Political leaders' willingness to use force is central to many explanations of foreign policy and interstate conflict. Unfortunately, existing indicators typically measure one aspect of this general concept, have limited coverage, and/or are not derived independently of leaders' participation in interstate conflicts. We develop a strategy for constructing measures of leaders' underlying willingness to use force with data on their background experiences, political orientations, and psychological traits in a Bayesian latent variable framework. Our approach produces measures of latent hawkishness for all national leaders between 1875 and 2004 that offer advantages over existing proxies along multiple dimensions, including construct validity, predictive validity, and measurement uncertainty. Importantly, our statistical framework allows scholars to build upon our measures by incorporating additional data and altering the assumptions underlying our models.

Blunt, penetrating trauma to the ear, nose, and throat, and related structures are striking. Injuries may range from simple soft tissue wounds to complex injuries of the face, neck, and brain. Proximity of the cervical spine and airway complicate anesthetic management. A multidisciplinary approach is required. Airway control has highest priority in initial care. Management of airway, breathing, and circulation need to be tailored to the patient. Decisions regarding airway management, ventilation strategies, monitoring, and fluid and blood administration should be based on the patient’s condition, clinical setting, and the available personnel, expertise, and equipment.

The Bonhoeffer–van der Pol (BVP) or the FitzHugh–Nagumo (FHN) neuronal model is well known to be a simplified and a tractable model of the Hodgkin-Huxley (HH) model, and preserves several neuronal properties such as an excitability, a refractoriness, a repetitive activity by an external current. This chapter presents the BVP neuronal model and briefly explains the neuronal feature (excitability, refractoriness, repetitive activity, etc.) of the model. It considers the model in the (singular) limit of a parameter and studies the effects of a sinusoidal input on the singular model. The effects of the asymmetry of the model on the bifurcation structures are also analyzed. If the period of the sinusoidal input is long, then the BVP neuron model produces a bursting oscillation, in which an active phase with successive spikes and a silent phase without spikes alternate.

The explosive growth in the demand for wireless communication and information transfer using handsets and personal communication system devices has created the need for major advancements of antenna design as a fundamental part of wireless systems. Variation of antenna length and shape, such as conical and folded, can be used to increase the input impedance and/or bandwidth while maintaining the same basic radiation pattern. Another variation of the dipole/monopole is the sleeve antenna where the feed point is moved away from the ground plane in the case of the monopole. For a rectangular patch, the horizontal electric field along the edges of the patch has the same direction, which results in a maximum broadside radiation pattern. Signal fading in mobile communications is one of the more difficult problems to address in the complex propagation environment that exists in practice. Multiple reflections from stationary structures and moving bodies can cause serious fading in handheld reception systems.

A small-but-growing number of social scientists have in recent years begun to explore the purchase of formalisms and a probability theory originally developed to accommodate nonclassical experimental results in particle physics. Motivated by the desire to explain empirical outcomes that do not fit comfortably with the axioms of rational choice theory—and that are thus related tenets of classical probability theory—these scholars have begun to examine and embrace the theory of probability namesaked for Max Born as a general framework for understanding and modeling choice. Born's (1926) account of probability differs from the familiar, classical context of Kolmogorov both in terms of its mathematical exposition/foundation and with respect to its governing axioms. The Born theory is expressly geometric as opposed to set-theoretic. Its axioms are formalized in the (usually) complex planes of Hilbert spaces, where distances are most generally conceptualized as metrics between (sometimes high-dimensional) spaces as opposed to points. In this framework, certain of Kolmogorov's set-theoretic axioms can be relaxed, and empirical results that do not agree with them can be systematically accommodated.

Fear-conditioned analgesia (FCA) is modulated by brain areas involved in the descending inhibitory pain pathway such as the basolateral (BLA) and central amygdala (CEA). The BLA contains Ca2+/calmodulin-dependent protein kinase II (CaMKII) and parvalbumin (PV) neurons. CEA neurons are primarily inhibitory (GABAergic) that comprise enkephalin (ENK) interneurons and corticotropin-releasing factor (CRF) - neurons that project to the periaqueductal grey. The purpose of our experiment was to determine the pattern of activation of CaMKII/PV and ENK/CRF neurons following the expression of acute pain, conditioned fear, and FCA. A significant reduction was observed in nociceptive behaviors in mice re-exposed to a contextually-aversive environment. Using NeuN and cFos as markers for activated neurons, CaMKII, PV, ENK, or CRF were used to identify neuronal subtypes. We find that mice expressing conditioned fear displayed an increase in c-Fos/CaMKII co-localization in the lateral amygdala and BLA compared to controls. Additionally a significant increase in cFos/CRF co-localization was observed in mice expressing FCA. These results show that amygdala processing of conditioned contextual aversive, nociceptive, and FCA behaviors involve different neuronal phenotypes and neural circuits between, within, and from various amygdala nuclei. This information will be important in developing novel therapies for treating pain and emotive disorders in humans.

