric M. Pieracci, Jeffry L. Kashuk,
and Ernest E. Moore
14. Emergency Department Thoracotomy . . . 236
Clay Cothren Burlew and Ernest E. Moore
15. Diagnostic and Interventional Radiology . . 251
Salvatore J.A. Sclafani
16. Surgeon-Performed Ultrasound
in Acute Care Surgery . . . . . . . . . . . . . . 301
Christopher J. Dente and Grace S. Rozycki
17. Principles of Anesthesia and
Pain Management . . . . . . . . . . . . . . . . . 322
Dirk Younker
18. Infections . . . . . . . . . . . . . . . . . . . . . . . 330
Michael A. West and Daniel Dante Yeh
SECTION 3
MANAGEMENT OF SPECIFIC INJURIES
19. Injury to the Brain . . . . . . . . . . . . . . . . . 356
Alexander F. Post, Thomas Boro,
and James M. Ecklund
20. Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
Petros E. Carvounis and Yvonne I. Chu
21. Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
Robert M. Kellman
22. Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
David V. Feliciano and Gary A. Vercruysse
23. Vertebrae and Spinal Cord . . . . . . . . . . 430
Maneesh Bawa and Reginald Fayssoux
24. Trauma Thoracotomy:
Principles and Techniques . . . . . . . . . . . 461
Kenneth L. Mattox, Matthew J. Wall, Jr.,

and Peter Tsai
25. Lung, Trachea, and Esophagus . . . . . . . 468
Joseph A. DuBose, James V. O’Connor,
and Thomas M. Scalea
26. Heart and Thoracic Vascular Injuries . . . . 485
Matthew J. Wall, Jr., Peter Tsai,
and Kenneth L. Mattox
27. Trauma Laparotomy:
Principles and Techniques . . . . . . . . . . . 512
Asher Hirshberg
28. Diaphragm . . . . . . . . . . . . . . . . . . . . . . 529
Kevin M. Schuster and Kimberly A. Davis
29. Liver and Biliary Tract . . . . . . . . . . . . . . 539
Timothy C. Fabian and Tiffany K. Bee
30. Injury to the Spleen . . . . . . . . . . . . . . . 561
David H. Wisner
31. Stomach and Small Bowel . . . . . . . . . . 581
Lawrence N. Diebel
32. Duodenum and Pancreas . . . . . . . . . . . 603
Walter L. Biffl
33. Colon and Rectal Trauma . . . . . . . . . . . 620
Demetrios Demetriades and Kenji Inaba
34. Abdominal Vascular Injury . . . . . . . . . . 632
Christopher J. Dente and David V. Feliciano
35. Pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . 655
George C. Velmahos
36. Genitourinary Trauma . . . . . . . . . . . . . . 669
Michael Coburn
37. Trauma in Pregnancy . . . . . . . . . . . . . . 709
M. Margaret Knudson and

Daniel Dante Yeh
38. Trauma Damage Control . . . . . . . . . . . . 725
Amy D. Wyrzykowski and David V. Feliciano
39. Upper Extremity . . . . . . . . . . . . . . . . . . 747
Nata Parnes, Peleg Ben-Galim,
and David Netscher
40. Lower Extremity . . . . . . . . . . . . . . . . . . 783
Philip F. Stahel, Wade R. Smith,
and David J. Hak
41. Peripheral Vascular Injury . . . . . . . . . . . 816
Michael J. Sise and Steven R. Shackford
viii Contents
SECTION 4
SPECIFIC CHALLENGES IN TRAUMA
42. Alcohol and Drugs . . . . . . . . . . . . . . . . . 850
Larry M. Gentilello
43. The Pediatric Patient . . . . . . . . . . . . . . . 859
David W. Tuggle and Nathaniel S. Kreykes
44. The Geriatric Patient . . . . . . . . . . . . . . . 874
Jay A. Yelon
45. Ethics of Acute Care Surgery . . . . . . . . . 886
Laurence B. McCullough
46. Social Violence . . . . . . . . . . . . . . . . . . . 890
James W. Davis
47. Wounds, Bites, and Stings . . . . . . . . . . . 896
Charles A. Adams, Jr., Daithi S. Heffernan,
and William G. Cioffi
48. Burns and Radiation . . . . . . . . . . . . . . . 922
Jong O. Lee and David N. Herndon
49. Temperature-Related Syndromes:

Hyperthermia, Hypothermia,
and Frostbite . . . . . . . . . . . . . . . . . . . . . 938
David H. Ahrenholz
50. Organ Procurement for Transplantation . . . 944
Aditya K. Kaza and Max B. Mitchell
51. Rehabilitation . . . . . . . . . . . . . . . . . . . . 950
Paul F. Pasquina, Caitlin L. McAuliffe,
and Kevin F. Fitzpatrick
52. Modern Combat Casualty Care . . . . . . . 964
Jay Johannigman, Peter Rhee, Donald Jenkins,
and John B. Holcomb
53. Genomics and Acute Care Surgery . . . . 991
Grant E. O’Keefe and J. Perren Cobb
54. Trauma, Medicine, and the Law . . . . . . 997
Kenneth L. Mattox and Stacey A. Mitchell
ixContents
55. Principles of Critical Care . . . . . . . . . . . 1006
Raul Coimbra, Jay Doucet, and Vishal Bansal
56. Cardiovascular Failure . . . . . . . . . . . . . 1041
Mary Margaret Wolfe and Fred Luchette
57. Respiratory Insufficiency . . . . . . . . . . . 1055
Jeffrey L. Johnson and James B. Haenel
58. Gastrointestinal Failure . . . . . . . . . . . . 1073
Rosemary A. Kozar and Frederick A. Moore
59. Renal Failure . . . . . . . . . . . . . . . . . . . . 1084
Charles E. Lucas, Michael T. White,
and Anna M. Ledgerwood
60. Nutritional Support and Electrolyte
Management . . . . . . . . . . . . . . . . . . . . 1100
Kenneth A. Kudsk and Caitlin Curtis

