BOOK REVIEWS
special types of trauma and discusses hanging and strangulation, as well as unusual penetrating injuries. This chapter details some unusual circumstances that may be seen in EDs. The remaining chapters cover trauma by bodyareas and also include sections on hand infection, replanta•ion, and trauma in pregnancy. The fourth section, on toxicological emergencies, begins with discussions on general management and gastrointestinal decontamination. Fifty-nine different classes or agents, including mushroom, cigua•era, and scombroid fish poisoning, vitamins, and plant poisonings, are discussed. A unique chapter in this section is a detailed discussion of dystonic reactions. Environmental emergencies are presented in the fifth section. Included are discussions on bites, envenomations, cold and heat, dysbar•sin, with sections on smoke inhalation, electrical injuries, and both radiation and lightning injuries. The chapters on high-altitude illness and high-pressure injection are particularly noteworthy. Section Vl is concerned with pediatrics. The first two chapters deal with resuscitation, and the next discuss16 common presenting signs and symptons in pediatric emergency medicine. As with the first section of the book, this is very informative and useful, both for teaching and for reference. The following two subsections deal with specific diseases and pediatric trauma. These subsections could easily have been published as a stand-alone pediatric emergency medicine text. The seventh and last section encompasses medical emergencies. Beginning with a discussion on resuscitation, this section includes cardiovascular; pulmonary; gastrointestinal; renal, metabolic, and endocrine; infectious disease; neurologic; hematologic and oncologic; allergy-related and immunologic; rheumatologic; dermatologic; and psychiatric emergencies. This section concludes with two unique chapters. The first discusses the medical complications of alcohol abuse. The common pitfalls of this
146/108
I
chapter are particularly poignant and good reading for residents and as reminders to practitioners. The last chapter of the text describes the use of sonography in emergency medicine in pictures and words. This chapter outlines the usefulness and limitations of these techniques and the contributions to ED evaluation. The text focus is entirely clinical emergency medicine and, consequently, there are no EMS or ethics chapters as in the Tint•nail• et al text. The book is very readable, to the point of being enjoyable, and I found it more so than the book by Rosen et al. Unlike Rosen's book, however, there is no chapter on the overall approach to the ED patient and no discussion on death and dying, sections I feel are particularly useful. Overall, I believe the editors accomplished their task and have created a new and useful text. The information presented is timely, and each chapter has an abbreviated list of references that can be used for additional reading and research. The text is useful to residents and their mentors. At the very least, the average practitioner would enjoy the common pitfalls as a very quick review of approaches to a problem. I recommend its addition to your library and residents' reading list. •
Joseph A SalomoneIII, MD, FACEP Departmentof EmergencyMedicine TrumanMedical Center Kansas City, Missouri
Emergency Drug Therapy WG Barsan, MS Jastremski, SA Syverud (eds) 1991, WB Saunders, 672 pages, $75.O0 The renowned editors of this relatively inexpensive textbook have deftly selected a group of distinguished emergency physicians, peppered with other noted specialists, to create a comprehensive yet readable guide to drug therapy. Such a resource book for the emergency medicine clinician has not been
available until now, and this fills the void nicely. The 26 different chapters are divided into two main groups: chapters 1 through 4 review basics of drug therapy, including pharmacokinetics, routes of drug administration, and special consideration to be taken with the pregnant, lactating, or pediatric patient. Chapters 5 through 26 concisely discuss specific classes of drugs ranging from the basics of fluid and electrolyte therapy to plasma and volume expanders and then on through the armamentar•urn of drugs used by our specialty. Each of these later 22 chapters is formatted in the same efficient style, making the book easily usable. After an appropriately short introduction, the chapter authors spell out the "Conditions" for which their specific drug class may be used. Within each "Conditions" section the text is divided into the "Diagnosis" and "Indications for Treatment" subsections, and finally a "Discussion" subsection. Each chapter ends with a complete review of the specific therapeutic agents that have been noted in the chapter. This synopsis of the specific agents includes their mechanism of action, kinetics, metabolism, clinical effects, drug interactions, and even treatment of any iatregenic toxicity. For those readers who are looking for a quick answer in an acute situation, each chapter includes a "Drug Treatment" outline that gives the suggested initial and repeat doses, as well as the endpoint of pharmacological treatment, for first-, second-, and third-line drugs of choice for the emergency conditions. These "Drug Treatment" outlines are just that, outlines; more in-depth information is presented in the text. As with any textbook, some readers may find areas that they believe are inadequate or are not consistent with their lecale's standard of care. Some of the discrepancies include the following. The chapter pertaining to analgesics makes no mention of ketorolac as an effective parenteral, nonsteroidal anti-inflammatory drug, especially in the emergency treatment of renal colic. The sedative-