INTRODUCTION:Thoracic trauma is the second most prevalent nonintentional injury in the United States and is associated with significant morbidity. Analgesia for blunt thoracic trauma was first addressed by the Eastern Association for the Surgery of Trauma (EAST) with a practice management guideline published in 2005. Since that time, it was hypothesized that there have been advances in the analgesic management for blunt thoracic trauma. As a result, updated guidelines for this topic using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework recently adopted by EAST are presented.METHODS:Five systematic reviews were conducted using multiple databases. The search retrieved articles regarding analgesia for blunt thoracic trauma from January1967 to August 2015. Critical outcomes of interest were analgesia, postoperative pulmonary complications, changes in pulmonary function tests, need for endotracheal intubation, and mortality. Important outcomes of interest examined included hospital and intensive care unit length of stay.RESULTS:Seventy articles were identified. Of these, 28 articles were selected to construct the guidelines. The overall risk of bias for all studies was high. The majority of included studies examined epidural analgesia. Epidural analgesia was associated with lower short-term pain scores in most studies, but the quality and quantity of evidence were very low, and no firm evidence of benefit or harm was found when this modality was compared with other analgesic interventions. The quality of evidence for paravertebral block, intrapleural analgesia, multimodal analgesia, and intercostal nerve blocks was very low as assessed by GRADE. The limitations with the available literature precluded the formulation of strong recommendations by our panel.CONCLUSION:We propose two evidence-based recommendations regarding analgesia for patients with blunt thoracic trauma. The overall risk of bias for all studies was high. The limitations with the available literature precluded the formulation of strong recommendations by our panel. We conditionally recommend epidural analgesia and multimodal analgesia as options for patients with blunt thoracic trauma, but the overall quality of evidence supporting these modalities is low in trauma patients. These recommendations are based on very low-quality evidence but place a high value on patient preferences for analgesia. These recommendations are in contradistinction to the previously published Practice Management Guideline published by EAST.

There is a lack of evidence-based approach regarding the best practice for airway management in patients with a traumatized airway. General recommendations for the management of the traumatized airway are summarized in table 5. Airway trauma may not be readily apparent, and its evaluation requires a high level of suspicion for airway disruption and compression. For patients with facial trauma, control of the airway may be significantly impacted by edema, bleeding, inability to clear secretions, loss of bony support, and difficulty with face mask ventilation. With the airway compression from neck swelling or hematoma, intubation attempts can further compromise the airway due to expanding hematoma. For patients with airway disruption, the goal is to pass the tube across the injured area without disrupting it or to insert the airway distal to the injury using a surgical approach. If airway injury is extensive, a surgical airway distal to the site of injury may be the best initial approach. Alternatively, if orotracheal intubation is chosen, spontaneous ventilation may be maintained or RSI may be performed. RSI is a common approach. Thus, some of the patients intubated may subsequently require tracheostomy. A stable patient with limited injuries may not require intubation but should be watched carefully for at least several hours. Because of a paucity of evidence-based data, the choice between these approaches and the techniques utilized is a clinical decision depending on the patient's condition, clinical setting, injuries to airway and other organs, and available personnel, expertise, and equipment. Inability to obtain a definitive airway is always an absolute indication for an emergency cricothyroidotomy or surgical tracheostomy.