61. Multiple Organ Failure . . . . . . . . . . . . . 1128
Angela Sauaia, Frederick A. Moore,
and Ernest E. Moore
SECTION 5
MANAGEMENT OF COMPLICATIONS AFTER TRAUMA
x Contents
SECTION 6
Introduction to the Atlas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1148
Head and Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1149
Thoracic Outlet and Chest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1155
Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1175
Vascular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1192
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1201
ATLAS OF TRAUMA
CONTRIBUTORS
Charles A. Adams, Jr., MD, FACS
Assistant Professor of Surgery
Alpert Medical School of Brown University
Chief
Division of Trauma and Surgical Critical Care
Department of Surgery
Rhode Island Hospital
Providence, Rhode Island
Chapter 47: Wounds, Bites, and Stings
David H. Ahrenholz, MD, FACS
Associate Professor of Surgery
University of Minnesota Medical School
St. Paul, Minnesota
Chapter 49: Temperature-Related Syndromes: Hyperthermia,
Hypothermia, and Frostbite

Louis H. Alarcon, MD
Associate Professor of Surgery and Critical Care Medicine
Medical Director of Trauma Surgery
University of Pittsburgh
Pittsburgh, Pennsylvania
Chapter 12: Management of Shock
Vishal Bansal, MD, FACS
Assistant Professor of Surgery
Assistant Director
Trauma Services
University of California, San Diego
San Diego, California
Chapter 4: Trauma Systems, Triage, and Transport
Chapter 55: Principles of Critical Care
Maneesh Bawa, MD
San Diego Orthopaedic Associates/Mercy Hospital
San Diego, California
Assistant Professor
Chief of Trauma Spine Surgery
Emory University Department of Orthopaedic Surgery
Atlanta, Georgia
Chapter 23: Vertebrae and Spinal Cord
Robert D. Becher, MD
Howard H. Bradshaw Surgical Research Fellow
Department of General Surgery
Wake Forest University School of Medicine
Winston-Salem, North Carolina
Chapter 5: Injury Severity Scoring and Outcomes Research
Tiffany K. Bee, MD
Associate Professor of Surgery

University of Tennessee Health Science Center
Memphis, Tennessee
Chapter 29: Liver and Biliary Tract
Peleg Ben-Galim, MD
Assistant Professor
Department of Orthopedic Surgery
Baylor College of Medicine
Houston, Texas
Chapter 39: Upper Extremity
Walter L. Biffl, MD
Professor of Surgery
Denver Health Medical Center
University of Colorado School of Medicine
Denver, Colorado
Chapter 32: Duodenum and Pancreas
Thomas Boro, MD
Chief Trauma Resident
Department of Surgery
Inova Fairfax Hospital
Falls Church, Virginia
Chapter 19: Injury to the Brain
Karen J. Brasel, MD, MPH
Professor of Surgery, Bioethics and Humanities
Medical College of Wisconsin
Milwaukee, Wisconsin
Chapter 2: Epidemiology
Chapter 10: Initial Assessment and Management
Clay Cothren Burlew, MD
Director
Surgical Intensive Care Unit

Associate Professor of Surgery
Denver, Colorado
Chapter 14: Emergency Department Thoracotomy
Petros E. Carvounis, MD
Assistant Professor
Baylor College of Medicine
Houston, Texas
Chapter 20: Eye
Yvonne I. Chu, MD
Assistant Professor
Baylor College of Medicine
Houston, Texas
Chapter 20: Eye
William G. Cioffi, MD
J. Murray Beardsley Professor and Chairman
Department of Surgery
Alpert Medical School of Brown University
Surgeon-in-Chief
Rhode Island Hospital
Providence, Rhode Island
Chapter 47: Wounds, Bites, and Stings
xi
xii Contributors
J. Perren Cobb, MD, PhD
Director
Critical Care Center
Massachusetts General Hospital
Associate Professor of Anaesthesia and Surgery
Harvard Medical School
Boston, Massachusetts

Chapter 53: Genomics and Acute Care Surgery
Michael Coburn, MD
Professor and Chair
Scott Department of Urology
Baylor College of Medicine
Chief of Urology
Ben Taub General Hospital
Houston, Texas
Chapter 36: Genitourinary Trauma
Panna A. Codner, MD, FACS
Assistant Professor
Department of Surgery
Medical College of Wisconsin
Milwaukee, Wisconsin
Chapter 10: Initial Assessment and Management
Raul Coimbra, MD, PhD, FACS
The Monroe E. Trout Professor of Surgery
Executive Vice-Chairman
Department of Surgery
Chief
Division of Trauma, Surgical Critical Care,
and Burns
Director
Surgical Critical Care Fellowship Program
University of California San Diego School of Medicine
San Diego, California
Chapter 4: Trauma Systems, Triage, and Transport
Chapter 55: Principles of Critical Care
Caitlin Curtis, MD
Nutrition Support Pharmacist

University of Wisconsin Hospital and Clinics
Madison, Wisconsin
Chapter 60: Nutritional Support and Electrolyte Management
James W. Davis, MD, FACS
Professor of Clinical Surgery
University of California, San Francisco, Fresno
Chief of Trauma
Community Regional Medical Center
Fresno, California
Chapter 46: Social Violence
Kimberly A. Davis, MD, FACS, FCCM
Associate Professor of Surgery
Vice Chair for Clinical Affairs
Chief of the Section of Trauma, Surgical Critical Care
and Surgical Emergencies
Department of Surgery
Yale University School of Medicine
New Haven, Connecticut
Chapter 28: Diaphragm
Demetrios Demetriades, MD, PhD, FACS
Professor and Vice-Chairman of Surgery
University of Southern California
Director of Trauma
Division of Emergency Surgery and Surgical Intensive Care Unit
Los Angeles County and University of Southern California
Medical Center
Sierra Madre, California
Chapter 33: Colon and Rectal Trauma
Christopher J. Dente, MD, FACS
Assistant Professor of Surgery

Emory University School of Medicine
Associate Director of Trauma
Grady Memorial Hospital
Atlanta, Georgia
Chapter 16: Surgeon-Performed Ultrasound in Acute Care Surgery
Chapter 34: Abdominal Vascular Injury
Lawrence N. Diebel, MD
Professor of Surgery
Department of Surgery
Wayne State University School of Medicine
Detroit, Michigan
Chapter 31: Stomach and Small Bowel
Jay Doucet, MD, MSc, FRCSC, FACS
Associate Professor of Clinical Surgery
Director
Surgical Intensive Care Unit
University of California, San Diego
San Diego, California
Chapter 55: Principles of Critical Care
Joseph A. DuBose, MD
Major
USAF MC
University of Maryland Medical System
R Adams Cowley Shock Trauma Center
Air Force/C-STARS
Baltimore, Maryland
Chapter 25: Lung, Trachea, and Esophagus
James M. Ecklund, MD, FACS
Chairman
Department of Neurosciences