hypnotic chapter lists atracurium as a fourth-line drug for the control of traumatized or medically unstable adult, but then fails to discuss it in the "Specific Agents" or "Discussion" section of the chapter. The placement of this drug in this section may be confusing as atracurium, a nondepolarizing neuromuscular blocking agent with no central nervous system sedative effects, is not as well known as its cousins vecuronium and pancuronium in many parts of the country. Some confusion may be created by the different infusion rates for phenytoin as it is recommended for convulsive status epilepticus (50 rag/rain)in the anticonvulsant chapterversusthat recommended for ventriculararrhythmias(20 rag/rain) in the discussion of antiarrhythmics. The antidote chapter is very good overall; however, it is already dated, as it makes no mention of the newer orally-active lead chelator dimercaptosuccinic acid (Succimer~). Overall, the authors and editors of this text have done a fine job with a very difficult concept. Although the emphasis is on drug therapy, there is ample clinical information presented on numerous pathologic entities. This prevents their work from reading as a pharmacology textbook. Any textbook, but especially one dealing with pharmaceuticals, is rapidly outdated. Despite this inherent drawback, the comprehensive and easy-to-use EmergencyDrug Therapyis a must for emergency departments. •
FredHarchelroad, Jr, MD, FACEP, DABMT Allegheny GeneralHospital Pittsburgh, Pennsylvania
Goldfrank's Toxicologic Emergencies, ed 4 LR Goldfrank, NE Flomenbaum, NA Levin, et al 1990, Appleton & Lange, 947 pages, $135.00
Toxicologic Emergenciesis another first-rate volume that merits •
ANNALS OF EMERGENCY MEDICINE 21:1 JANUARY 1992
BOOK REVIEWS
space on your referenceshelf. The core of its nearly 1,000 pages is the expected substance-by-substance discussion of case management, from acetaminophenand amphetamines to vitamin A. In addition, quite a few unusualtopics are added. "Diets" examinesproblems associatedwith extreme attempts to lose weight, and "Herbal Preparations" is a brief and handy survey of the growing "alternative" medicine chest and its associated toxicities. The core section, entitled "Case Studies and ProblemSolving in ToxicologicEmergencies,"begins eachtopic with realisticcase presentations. The cases then suggest a series of questions, posed and answered as broadly as possible. Thus, after we hear of a 17-year-old on PCP,the first question is: "What general measuresshould be used for patients with suspecteddruginduced psychoses?"In another chapter, a patient with coma, seizures, and antichelinergic signs is presented,promptingthe question: "What substancesare capable of producing this syndrome?"(One suspects that many of these chapters began as "teaching rounds.") Initially, I found this format a bit
JANUARY 1992
distracting and heavy-handed,especially when trying to quickly dig out specific facts for patient management. But despite the question-andanswer format, the information neededfor patient care is consistently easy to find. The reader is assisted by ample and clearly constructed tables and algorithm flowcharts. Using the book over a few months, I warmed to the authors' approach, especially when readingthrough a chapter at my leisure. The use of cases and the problem-oriented approach bring a much-appreciated focus to the discussion of each topic. The authors clearly want to teach you, which I think is a major asset of the book. In addition to the core management chapters, there are two other large sections. One of these is a 150-page "workbook" with lively case studies and a large number of multiple-choice questions(with a separate answer key). The other, occupying about a quarter of the book, is "A GeneralApproachto Medical Toxicology," almost mini textbook of medicine as seen through the eyes of emergency departmenttoxicology. "He who
21:1 ANNALS OF EMERGENCY MEDICINE
knows toxicology, knows medicine" might be its slogan. For example, a chapter on dermatology surveys the various reaction patterns associatedwith drugs, and presents a large table of plant chemicals causing dermatitis. "Immune Principles" includes an in-depth treatment of the subject of anaphylactic reactions,with a detailed discussion of the use of IV epinephrine(a topic best reviewed before you need to use it). "Pulmonary Principles" briefly deals with such topics as ventilation-perfusion mismatch and A-a gradients as applied to toxicologic patients. Was it wise to attempt this kind of breadth in a toxicology text? A qualified yes: at times the necessary brevity may be a problem,but the overall effect is useful and informative. Takentogether,the "Workbook" and "General Approach" sections allow this bookto qualify as both a reference and a review textbook. Another particularly nice feature is a group of 24 self-contained essays on "Antidotes in Depth" - - deferoxamine, methylene blue, and so on. These are scattered amongthe various chapters, but also listed in a handy separatetable of contents.