A massive transfusion protocol is increasingly used in trauma patients. However, the ideal ratio of plasma to other factors has been the subject of significant debate.1–5 The current published data and clinical practice are based primarily on retrospective database analyses. The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial,6 the largest multicentered prospective randomized controlled trial to date, compared outcomes in hemorrhaging trauma patients with a 1:1:1 ratio of plasma, platelets, and red blood cells versus a 1:1:2 ratio. Although no mortality difference was found, patients in the 1:1:1 group had fewer deaths from exsanguination and improved hemostasis. The authors of the PROPPR trial have interpreted their findings as favoring a 1:1:1 ratio of plasma, platelets, and red blood cells as the key resuscitative formula in massively hemorrhaging patients when compared with a 1:1:2 ratio. However, we believe that a critical examination of the methodology and conclusions necessitates cautious interpretation of these results. The rationale behind early massive transfusion protocols such as those tested in the PROPPR trial is to rapidly provide blood products in the face of time pressure and clinical uncertainty regarding the extent and future duration of severe bleeding. Ratio-based transfusion is not intended to replace transfusion based on coagulation testing but rather to supplement it with the goal of more effective control of acute trauma coagulopathy and hemorrhagic shock. However, acute trauma coagulopathy is a multifactorial process often initiated by shock-induced tissue hypoperfusion and injury and exacerbated by hypothermia, acidemia, and dilutional coagulopathy after infusion of fluids and blood components.7 Given the multifactorial etiology, preset ratios of blood components may thus have a limited ability to address all types of acute trauma coagulopathy. Fibrinogen is often the first coagulation factor that declines to critical levels in massive bleeding, yet the fibrinogen content of plasma is relatively low compared with cryoprecipitate; therefore, fresh frozen plasma and/or thawed plasma are likely not the best choices for fibrinogen replacement.7,8 Furthermore, studies suggest that a ratio of red blood cells to plasma units varying from 1:1 to 1:2 does not improve rotational thromboelastometry-based coagulation measurements in trauma patients and is not a patient-driven approach.9 Therefore, a ratio-driven transfusion protocol is unlikely to accurately address hemostatic requirements in a hemorrhaging patient. According to prepublication descriptions of the PROPPR design and implementation,10 the study was undertaken primarily to investigate whether in-hospital death from massive truncal hemorrhage could be reduced when a 1:1:1 transfusion ratio was used to achieve rapid hemorrhage control. The hypothesis was that improved resuscitation techniques such as a 1:1:1 ratio and earlier use of platelets would prevent and treat coagulopathy, minimize the use crystalloid fluids, and improve survival. The tenets of hemostatic resuscitation using a massive transfusion protocol permit early mobilization of resources, including blood products, thus reducing logistic barriers to effective care. However, rapid anatomic control of bleeding (e.g., primary surgical hemostasis) is often the most influential factor for survival. Thus, if rapid surgical hemostasis is obtained, should one expect that the early fixed ratio administration of platelets and plasma will have any appreciable effect on fluid management and outcome? This direct effect of surgical hemostasis on outcome may have played a role in the PROPPR results. Both study groups had a similarly small occurrence of massive transfusion, defined as at least 10 units of packed red blood cells in the first 24 hours. If less than one-half of patients receive a massive transfusion (45% of the 1:1:1 group versus 47% of the 1:1:2 group), is it logical to expect a difference in outcomes related to massive transfusion protocols? The inclusion criteria for the study consisted of 2 or more Assessment of Blood Consumption (ABC) criteria that, according to previously published reports, have a sensitivity of 75% to 90% and a specificity of 67% to 88% for determining who will require a massive transfusion.11,12 An alternative inclusion criterion was the perceived need for massive transfusion, but these combined criteria inaccurately predicted massive transfusion in >50% of patients in the PROPPR trial. Although this rate of massive transfusion is comparable to other prospective, randomized trauma trials such as CONTROL and CRASH-2 (Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage),13,14 frontline physicians cannot predict with certainty those patients who will require a massive transfusion and those in whom the surgeon will obtain early control of bleeding. A post hoc analysis of any mortality differences that may have existed in the studied patients who actually did require massive transfusion would help to clarify the effect of transfusion ratios per se. The randomization protocol in the PROPPR study also dictated methodologic differences in product administration beyond that calculated by a difference in resuscitative formulas. Although the ratio of red blood cells to plasma was targeted as the major independent variable, the study methodology dictated that the 1:1:1 group would receive platelets in the initial container sent for the first “round” of transfusion, whereas the 1:1:2 group would receive no platelets in the initial container. Because each unit of pooled platelets was counted as 6 units, everyone in the 1:1:1 group received 6 units of platelets along with the first 6 units of packed red blood cells. In contrast, subjects randomly assigned to the 1:1:2 group who received 9 units of products or less (6 units red blood cells + 3 units plasma) never received platelets at all. By protocol, therefore, patients randomly assigned to the 1:1:2 group would only receive platelets when >9 units of products were administered. This variance necessarily introduced a serious confounder, especially if one includes the volume of plasma given with platelets. This asymmetry in platelet administration between groups can be seen clearly in the results of the PROPPR trial, which reported a median platelet dose of 12 units in the 1:1:1 group but only 6 in the 1:1:2 group (P < 0.001). The plasma difference between the groups (median of 7 vs 5, respectively) was also statistically significant because the 1:1:1 group should have received 1 unit of plasma for every 3 units of product versus 1 unit of every 4 in the 1:1:2 group. In the light of these methodologic limitations, it is important to understand that the median number of transfused red blood cell units did not differ between groups, causing the reader to question whether or not improved hemostasis in the 1:1:1 group was clinically significant. In addition, based on median units transfused, the ratios administered to the 1:1:1 and 1:1:2 groups calculate to 1:1.7:1.3 versus 1:1.2:1.8, respectively, further leading the reader to wonder if the target ratios were actually achieved. Although the median total blood products were the same between the 1:1:1 group and the 1:1:2 group (15 vs 14 units) during the intervention period, patients in the 1:1:2 group received less overall product in 24 hours (19 units) versus the 1:1:1 group (25.5 units). Because there were no differences in mortality between groups, the only positive study outcomes were differences in hemostasis achieved and in death because of exsanguination by 24 hours. Of note, the prespecified clinically meaningful difference in mortality was set at 10%, and death from exsanguination was not mentioned in any of the stated hypotheses or ancillary clinical aims.10 Hemostasis, as judged by unblinded surgeons, was statistically better in the 1:1:1 group, with an absolute difference of 8% (86.1% in 1:1:1 vs 78.1% in 1:1:2). Death from exsanguination differed in the first 24 hours by 5.4% (9.2% in 1:1:1 vs 14.6% in 1:1:2). However, because the median time to mortality from exsanguination was 2.3 hours in the study, it may be misleading to suggest that the resuscitation ratio played a significant role in the creation of hemostasis within this time period. Rather, unexpected differences in the number of survivable injuries may have been present between groups. One could instead infer that if patients did not succumb to early exsanguination from failed surgical control of hemorrhage, primary or secondary 24-hour outcomes would not differ between groups. Because data on anatomic injuries and their severity are not reported, we cannot determine the relative impact of early exsanguination or hemostasis between groups. It is noteworthy that the one transfusion-related mortality was in the 1:1:1 group and attributed to transfusion-associated circulatory overload, a potentially