Inova Fairfax Hospital
Medical Director
Neurosciences
Inova Health System
Professor of Surgery
Uniformed Services University
Professor of Neurosurgery
George Washington University
Professor of Neurosurgery
Virginia Commonwealth University, School of Medicine – Inova
Campus
Falls Church, Virginia
Chapter 19: Injury to the Brain
xiiiContributors
Thomas J. Esposito, MD, MPH
Professor and Chief
Division of Trauma, Surgical Critical Care & Burns
Department of Surgery
Director
Injury Analysis & Prevention Programs
Loyola University Burn & Shock Trauma Institute
Loyola University Stritch School of Medicine
Maywood, Illinois
Chapter 2: Epidemiology
Timothy C. Fabian, MD, FACS
Harwell Wilson Professor and Chairman
Department of Surgery
University of Tennessee Health Sciences Center
Memphis, Tennessee
Chapter 29: Liver and Biliary Tract

Reginald Fayssoux, MD
Eisenhower Medical Center
Rancho Mirage, California
Chapter 23: Vertebrae and Spinal Cord
David V. Feliciano, MD
Attending Surgeon, Atlanta Medical Center
Atlanta, Georgia
Attending Surgeon, Medical Center of Central Georgia
Macon, Georgia
Professor of Surgery
Mercer University School of Medicine
Macon, Georgia
Adjunct Professor of Surgery
Uniformed Services University of the Health Sciences
Bethesda, Maryland
Chapter 22: Neck
Chapter 34: Abdominal Vascular Injury
Chapter 38: Trauma Damage Control
Kevin F. Fitzpatrick, MD
Physiatrist
Inova Fairfax Hospital
Falls Church, Virginia
Major
U.S. Army Medical Corps
Walter Reed Army Medical Center
Washington, District of Columbia
Chapter 51: Rehabilitation
Eric R. Frykberg, MD, FACS
Professor of Surgery
University of Florida College of Medicine

Chief
Division of General Surgery
Shands Jacksonville Medical Center
Jacksonville, Florida
Chapter 8: Disaster and Mass Casualty
Larry M. Gentilello, MD
Professor of Surgery
University of Texas
Texas
Chapter 42: Alcohol and Drugs
James B. Haenel, RRT
Surgical Critical Care Specialist
Department of Surgery
Denver Health Medical Center
Denver, Colorado
Chapter 57: Respiratory Insufficiency
David J. Hak, MD
Professor
Department of Orthopaedic Surgery
Denver Health Medical Center
University of Colorado School of Medicine
Denver, Colorado
Chapter 40: Lower Extremity
Daithi S. Heffernan, MD, AFRCSI
Department of Surgery
Division of Trauma and Surgical Critical Care
Rhode Island Hospital
Assistant Professor of Surgery
Brown University
Providence, Rhode Island

Chapter 47: Wounds, Bites, and Stings
David N. Herndon, MD
Jesse H. Jones Distinguished Chair in Burn Surgery
Professor of Surgery
Chief of Staff
Shriners Hospitals for Children
University of Texas Medical Branch
Galveston, Texas
Chapter 48: Burns and Radiation
Asher Hirshberg, MD, FACS
Professor of Surgery
SUNY Downstate College of Medicine
Director
Emergency Vascular Surgery
Kings County Hospital Center
Brooklyn, New York
Chapter 27: Trauma Laparotomy: Principles and Techniques
John B. Holcomb, MD, FACS
Vice Chair and Professor of Surgery
Chief
Division of Acute Care Surgery
Director
Center for Translational Injury Research
Jack H. Mayfield, M.D. Chair in Surgery
University of Texas Health Science Center
Houston, Texas
Chapter 52: Modern Combat Casualty Care
David B. Hoyt, MD
Executive Director
American College of Surgeons

Chicago, Illinois
Chapter 4: Trauma Systems, Triage, and Transport
John P. Hunt, MD, MPH
Professor of Surgery
Louisiana State University Health Science Center
New Orleans, Louisiana
Chapter 1: Kinematics
xiv Contributors
Kenji Inaba, BS, MS, MD, FRCSC, FACS
Assistant Professor of Surgery
University of Southern California
Medical Director
Surgical Critical Care Fellowship Program
Division of Trauma, Emergency Surgery and
Surgical Intensive Care Unit
Los Angeles and University of Southern California Medical Center
Los Angeles, California
Chapter 33: Colon and Rectal Trauma
Donald Jenkins, MD
Consultant
Division of Trauma, Critical Care and General Surgery
Associate Professor of Surgery
College of Medicine
Medical Director
Trauma Center
Mayo Clinic
Rochester, Minnesota
Chapter 52: Modern Combat Casualty Care
Jay Johannigman, MD
Professor of Surgery

University of Cincinnati College of Medicine
Cincinnati, Ohio
Chapter 52: Modern Combat Casualty Care
Jeffrey L. Johnson, MD
Associate Professor of Surgery
University of Colorado Denver
Denver, Colorado
Chapter 57: Respiratory Insufficiency
Gregory J. Jurkovich, MD
Professor of Surgery
University of Washington
Chief of Trauma
Harborview Medical Center
Seattle, Washington
Chapter 6: Acute Care Surgery
Jeffry L. Kashuk, MD, FACS
Associate Professor of Surgery
University of Colorado
Denver Health Medical Center
Trauma, Acute Care Surgery and Surgical Critical Care
Denver, Colorado
Chapter 13: Postinjury Hemotherapy and Hemostasis
Aditya K. Kaza, MD
Assistant Professor of Surgery
University of Utah and Primary Children’s Medical Center
Salt Lake City, Utah
Chapter 50: Organ Procurement for Transplantation
Robert M. Kellman, MD, FACS
Professor and Chair
SUNY Upstate Medical University