Overall,the authors" perspective appearsto clearly arise from an actual immersion in real-world emergencymedicine(as experienced at a big-city teaching institution). I much prefer this to the manytextbooks with seeminglyno coherent perspective at all and no roots in the practice of emergencymedicine. In sum, this is a first-rate reference and a readableway to review the subject. •
David H Lander, MD Emergency Services Montgomery Regional Hospital Blacksburg, Virginia
109/147
I
special types of trauma and discusses hanging and strangulation, as well as unusual penetrating injuries. This chapter details some unusual circumstances that may be seen in EDs. The remaining chapters cover trauma by bodyareas and also include sections on hand infection, replanta•ion, and trauma in pregnancy. The fourth section, on toxicological emergencies, begins with discussions on general management and gastrointestinal decontamination. Fifty-nine different classes or agents, including mushroom, cigua•era, and scombroid fish poisoning, vitamins, and plant poisonings, are discussed. A unique chapter in this section is a detailed discussion of dystonic reactions. Environmental emergencies are presented in the fifth section. Included are discussions on bites, envenomations, cold and heat, dysbar•sin, with sections on smoke inhalation, electrical injuries, and both radiation and lightning injuries. The chapters on high-altitude illness and high-pressure injection are particularly noteworthy. Section Vl is concerned with pediatrics. The first two chapters deal with resuscitation, and the next discuss16 common presenting signs and symptons in pediatric emergency medicine. As with the first section of the book, this is very informative and useful, both for teaching and for reference. The following two subsections deal with specific diseases and pediatric trauma. These subsections could easily have been published as a stand-alone pediatric emergency medicine text. The seventh and last section encompasses medical emergencies. Beginning with a discussion on resuscitation, this section includes cardiovascular; pulmonary; gastrointestinal; renal, metabolic, and endocrine; infectious disease; neurologic; hematologic and oncologic; allergy-related and immunologic; rheumatologic; dermatologic; and psychiatric emergencies. This section concludes with two unique chapters. The first discusses the medical complications of alcohol abuse. The common pitfalls of this
146/108
I
chapter are particularly poignant and good reading for residents and as reminders to practitioners. The last chapter of the text describes the use of sonography in emergency medicine in pictures and words. This chapter outlines the usefulness and limitations of these techniques and the contributions to ED evaluation. The text focus is entirely clinical emergency medicine and, consequently, there are no EMS or ethics chapters as in the Tint•nail• et al text. The book is very readable, to the point of being enjoyable, and I found it more so than the book by Rosen et al. Unlike Rosen's book, however, there is no chapter on the overall approach to the ED patient and no discussion on death and dying, sections I feel are particularly useful. Overall, I believe the editors accomplished their task and have created a new and useful text. The information presented is timely, and each chapter has an abbreviated list of references that can be used for additional reading and research. The text is useful to residents and their mentors. At the very least, the average practitioner would enjoy the common pitfalls as a very quick review of approaches to a problem. I recommend its addition to your library and residents' reading list. •
Joseph A SalomoneIII, MD, FACEP Departmentof EmergencyMedicine TrumanMedical Center Kansas City, Missouri
Emergency Drug Therapy WG Barsan, MS Jastremski, SA Syverud (eds) 1991, WB Saunders, 672 pages, $75.O0 The renowned editors of this relatively inexpensive textbook have deftly selected a group of distinguished emergency physicians, peppered with other noted specialists, to create a comprehensive yet readable guide to drug therapy. Such a resource book for the emergency medicine clinician has not been
available until now, and this fills the void nicely. The 26 different chapters are divided into two main groups: chapters 1 through 4 review basics of drug therapy, including pharmacokinetics, routes of drug administration, and special consideration to be taken with the pregnant, lactating, or pediatric patient. Chapters 5 through 26 concisely discuss specific classes of drugs ranging from the basics of fluid and electrolyte therapy to plasma and volume expanders and then on through the armamentar•urn of drugs used by our specialty. Each of these later 22 chapters is formatted in the same efficient style, making the book easily usable. After an appropriately short introduction, the chapter authors spell out the "Conditions" for which their specific drug class may be used. Within each "Conditions" section the text is divided into the "Diagnosis" and "Indications for Treatment" subsections, and finally a "Discussion" subsection. Each chapter ends with a complete review of the specific therapeutic agents that have been noted in the chapter. This synopsis of the specific agents includes their mechanism of action, kinetics, metabolism, clinical effects, drug interactions, and even treatment of any iatregenic toxicity. For those readers who are looking for a quick answer in an acute situation, each chapter includes a "Drug Treatment" outline that gives the suggested initial and repeat doses, as well as the endpoint of pharmacological treatment, for first-, second-, and third-line drugs of choice for the emergency conditions. These "Drug Treatment" outlines are just that, outlines; more in-depth information is presented in the text. As with any textbook, some readers may find areas that they believe are inadequate or are not consistent with their lecale's standard of care. Some of the discrepancies include the following. The chapter pertaining to analgesics makes no mention of ketorolac as an effective parenteral, nonsteroidal anti-inflammatory drug, especially in the emergency treatment of renal colic. The sedative-