avoidable death. Although the death happened outside the first 24 hours, it is not clear whether this patient actually experienced massive hemorrhage and/or whether the death was a consequence of the products issued during the study. Another critical consideration is that cryoprecipitate administration in the PROPPR study was not controlled. Significant differences were reported in cryoprecipitate use between groups, with the 1:1:2 group receiving more cryoprecipitate. Initial laboratory data demonstrated that only approximately 25% of patients had evidence of even mild coagulopathy (international normalized ratio >1.5 or TEG® [Hemoscope Corp., Niles, IL] r value > 8 minutes), and none had evidence of fibrinogen dysfunction or deficiency. No explanation is available for the variable cryoprecipitate administration to study groups with injuries perceived (although not reported) to be comparable. Such a difference in cryoprecipitate administration is clinically relevant because fibrinogen rapidly declines and fibrinolysis starts within 15 minutes of major blunt trauma. The Prehospital Air Medical Plasma (PAMPer) trial, among others, strongly suggests that fresh frozen plasma and cryoprecipitate should be started by first responders.15 The PROPPR trial did demonstrate that early hemostatic intervention is important in a portion of severely injured patients. All the health care teams caring for severe trauma patients at the 12 participating centers are to be commended for a lower than predicted mortality rate from major trauma when compared with historic controls. Although patients in both arms of the PROPPR study had outcomes substantially better than previous research cohorts, additional unreported results that would aid interpretation are the outcomes in the patients who actually required massive transfusion but survived early exsanguination and if there were any differences as a result of different transfusion protocols. Also not reported in this article are the point-of-care assays that may have been available when the injured patients were presented. Information from these assays may have helped to guide targeted and specific hemostatic therapy without the need for an empiric transfusion ratio. Another limitation of the PROPPR study is that blood pressure management was not addressed. The absence of information on blood pressure management in the PROPPR study also limits its generalizability to all trauma patients. Although theoretically lower mean arterial blood pressures may be useful in decreasing potential bleeding, this strategy may worsen outcomes in patients with severe head injuries.16,17 Furthermore, hypotension and lower blood pressures may also indicate uncontrolled shock that itself is associated with worse outcomes. In addition, because PROPPR subjects were >75% men approximately 34 years of age, clinicians should be cautious in applying these findings to major obstetrical, gastrointestinal, or postcardiotomy hemorrhage. Despite the above limitations, the authors and numerous institutions involved in the PROPPR trial are to be congratulated on their concentrated efforts to study an extremely difficult clinical question in the challenging environment of acute trauma resuscitation. Emergency research with an exception from informed consent, community consultation, and public disclosure are important and often costly considerations that are needed before study initiation.18 Appropriate study end points, trauma epidemiology (e.g., heterogeneous patients with heterogeneous injuries), patient enrollment, and inclusion criteria are also critical in the success of emergency research in trauma care.19 The PROPPR investigators identified clear, unambiguous end points (such as 24-hour and 30-day mortality), performed external data and safety monitoring, navigated a difficult consent issue, using exception from informed consent but performing community consultation with delayed patient or legally authorized representative consent. Finally, funding a 680-patient, multicenter study that uses no proprietary device or pharmaceutical is a major accomplishment. As the medical community struggles to improve local practice and outcomes, we caution providers to avoid the temptation to pool multitrauma patients into an algorithmic treatment plan rather than using well-described patient-centered therapies. Rather than focusing our efforts on finding an ideal resuscitative transfusion formula, we advocate continuous reassessment of ongoing hemostasis changes in individual patients guided by point-of-care coagulation monitoring. This approach turns the massive “transfusion” protocol into a massive “hemorrhage” protocol. The indications and end point of plasma use, platelet administration, and cryoprecipitate could perhaps be better guided by viscoelastic testing than by empiric formulas. Holcomb et al.20 suggest that point-of-care testing using thromboelastography predicts transfusion needs and correlates with mortality. Another dose-guided algorithm for use in trauma patients has been suggested by Johansson et al.,5 which indicates a dose of transfusion therapy that is graded to the degree of hemostatic impairment. Tapia et al.21 have used point-of-care viscoelastic testing in an algorithmic fashion for determining transfusion therapy for trauma patients. Using a before-after design, Tapia et al. found that point-of-care testing resulted in less plasma transfusion in blunt trauma patients receiving >6 units of red blood cells, but no difference in mortality. In patients with penetrating trauma receiving >10 units of red blood cell transfusion, the point-of-care group had a significantly lower mortality.21 This concept is also supported in a pediatric cardiac study published by Nakayama et al.22 where only platelets and plasma were available as hemostatic components. Thus, one is left to surmise about the necessity of either 1:1:1 or 1:1:2 in some patients who could have perhaps been more conservatively managed with strategies using crystalloid, colloid, and/or factor concentrates. In massive trauma, we believe clinicians should seek patient-specific therapies and not pool patients into a one-size-fits-all treatment plan. Overall, ratio-based transfusion is not intended to replace coagulation test-guided care but rather to supplement it in the face of time pressure or clinical uncertainty regarding the extent and future duration of hemorrhage. Point-of-care/laboratory-guided precision resuscitation is the theoretically optimal choice if the results are obtained rapidly, and the necessary blood products and/or pharmacologic treatments are immediately available. The clinical reality is that we have yet to achieve this goal. Rapid, ratio-based delivery of products to the bedside is one reason that patients in both arms of the PROPPR trial had lower than expected mortality. We advocate continuous reassessment of ongoing changes in individual patients guided by point-of-care coagulation monitoring and individualized hemodynamic monitoring.21–24 Rather than focusing on the application of a massive transfusion protocol, it may be more appropriate for clinicians to focus on a massive hemorrhage protocol that addresses patient-specific factors, source control of bleeding, hemostatic monitoring, and the optimization of relevant physiologic parameters. DISCLOSURES Name: Gregory M. Janelle, MD, FASE. Contribution: This author contributed directly to the authorship and editing process for the preparation of this manuscript. No relevant study design, data collection, or data analysis exist for this manuscript. Attestation: Gregory M. Janelle approved the final manuscript and will be the archival author, although there is no relevant database for this manuscript. Conflicts of Interest: None. Name: Linda Shore-Lesserson, MD, FAHA, FASE. Contribution: This author contributed directly to the authorship and editing process for the preparation of this manuscript. Attestation: Linda Shore-Lesserson approved the final manuscript. Conflicts of Interest: Dr. Shore-Lesserson has consultant roles with Haemonetics. Name: Charles E. Smith, MD. Contribution: This author contributed directly to the authorship and editing process for the preparation of this manuscript. Attestation: Charles E. Smith approved the final manuscript. Conflicts of Interest: None. Name: Jerrold H. Levy, MD, FAHA, FCCM. Contribution: This author contributed directly to the authorship and editing process for the preparation of this manuscript. Attestation: Jerrold H. Levy approved the final manuscript. Conflicts of Interest: Jerrold H. Levy serves on Steering Committees for CSL Behring, Grifols. Name: Aryeh Shander, MD, FCCP, FCCM. Contribution: This author contributed directly to the authorship and editing process for the preparation of this manuscript. Attestation: Aryeh Shander approved the final manuscript. Conflicts of Interest: None. This manuscript was handled by: Avery Tung, MD.