Syracuse, New York
Chapter 21: Face
Patrick D. Kilgo, MS
Senior Associate Faculty
Department of Biostatistics
Emory University School of Public Health
Atlanta, Georgia
Chapter 5: Injury Severity Scoring and Outcomes Research
M. Margaret Knudson, MD
Professor of Surgery
University of California, San Francisco
San Francisco, California
Chapter 37: Trauma in Pregnancy
Rosemary A. Kozar, MD
Professor of Surgery
The University of Texas Medical School at Houston
Houston, Texas
Chapter 58: Gastrointestinal Failure
Nathaniel S. Kreykes, MD
Surgeon
Pediatric Surgical Associates, LTD
Minneapolis, Minnesota
Chapter 43: The Pediatric Patient
Kenneth A. Kudsk, MD
Professor of Surgery
University of Wisconsin-Madison
Madison, Wisconsin
Chapter 60: Nutritional Support and Electrolyte Management
Anna M. Ledgerwood, MD
Professor of Surgery

Wayne State University School of Medicine-Trauma
Medical Director
Detroit Receiving Hospital
Detroit, Michigan
Chapter 59: Renal Failure
Jong O. Lee, MD
Associate Professor of Surgery
Annie Laurie Howard Chair in Burn Surgery
University of Texas Medical Branch
Attending Surgeon
Shriners Hospitals for Children
Galveston, Texas
Chapter 48: Burns and Radiation
Charles E. Lucas, MD
Professor
Department of Surgery
Wayne State University
Detroit, Michigan
Chapter 59: Renal Failure
Fred Luchette, MD
The Ambrose and Gladys Bowyer Professor of Surgery
Loyola University Chicago Stritch School of Medicine
Maywood, Illinois
Chapter 56: Cardiovascular Failure
xvContributors
Ronald V. Maier, MD, FACS
Jane and Donald D. Trunkey Professor and Vice Chair
Department of Surgery
University of Washington
Surgeon-in-Chief

Harborview Medical Center
Seattle, Washington
Chapter 3: Injury Prevention
Alan B. Marr, MD, FACS
Professor of Clinical Surgery
Vice Chairman of Education and Informatics
Louisiana State Univeristy Health Sciences Center at New Orleans
Attending in Trauma and Critical Care
Medical Center of Louisiana in New Orleans
New Orleans, Louisiana
Chapter 1: Kinematics
Kenneth L. Mattox, MD
Distinguished Service Professor
Baylor College of Medicine
Michael E. DeBakey Department of Surgery
Chief of Staff
Chief of Surgery
Ben Taub General Hospital
Houston, Texas
Chapters 24: Trauma Thoracotomy: Principles and Techniques
Chapters 26: Heart and Thoracic Vascular Injuries
Chapters 54: Trauma, Medicine, and the Law
Caitlin L. McAuliffe, BS
Research Assistant
Center for Neuroscience and Regenerative Medicine
Uniformed Services University of the Health Sciences
Bethesda, Maryland
Chapter 51: Rehabilitation
Laurence B. McCullough, PhD
Dalton Tomlin Chair in Medical Ethics and Health Policy

Center for Medical Ethics and Health Policy
Baylor College of Medicine
Houston, Texas
Chapter 45: Ethics of Acute Care Surgery
J. Wayne Meredith, MD
Richard T. Myers Professor and Chair
Department of General Surgery
Director
Division of Surgical Sciences
Wake Forest University School of Medicine
Winston-Salem, North Carolina
Chapter 5: Injury Severity Scoring and Outcomes Research
Max B. Mitchell, MD
Professor of Surgery
University of Colorado at Denver and
Children’s Hospital Colorado Heart Institute
Aurora, Colorado
Chapter 50: Organ Procurement for Transplantation
Stacey A. Mitchell, DNP, MBA, RN, SANE-A, SANE-P
Director
Forensic Nursing Services
Harris County Hospital District
Houston, Texas
Chapter 54: Trauma, Medicine, and the Law
Charles Mock, MD, PhD
Professor
Department of Surgery and Department of Epidemiology
Harborview Injury Prevention and Research Center
University of Washington
Seattle, Washington

Chapter 3: Injury Prevention
Ernest E. Moore, MD
Professor and Vice Chairman
Department of Surgery
University of Colorado at Denver and Health Sciences Center
Bruce M. Rockwell Distinguished Chair of Trauma Surgery
Rocky Mountain Regional Trauma Center
Chief of Surgery
Denver Health Medical Center
Denver, Colorado
Chapter 13: Postinjury Hemotherapy and Hemostasis
Chapter 14: Emergency Department Thoracotomy
Chapter 61: Multiple Organ Failure
Frederick A. Moore, MD
Professor of Surgery
The Methodist Hospital Research Institute
Chief, Division of Acute Care Surgery and Critical Care
The Methodist Hospital
Houston, Texas
Chapters 58: Gastrointestinal Failure
Chapters 61: Multiple Organ Failure
David Netscher, MD
Clinic Professor
Division of Plastic Surgery
Professor
Department of Orthopedic Surgery
Chief of Hand Surgery
Baylor College of Medicine
Houston, Texas
Chapter 39: Upper Extremity

James V. O’Connor, MD, FACS
Trauma Medical Director
CaroMont Health
Gastonia, North Carolina
Chapter 25: Lung, Trachea, and Esophagus
Grant E. O’Keefe, MD
Professor
Department of Surgery
University of Washington
Harborview Medical Center
Seattle, Washington
Chapter 53: Genomics and Acute Care Surgery
Nata Parnes, MD
Director
Tri-County Orthopaedics
Carthage Area Hospital
Carthage, New York
Chapter 39: Upper Extremity
xvi Contributors
Paul F. Pasquina, MD
Colonel
U.S. Army Medical Corps
Chief
Department of Orthopaedics and Rehabilitation
Walter Reed National Military Medical Center
Washington, District of Columbia
Chapter 51: Rehabilitation
Andrew B. Peitzman, MD
Mark M. Ravitch Professor
Executive Vice-Chair