hypnotic chapter lists atracurium as a fourth-line drug for the control of traumatized or medically unstable adult, but then fails to discuss it in the "Specific Agents" or "Discussion" section of the chapter. The placement of this drug in this section may be confusing as atracurium, a nondepolarizing neuromuscular blocking agent with no central nervous system sedative effects, is not as well known as its cousins vecuronium and pancuronium in many parts of the country. Some confusion may be created by the different infusion rates for phenytoin as it is recommended for convulsive status epilepticus (50 rag/rain)in the anticonvulsant chapterversusthat recommended for ventriculararrhythmias(20 rag/rain) in the discussion of antiarrhythmics. The antidote chapter is very good overall; however, it is already dated, as it makes no mention of the newer orally-active lead chelator dimercaptosuccinic acid (Succimer~). Overall, the authors and editors of this text have done a fine job with a very difficult concept. Although the emphasis is on drug therapy, there is ample clinical information presented on numerous pathologic entities. This prevents their work from reading as a pharmacology textbook. Any textbook, but especially one dealing with pharmaceuticals, is rapidly outdated. Despite this inherent drawback, the comprehensive and easy-to-use EmergencyDrug Therapyis a must for emergency departments. •
FredHarchelroad, Jr, MD, FACEP, DABMT Allegheny GeneralHospital Pittsburgh, Pennsylvania
Goldfrank's Toxicologic Emergencies, ed 4 LR Goldfrank, NE Flomenbaum, NA Levin, et al 1990, Appleton & Lange, 947 pages, $135.00
Toxicologic Emergenciesis another first-rate volume that merits •
ANNALS OF EMERGENCY MEDICINE 21:1 JANUARY 1992
BOOK REVIEWS
space on your referenceshelf. The core of its nearly 1,000 pages is the expected substance-by-substance discussion of case management, from acetaminophenand amphetamines to vitamin A. In addition, quite a few unusualtopics are added. "Diets" examinesproblems associatedwith extreme attempts to lose weight, and "Herbal Preparations" is a brief and handy survey of the growing "alternative" medicine chest and its associated toxicities. The core section, entitled "Case Studies and ProblemSolving in ToxicologicEmergencies,"begins eachtopic with realisticcase presentations. The cases then suggest a series of questions, posed and answered as broadly as possible. Thus, after we hear of a 17-year-old on PCP,the first question is: "What general measuresshould be used for patients with suspecteddruginduced psychoses?"In another chapter, a patient with coma, seizures, and antichelinergic signs is presented,promptingthe question: "What substancesare capable of producing this syndrome?"(One suspects that many of these chapters began as "teaching rounds.") Initially, I found this format a bit
JANUARY 1992
distracting and heavy-handed,especially when trying to quickly dig out specific facts for patient management. But despite the question-andanswer format, the information neededfor patient care is consistently easy to find. The reader is assisted by ample and clearly constructed tables and algorithm flowcharts. Using the book over a few months, I warmed to the authors' approach, especially when readingthrough a chapter at my leisure. The use of cases and the problem-oriented approach bring a much-appreciated focus to the discussion of each topic. The authors clearly want to teach you, which I think is a major asset of the book. In addition to the core management chapters, there are two other large sections. One of these is a 150-page "workbook" with lively case studies and a large number of multiple-choice questions(with a separate answer key). The other, occupying about a quarter of the book, is "A GeneralApproachto Medical Toxicology," almost mini textbook of medicine as seen through the eyes of emergency departmenttoxicology. "He who
21:1 ANNALS OF EMERGENCY MEDICINE
knows toxicology, knows medicine" might be its slogan. For example, a chapter on dermatology surveys the various reaction patterns associatedwith drugs, and presents a large table of plant chemicals causing dermatitis. "Immune Principles" includes an in-depth treatment of the subject of anaphylactic reactions,with a detailed discussion of the use of IV epinephrine(a topic best reviewed before you need to use it). "Pulmonary Principles" briefly deals with such topics as ventilation-perfusion mismatch and A-a gradients as applied to toxicologic patients. Was it wise to attempt this kind of breadth in a toxicology text? A qualified yes: at times the necessary brevity may be a problem,but the overall effect is useful and informative. Takentogether,the "Workbook" and "General Approach" sections allow this bookto qualify as both a reference and a review textbook. Another particularly nice feature is a group of 24 self-contained essays on "Antidotes in Depth" - - deferoxamine, methylene blue, and so on. These are scattered amongthe various chapters, but also listed in a handy separatetable of contents.
Overall,the authors" perspective appearsto clearly arise from an actual immersion in real-world emergencymedicine(as experienced at a big-city teaching institution). I much prefer this to the manytextbooks with seeminglyno coherent perspective at all and no roots in the practice of emergencymedicine. In sum, this is a first-rate reference and a readableway to review the subject. •
David H Lander, MD Emergency Services Montgomery Regional Hospital Blacksburg, Virginia
109/147
I