Background Non-steroidal anti-inflammatory drugs (NSAIDs), transdermal fentanyl patches, and transmucosal buprenorphine are probably the most commonly used options for providing post-operative analgesia in the early at-home period. However, these require daily administration or are associated with abuse concerns. One of the significant unmet needs in veterinary surgery and pain management is for longer acting opioids for cats to effectively bridge the gap between the in-hospital and at-home recovery periods. A proof of concept study of an extended release formulation of buprenorphine HCL (ER-Bup) was conducted using objective kinetic measures and a unilateral onychectomy model. Using a blinded, randomized, two period crossover design, four cats were allocated to control (saline) or ER-Bup (0.6 mg/kg, subcutaneously [SC]) treatment groups. All animals underwent a unilateral forelimb onychectomy per period with a washout/recovery period in between. Observational pain scores and kinetic data (using a pressure sensitive walkway [PSW]) were collected prior to (baseline) and at intervals for 72 h following surgery. Symmetry indices were derived for kinetic variables (peak vertical force [PVF]; vertical impulse [VI]) of each forelimb for landing following a jump and for walking. A rescue analgesic protocol was in place. Effect of surgery and treatment were evaluated using a mixed model statistical approach. Results No cats required rescue analgesics based on subjective pain score. ER-Bup had a positive influence on subjective pain scores during the 72 h postsurgery ( p = 0.0473). PVF and VI of the operated limb were significantly decreased for both landing ( p < 0.0001 and p < 0.0001) and walking ( p < 0.0001 and p < 0.0001 respectively) compared to control. ER-Bup resulted in significantly decreased asymmetry in limb use during landing (PVF, p < 0.0001; VI, p < 0.0001) and walking (PVF, p = 0.0002, VI, p < 0.0001). The novel use of data collected following a jump from an elevated platform appeared to provide all desired information and was easier to collect than walking data. Conclusion This study demonstrates that SC administration of ER-Bup may be an effective analgesic for a 72 h period postoperatively. Furthermore, landing onto a PSW from an elevated perch may be a useful and efficient way to assess analgesics in cats using a unilateral model of limb pain.