Department of Surgery
University of Pittsburgh
Pittsburgh, Pennsylvania
Chapter 12: Management of Shock
Fredric M. Pieracci, MD, MPH
Assistant Professor of Surgery
Denver Health Medical Center
University of Colorado School of Medicine
Denver, Colorado
Chapter 13: Postinjury Hemotherapy and Hemostasis
Alexander F. Post, MD
Assistant Professor
George Washington University and Virginia Commonwealth University
Pediatric Neurosurgery
Department of Neuroscience
Inova Fairfax Hospital
Falls Church, Virginia
Chapter 19: Injury to the Brain
Juan Carlos Puyana, MD, FACS, FACCP, FRCSC
Director
Global Health – Surgery
Associate Professor Surgery and Clinical Translational Science
University of Pittsburgh
President Pan-American Trauma Society
Pittsburgh, Pennsylvania
Chapter 12: Management of Shock
Peter Rhee, MD, MPH, FACS, FCCM, DMCC
Professor of Surgery
Chief of Trauma, Critical Care, Emergency Surgery
University of Arizona

Tucson, Arizona
Chapter 52: Modern Combat Casualty Care
Charles F. Rinker II, MD, FACS
Adjunct Clinical Professor of Medicine
Montana State University
Bozeman, Montana
Chapter 9: Rural Trauma
Michael F. Rotondo, MD, FACS
Professor and Chair
Department of Surgery
Brody School of Medicine at East Carolina University
Greenville, North Carolina
Chapter 11: Airway Management
Grace S. Rozycki, MD, RDMS, FACS
Professor of Surgery
Emory University School of Medicine and Grady Memorial Hospital
Atlanta, Georgia
Chapter 16: Surgeon-Performed Ultrasound in Acute Care Surgery
Scott G. Sagraves, MD, FACS
Chief
Division of Trauma and Surgical Critical Care
Associate Professor of Surgery
Brody School of Medicine at East Carolina University
Greenville, North Carolina
Chapter 11: Airway Management
Jeffrey P. Salomone, MD, FACS, NREMT-P
Associate Professor of Surgery
Emory University School of Medicine
Deputy Chief of Surgery
Grady Memorial Hospital

Atlanta, Georgia
Chapter 7: Prehospital Care
Joseph A. Salomone III, MD, FAAEM
Associate Professor of Emergency Medicine
University of Missouri Kansas City School of Medicine
EMS Medical Director
Kansas City Fire Department
Kansas City, Missouri
Chapter 7: Prehospital Care
Nels D. Sanddal, MS, REMT-B
President and CEO
Critical Illness and Trauma Foundation
Bozeman, Montana
Chapter 9: Rural Trauma
Angela Sauaia, MD, PhD
Associate Professor of Medicine
Public Health and Surgery
Department of Surgery
University of Colorado Denver, School of Medicine
Aurora, Colorado
Chapter 61: Multiple Organ Failure
Thomas M. Scalea, MD
Physician-in-Chief
R Adams Cowley Shock Trauma Center
Baltimore, Maryland
Chapter 25: Lung, Trachea, and Esophagus
William P. Schecter, MD, FACS
Professor of Clinical Surgery
University of California, San Francisco
San Francisco General Hospital

San Francisco, California
Chapter 8: Disaster and Mass Casualty
Kevin M. Schuster, MD, FACS
Assistant Professor of Surgery
Section of Trauma, Surgical Critical Care and Surgical Emergencies
Department of Surgery
Yale University School of Medicine
New Haven, Connecticut
Chapter 28: Diaphragm
Salvatore J.A. Sclafani, MD
Professor and Chairman of Radiology
Professor of Clinical Surgery and Clinical Emergency Medicine
State University of New York Health Science Center at Brooklyn
Brooklyn, New York
Chapter 15: Diagnostic and Interventional Radiology
xviiContributors
Steven R. Shackford, MD
Professor of Surgery Emeritus
University of Vermont School of Medicine
Director Trauma Graduate Medical Education
Scripps Mercy Hospital
San Diego, California
Chapter 41: Peripheral Vascular Injury
Michael J. Sise, MD, FACS
Clinical Professor of Surgery
UCSD School of Medicine
Trauma Medical Director
Scripps Mercy Hospital
San Diego, California
Chapter 41: Peripheral Vascular Injury

Wade R. Smith, MD, FACS
Professor
Department of Orthopaedics
University of Colorado School of Medicine
Englewood, Colorado
Chapter 40: Lower Extremity
Philip F. Stahel, MD, FACS
Professor of Orthopaedics and Neurosurgery
University of Colorado (CU)
School of Medicine
Denver Health Medical Center
Denver, Colorado
Chapter 40: Lower Extremity
Lance E. Stuke, MD, MPH
Assistant Professor of Surgery
Department of Surgery
Louisiana State University Health Science Center
New Orleans, Louisiana
Chapter 1: Kinematics
Eric A. Toschlog, MD, FACS, FCCM
Associate Professor of Surgery
Director
Surgical Critical Care
Brody School of Medicine at East Carolina University
Greenville, North Carolina
Chapter 11: Airway Management
Peter Tsai, MD
Assistant Professor of Cardiothoracic Surgery
Michael E. DeBakey Department of Surgery
Baylor College of Medicine

Staff Surgeon
Ben Taub General Hospital
Houston, Texas
Chapters 24: Trauma Thoracotomy: Principles and Techniques
Chapters 26: Heart and Thoracic Vascular Injuries
David W. Tuggle, MD
Chief
Pediatric Surgery
The University of Oklahoma College of Medicine
Oklahoma City, Oklahoma
Chapter 43: The Pediatric Patient
George C. Velmahos, MD, PhD, MSEd
John F. Burke Professor of Surgery
Chief
Division of Trauma, Emergency Surgery, and Surgical Critical Care
Harvard Medical School
Massachusetts General Hospital
Boston, Massachusetts
Chapter 35: Pelvis
Gary A. Vercruysse, MD
Assistant Professor of Surgeon
Emory University School of Medicine
Co-Director
Burn Center
Attending Surgeon
Grady Memorial Hospital
Atlanta, Georgia
Chapter 22: Neck
Matthew J. Wall, Jr., MD
Professor of Surgery