Cardiothoracic trauma represents a significant challenge for the anesthesiologist, and little robust investigational evidence exists to guide management decisions. Injury patterns are potentially diverse and often severe, and mortality rates are second only to those of traumatic brain injury. As such, anesthesiologists must be familiar both with the fundamentals of trauma patient care and considerations unique to cardiothoracic injury. Herein, we discuss anesthetic considerations related to traumatic injury of the heart, great vessels, conducting airways, and lungs. As the rate of respiratory failure and acute respiratory distress syndrome (ARDS) exceeds that of the general trauma population, we then review the relevant fundamental aspects of mechanical ventilation and treatment of ARDS.

Purpose of reviewRecent advances in the understanding of transfusion practices during hemorrhagic shock in trauma have led to early administration of thawed plasma in increased ratios to packed red blood cells and have improved survival in the most severely injured patients. As an appreciation for the sequelae of massive transfusion continues to mature, it is becoming apparent that a more targeted approach to coagulation deficiencies may offer an advantage.Recent findingsFactor concentrate therapy offers the advantage of smaller volumes of resuscitative fluids directed at specific phases of coagulation identified by alternative laboratory assays (e.g., viscoelastic testing). Case reports, animal studies, and retrospective reviews offer encouraging data on the ability of factor concentrates to reverse coagulopathy and reduce blood product usage.SummaryThe use of factor concentrates to target specific phases of coagulation may offer benefit over blood product ratio-driven transfusion. The outcome benefit of factor concentrates, however, has not yet been demonstrated in well powered prospective trials.