Michael E. DeBakey Department of Surgery
Baylor College of Medicine
Deputy Chief of Surgery/Chief of Thoracic Surgery
Ben Taub General Hospital
Chairman of the Executive Medical Board
Ben Taub General Hospital
Houston, Texas
Chapters 24: Trauma Thoracotomy: Principles and Techniques
Chapters 26: Heart and Thoracic Vascular Injuries
Michael A. West, MD, PhD, FACS, FCCM
Professor and Vice Chair
Department of Surgery
University of California, San Francisco
Chief of Surgery
San Francisco General Hospital
San Francisco, California
Chapter 18: Infections
Michael T. White, MD
Assistant Professor of Surgery & Director
Burn Center
Detroit Receiving Hospital
Department of Surgery
Detroit Medical Center/Wayne State University
Detroit, Michigan
Chapter 59: Renal Failure
David H. Wisner, MD
Professor and Chairman
Department of Surgery
University of California, Davis
Sacramento, California

Chapter 30: Injury to the Spleen
Mary Margaret Wolfe, MD
Assisstant Clinical Professor of Surgery
University of California, San Francisco - Fresno
Fresno, California
Chapter 56: Cardiovascular Failure
xviii Contributors
Amy D. Wyrzykowski, MD
Assistant Professor of Surgery
Emory University School of Medicine
Grady Memorial Hospital
Atlanta, Georgia
Chapter 38: Trauma Damage Control
Daniel Dante Yeh, MD
Clinical Instructor
Harvard Medical School
Massachusetts General Hospital
Boston, Massachusetts
Chapter 18: Infections
Chapter 37: Trauma in Pregnancy
Jay A. Yelon, DO, FACS, FCCM
Chairman
Department of Surgery
Lincoln Medical Center
Bronx, New York
Chapter 44: The Geriatric Patient
Dirk Younker, MD
Shelden Professor and Vice-Chairman
Department of Anesthesiology and Perioperative Medicine
University of Missouri at Columbia

Chapter 17: Principles of Anesthesia and Pain Management
PREFACE
Almost 30 years ago, two ambitions and competitive surgeons,
both of whom had received some specialized advanced training
in cardiovascular surgery and surgical research, were acquiring
reputations in the exploding field of “trauma.”
Physicians and physiologists have been interested in the
field of trauma for thousands of years, as manifest by the
earliest of surgical writings, the Edwin Smith Surgical
Papyrus, in which almost all case studies focused on the
injured patient. The explosion of interest in trauma during
the 1970s and 1980s was brought about by the simultaneous
juxtaposition of many factors:
• EMS development
• Emergency medicine as a specialty
• Critical care as a discipline
• Increased sophistication in human physiological
monitoring
• Advances in blood banking and hemotherapy
• Advances in vascular surgery
• Surgeons returning from the Vietnam conflict
• Broadening the scope of military medicine via the
Uniformed Services University of the Health Sciences
• Last, but far from least, a large group of young, aggressive,
eager surgeons who enjoyed the challenge of taking care of
acutely injured patients with severe anatomic and
physiological derangements
During the 1970s and early 1980s, trauma textbooks available
to an aspiring academic surgeon or a practicing community
surgeon seeking to master new techniques were few and rather

limited in scope. Most recommendations contained therein
were based on “expert opinion” and trial and error, rather than
any evidence-based approach. Injury classification was in its
infancy, and quality management matrix analyses had yet to be
described. Almost simultaneously, Doctor Kenneth Mattox, in
Houston, and Doctor Ernest Eugene (Gene) Moore, in Denver,
recognized “there has to be a better way and a better textbook.”
Doctors Moore and Mattox, independently and unbeknownst
to each other, began to construct outlines for a practical trauma
book employing the leading “trauma surgeons” of the day to
contribute.
While both were in the challenging “convincing stages” with
their respective publishers, they were assembling a group of
authors to participate in their respective endeavors. At this
point, they discovered, they were pursuing similar projects and
recruiting similar authors. A major merger followed, and at our
initial meeting, the current format for the book Trauma was
born. David Feliciano was invited to be the third editor, and
the legacy began. We agreed to rotate the first editor spot with
each subsequent edition, and the subsequent six editions are
history. During the past 30 years, Trauma has been the
dominant textbook in its field throughout the world. It led in
the fields of surgical critical care and acute care surgery, long
before these were disciplines. This Seventh Edition marks a
milestone in a textbook that continues to be the best seller in
its field and have the same three medical editors.
Since the mid-1980s, we have seen many changes in our
society, medicine, and surgery, in general. HIV and AIDS
introduced new immunological and treatment dilemmas.
Inflammatory mediators, cytokines, and immunomodulation

have grown into scientific fields, all their own. The wars in the
Middle East have underscored the contemporary changes in
trauma management. We have witnessed the emergence of
damage control surgery and staged treatment. The most
pronounced aspect of this concept is the ability to transport
combat causalities across continents after initial damage control
treatment, administer intermediate treatment in a European
military hospital, and then transport, again, in a literal flying
ICU. During the growth and development of Trauma,
trauma center verification, designation, and recognition have
become widespread. The terms Level I, Level II, and Level III
Trauma Centers are now commonplace, and society expects
every major city to have appropriate trauma treatment capability.
Tenets of aggressive crystalloid resuscitation, precontrol
elevation of the blood pressure, and other traditional aggressive
resuscitation cultures have changed dramatically.
Each edition of Trauma is different from the previous one.
In preparing for the Seventh Edition and this preface, I
reviewed each edition, chapter by chapter. For this edition, as
in previous ones, we have invited new authors for many
chapters, and we requested that the number of references be
reduced to less than 50, when feasible for the subject, with both
historic and recent citations. We have again attempted to avoid
duplication of a subject or conflicting opinion, recognizing that
this is not always possible when we also ask that each author
make original contributions.
For this edition, we are very excited about the inclusion of a
Trauma Atlas of anatomic drawings and recognized surgical
approaches. The three editors selected the drawings we believe
best illustrate our current best practice for exposure and

reconstruction. The descriptors with each drawing are short
and succinct.
Finally, and most importantly, the authors acknowledge the
assistance of many people who make it possible to successfully
accomplish this major endeavor, edition after edition. We are
grateful to the authors who have contributed their knowledge,
experience, writing talent, and valuable time. The expertise of
the support personnel at all levels at McGraw-Hill Publishers is
essential and appreciated at each step for each edition. Each
xix
xx
editor has office assistants who have performed many tasks,
from interacting with authors to pushing the editors to meet
deadlines. Mary Allen, in Kenneth Mattox’s office, Jo Fields in
E. Eugene (Gene) Moore’s office, and Samantha Buckner in
David Feliciano’s office all worked diligently to support this
project. As assistant to the senior editor of the Seventh Edition,
Mary Allen was tireless in coordinating the work of editors and
authors to bring this project to fruition. Mary was present at
Preface
the very first concept formulation meeting, when Trauma
was just a dream, and has been present at all editorial meetings
since. Thank you, Mary, for your significant efforts in this and
all previous editions of Trauma.
Kenneth L. Mattox, MD
Ernest E. Moore, MD
David V. Feliciano, MD
SECTION 1
TRAUMA OVERVIEW
CHAPTER 1

Kin·e·mat·ics ( kn-mtks) n : The branch of mechanics that deals
with pure motion without reference to the masses or forces
involved in it. From Greek knma , knmat- , movement.
1
As can be presumed from the derivation of the word kine-
matics, its essence revolves around motion. All injury is
related to the interaction of the host and a moving object.
That object may be commonplace and tangible, such as a
moving vehicle or speeding bullet or more subtle as in the case
of the moving particles and molecules involved in injury from
heat, blasts, and ionizing radiation. Newtonian mechanics,
the basic laws of physics, and the anatomic and material prop-
erties of the human body explain many of the injuries and
injury patterns seen in blunt and penetrating trauma. Injury
is related to the energy of the injuring element and the inter-
action between that element and the victim. Although most
patients suffer a unique constellation of injuries with each
incident, there are quite definable and understandable energy
transfer patterns that result in certain predictable and specific
injuries. Knowing the details of a traumatic event may aid the
treating physician to further investigative efforts to uncover
occult but predictable injuries.
This chapter has been organized in a stepwise fashion.
First, the basic laws of physics and materials that dictate the
interaction between the victim and the injuring element are
reviewed. This is followed by a more detailed examination
of penetrating and blunt trauma and a synopsis of mechanisms
specific to organs and body regions. It is hoped that
this will offer the reader a better understanding of specific
injury patterns, how they occur, and which injuries may

result.
BASIC PRINCIPLES
Newton’s Laws, Impulse, ■
Momentum, Energy and Work,
Elastic and Inelastic Collisions
Newton’s first law states that every object will remain at rest or
in uniform motion in a straight line unless compelled to change
its state by the action of an external force. This is the definition
of inertia. Newton’s second law builds on the first and further
defines a force ( F ) to be equal to the product of the mass ( m )
and acceleration ( a ).
F ϭ ma.
The application of a force does not occur instantaneously,
but over time. If we multiply both sides of the above equation
by time
∫Fdt ϭ ma ( t ).
The product of force and time is known as impulse and
multiplying acceleration by time yields velocity. Momentum ( p )
is defined to be the mass ( m ) of an object times its velocity ( v ).
p ϭ mv ,
hence
impulse ϭ change in momentum.
The important fact is that a force or impulse will cause a
change in momentum and, likewise, a change in momentum
will generate a force.
2
This folds into Newton’s third law, which
Kinematics
John P. Hunt, Alan B. Marr, and Lance E. Stuke
2

3
CHAPTER XCHAPTER 1
Kinematics
passenger compartment. If the momentum of car A was
greater than that of car B by having a greater mass or velocity,
the resultant mass C will have momentum in the previous
direction in which car A was traveling.

In T-bone type crashes the directions of the momentum of
cars A and B are perpendicular. Therefore, in the momentum
axis of car A, car B has 0 momentum and, in the momentum
axis of car B, car A has no momentum. The conglomerate C
conserves momentum in both the A and B axes with the resul-
tant direction as shown in Fig. 1-1(B) . As a consequence, the
changes in momentum and force generated are far less than
that of a head-on collision. Also, C continues to have a veloc-
ity and, as such, kinetic energy. This means that some of the
initial kinetic energy was not converted to work, and less
damage to the automobiles will occur. In general, the closer to
a head-on collision the greater the change in momentum and,
thus, the greater the force generated.
In rear-end collisions the momentum of both cars is typi-
cally in the same direction, Fig. 1-1(C) . Therefore, the changes
states that for every action or force there is an equal and oppo-
site reaction.
3
For instance, when two objects of equal velocity
and mass strike each other, there velocities are reduced to zero
(at the moment of impact). This change in velocity and, hence,
momentum was caused by each object applying a force to the

other. During impact the forces are equal and opposite.
Recalling Newton’s second law, a force is associated with a
change in momentum. In this system, the net force is zero and,
therefore, the change in momentum is zero. This illustrates the
law of conservation of momentum. The total momentum of a
system will remain constant unless acted upon by an external
force. The momentum of this two object system is the same
after a collision as it was prior to impact.
4
The next important basic principles are those of work and
energy. Work ( W ) is defined as a force exerted over a distance
and is frequently written as
W ϭ ∫ Fdx ,
with F ϭ ma and a ϭ vdv / dx
W ϭ ∫ mvdv / dx ( dx ),
which after integration yields the familiar formula for kinetic
energy: 1/2 mv
2
W ϭ 1/2 mv
2
2
Ϫ 1/2 mv
1
2
.
Therefore, the work being done by a moving object, which
interacts with a second object, equals the kinetic energy of the
first object prior to doing work minus the kinetic energy after
the interaction. In other words, the work done is equal to the
change in kinetic energy of the first object.

5
When this interac-
tion sets the other body in motion, the second body now has
kinetic energy of its own, equal to the work done. James Joule
described the first law of thermodynamics in 1840, which sim-
ply states that energy can be neither created nor destroyed.
6
Interactions in which both momentum and energy are con-
served are termed elastic.
In trauma most collisions are inelastic. Inelastic collisions
conserve momentum, but not kinetic energy. In these instances
the kinetic energy “does work” in the deformation of materials
even to the point where objects can conglomerate and form a
single object. This is the hallmark of the inelastic collision. This
energy transfer or work done is what is typically responsible for
the injury sustained by the host.
Energy transfer and momentum conservation can be illus-
trated in the collision of two cars. Fig. 1-1(A) represents a
head-on collision of two cars with equal mass and velocity
and, thus, equal kinetic energy and momentum. The momen-
tums are equal, but in opposite directions. Thus, the total
momentum for the system is 0 prior to the crash and, by the
law of conservation of momentum, must be 0 after the crash.
Upon impact, both cars will come to rest. It is as if one of the
cars struck an immovable wall. Recalling Newton’s second
and third laws, this sudden change in momentum represents
a force, which is equally applied to both cars. Because the
final velocity is 0, the final kinetic energy is 0, meaning that
all the kinetic energy has been converted to work that stops
the other car and causes deformation such as breaking glass,