Prevention and control of postoperative pain are essential. Inadequate treatment of postoperative pain continues to be a major problem after many surgeries and leads to worse outcomes, including chronic postsurgical pain. Optimal management of postoperative pain requires an understanding of the pathophysiology of pain, methods available to reduce pain, invasiveness of the procedure, and patient factors associated with increased pain, such as anxiety, depression, catastrophizing, and neuroticism. Use of a procedure-specific, multimodal perioperative pain management provides a rational basis for enhanced postoperative pain control, optimization of analgesia, decrease in adverse effects, and improved patient satisfaction.

Our group developed a protocol, entitled Early Appropriate Care (EAC), to determine timing of definitive fracture fixation based on presence and severity of metabolic acidosis. We hypothesized that utilization of EAC would result in fewer complications than a historical cohort and that EAC patients with definitive fixation within 36 h would have fewer complications than those treated at a later time.

Objectives:We developed a protocol to determine the timing of definitive fracture care based on the adequacy of resuscitation. Inception of this project required a multidisciplinary group, including physicians from anesthesiology, general trauma and critical care, neurosurgery, orthopaedic spine, and orthopaedic trauma. The purposes of this study were to review our initial experience with adherence to protocol recommendations and to assess barriers to implementation.Design:Prospective.Setting:Level 1 trauma center.Intervention:Definitive fixation of pelvis, acetabulum, spine, and femur fractures within 36 hours of injury, based on laboratory parameters for acidosis.Main Outcome Measurements:Three hundred five consecutive skeletally mature patients with Injury Severity Score 16 (mean, 26.4) and 346 fractures of the proximal or diaphyseal femur (n = 152), pelvic ring (n = 56), acetabulum (n = 44), and/or spine (n = 94) were treated surgically. Adherence to the protocol was defined as definitive fixation within 36 hours of injury in resuscitated patients. All patients were adequately resuscitated within that time. Patient demographic and injury characteristics, date and time of presentation, and reasons for delay were recorded.Results:Two hundred fifty-one patients (82%) with 287 fractures were treated according to the protocol, whereas 54 patients (18%) with 59 fractures were definitively stabilized on a delayed basis (mean, 90 hours). Delay was not related to patient age, Injury Severity Score, day of week, or time of presentation. Before implementation of this protocol, 76% were treated on a delayed basis, demonstrating improvement for each fracture type: spine (79% of previous patients with delay), pelvis (57%), acetabulum (72%), and femur (22%); all P < 0.0001 for more frequently delayed surgery before the protocol. Surgeon choice to delay the procedure accounted for 67% of reasons for delay. Other reasons included intensivist choice (13%), operating room availability (7.4%), patient choice (3.7%), severe head injury (5.6%), or cardiac issues (3.7%). Our trauma center and surgeons became more accustomed to the protocol and had fewer delays over time; 10% were delayed 2 years after implementation.Conclusions:Management of trauma patients with injury to multiple systems requires teamwork among providers from related specialties and hospital support, in terms of operating room access, with appropriate ancillary personnel and equipment. Our system adjusted quickly to the protocol. Surgeon preference was the most common reason for delayed fixation, but within 24 months, only 10% of fractures were treated on a delayed basis, as long as patients were resuscitated.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Essentials of Trauma Anesthesia provides a concise, practical review of the essential elements in the care of the severely injured trauma patient, including emergency airway management, fluid and blood resuscitation, regional and general anesthesia, and perioperative care. Edited by two of the most experienced trauma anesthesiologists in the USA, with chapters written by experts from leading US and Canadian trauma centers with the highest and most varied caseload of critically injured patients, Essentials of Trauma Anesthesia identifies new trends in surgery and anesthesiology practices that impact on the management of trauma patients. Dedicated chapters address the management of special populations including pediatric, geriatric, burn and pregnant patients. Covering the most important topics in trauma anesthesia, Essentials of Trauma Anesthesia provides anesthesiology trainees and practitioners with a practical basis for managing trauma patients.