bending metal, and causing physical intrusion into the
FIGURE 1-1 Energy and momentum available in various motor
vehicle crash scenarios. (A) Frontal collisions have the greatest
change in momentum over the shortest amount of time and
hence the highest forces generated. (B) T-bone collision. When
cars A and B collide their resultant momentum directs them
toward their final position C; the individual momentums in the x
and y axis are dissipated over a greater time resulting in smaller
forces then head-on collision. (C) Rear-end collision. Since these
vehicles move in the same direction the change in momentum
and forces generated are smaller.
A
A
C
C
C
B
A
C
B
B
A. Frontal collisions
B. T-bone collision
C. Rear-end collision
SECTION X
4
Trauma Overview
SECTION 1
TABLE 1-1 Velocity and Kinetic Energy Characteristics
of Various Guns

Caliber
Velocity
(ft/s)
Muzzle Energy
(ft-lb)
Handguns
0.25 in.
0.32 in.
0.357 in.
0.38 in.
0.40 in.
0.44 in.
0.45 in.
9 mm
10 mm
810
745
1,410
855
985
1,470
850
935
1,340
73
140
540
255
390
1,150

370
345
425
Long guns/military weapons
0.243 Winchester
M-16
7.62 NATO
Uzi
AK47
3,500
3,650
2,830
1,500
3,770
1,725
1,185
1,535
440
1,735
in momentum and resultant forces generated are typically small
as is the conversion of kinetic energy to work. These principles
apply to all collisions whether they are a bullet penetrating a
victim, a car hitting a pedestrian, or a driver impacting the
windshield.
Penetrating Trauma and Ballistics ■
Although the above principles were elaborated in the setting of
blunt trauma, they are equally applicable to penetrating trauma.
The study of ballistics details the energy of projectiles as they
leave the firearm and the energy transfer once the bullet strikes
the victim. Theodore Kocher first proposed that the kinetic

energy possessed by the bullet was dissipated in the four follow-
ing ways: namely, heat, energy used to move tissue radially
outward, energy used to form a primary path by direct crush of
the tissue, and energy expended in deforming the projectile.
7
Despite limited techniques for studying ballistics, Kocher was
for the most part correct. Our more extensive knowledge of the
behavior of projectiles in a host comes from the observed per-
formance of bullets in gelatin, which has properties similar to
that of muscle and is thought to reflect the way in which energy
is transferred through tissue. From such experiments several
characteristics of a projectile piercing tissue have been described.
These include the following: (a) penetration (the distance the
projectile passes through tissue is reflected in the distance from
the cut edge of the gelatin block to where the projectile comes
to rest); (b) fragmentation (the pattern is assessed by biplaner
x-rays and the degree reflected in the difference of the weight of
the prefired projectile minus the weight of the collected
fragments); (c) permanent cavity (the tissue disintegrated by
direct contact with the missile and preserved in the gelatin);
and (d) temporary cavity (the amount of “stretch” caused by the
passing projectile). This is reflected by the distance from the
edge of the permanent cavity to the outer perimeter of
the cracks within the gelatin.
8
The performance of the bullet and the injury sustained is
reliant upon velocity, construction of the bullet, and composi-
tion of the target.
9
The energy and construction characteristics

of the projectile will be discussed here while target properties
will be reviewed in the section on biomaterials. The prominent
18th-century surgeon John Hunter stated, “If the velocity of the
ball is small, then the mischief is less in all, there is not so great
a chance of being compounded with fractures of bones etc.”
10
This astute observation reflects the exponential importance of
velocity in determining the amount of kinetic energy that a
particular projectile is capable of transmitting to a given target
(kinetic energy ϭ 1/2 mv
2
). As such, high-velocity missiles will
generally cause more tissue destruction than their lower velocity
counterparts. The velocities and kinetic energies
11 , 12
of common
handguns and rifles are listed in Table 1-1 .
The amount of energy imparted (or work) to the tissue by a
projectile is equal to the kinetic energy of the missile as it enters
the tissue minus the kinetic energy as it leaves the tissue. Bullets
are extremely aerodynamic, causing little disturbance while pass-
ing through the air. To some extent, this is similar in tissue (i.e.,
if the projectile moves with the point forward and passes in and
out of the tissue, only a small portion of its kinetic energy will
be transferred to the target). The characteristics of damage cre-
ated along the track of a bullet are divided into two components,
the temporary and the permanent cavities. The temporary cavity
is the momentary stretch or movement of tissue away from the
path of the bullet. This could be construed as an area of blunt
trauma surrounding the tract of the projectile. The temporary

cavity increases in size with increasing velocity. The largest por-
tion of the temporary cavity is on the surface where the velocity
of the striking missile is the greatest.
12
The concept of the tem-
porary cavity has been used to advocate excessive tissue debride-
ment in high-velocity wounds. In truth, postinjury observation
of wound healing and animal experiments involving microscopic
examination of tissue in the temporary cavity demonstrate that
the momentary stretch produced does not usually cause cell
death or tissue destruction.
13
As such, debridement of high-
velocity injuries should be confined to obviously devitalized tis-
sue. Bullets can be constructed to alter their performance and
increase the permanent cavity after they strike their target. This
can be enhanced in four ways that all work by increasing the
surface area of the projectile–tissue interface that facilitates the
transfer of kinetic energy to the target. These include the follow-
ing: (a) yaw, the deviation of the projectile in its longitudinal axis
from the straight line of flight; (b) tumbling, the forward rota-
tion around the center of mass; (c) deformation, a mushrooming
of the projectile that increases the diameter of the projectile, usu-
ally by a factor of 2, increases the surface area, and, hence, the
tissue contact area by four times; hollow point, soft nose, and
dum–dum bullets all promote deformation; and (d) fragmenta-
tion, in which multiple projectiles can weaken the tissue in
multiple places and enhance the damage rendered by cavitation.
This usually occurs in high-velocity missiles. Nonfragmenting
bullets will have a deeper penetration, whereas a fragmented