British Journal of Anaesthesia 89 (3): 530-3 (2002)

Book Reviews
Problems in Anesthesia Series. L. A. Fleisher and D. S. Prough
(editors-in-chief). Traumacare. R. P. Dutton (guest editor)
Published by Lippincott, Williams and Wilkins, Philadelphia.
Pp. 423; indexed; illustrated.

LMA is the property of Intavent Limited.

Accident and Emergency Diagnosis and Management. 4th Edn.

Anthony F. T. Brown Published by Arnold, London. Pp. 442;
indexed; illustrated. Price 18.99. ISBN 0340807202.
This pocket-sized handbook is aimed at senior house officers in
emergency medicine. The author promises 'practical didactic
advice' on managing 'every patient, however unusual, complex or
unexpected the presentation'. By and large, he delivers on this
promise.
The book is comprehensive and concise. Basic medical and
surgical emergencies are adequately covered. Critical points in
consolidating a diagnosis are followed by a clear outline of
management priorities for all common emergency conditions. The
section on administrative and legal considerations is excellent. It
covers dealing with the police, consent to treatment, and many
other difficult issues. All junior doctors should read this chapter
before starting work in an Accident and Emergency (A&E)
department. It would go a long way towards keeping them out of
trouble. The book is well indexed and cross-referenced. Webbased resources are included, as are contact numbers for relevant
organizations, such as the UK National Poisons Centre.

The Board of Management and Trustees of the British Journal of Anaesthesia 2002

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This book is part of the continuing Problems in Anesthesia series

published quarterly by Lippincott, Williams and Wilkins. The text
is detailed and scholarly and is divided into 12 sections, which
cover most of the interface the practising anaesthesiologist has
with the increasingly important field of trauma care.
The information is presented in classic American monograph
style and is generally readable, although the font size in some of
the reduced diagrams had this reviewer reaching for his number
two spectacles. Doubtless, younger eyes will fare better but may
desire more use of the text box in future volumes of the series to
present key synopses, particularly since there are no detailed
summaries of chapter contents.
The contributors are leading experts in the field and are almost
all from the United States. Although authoritative, this selection
gives only a partial view of the involvement of anaesthetists in
trauma care worldwide, particularly in Europe where they are
routinely involved in prehospital emergency care. The role of
anaesthetists in this text is confined to involvement with the
progression of the patient through hospital. Field and disaster
anaesthesia are not considered.
The guest editor and many of the contributors come from the
Baltimore Shock Trauma Center, which has done so much to
further advancement in this field. The text is presented in a
multidisciplinary way, but there is a logical progression of the
management of the trauma patient from the emergency room right
through to the intensive care unit.
Trauma is now the main cause of death in certain parts of the
world, particularly in the younger age groups, and the best
management is gained by the trauma team approach. The key role
of the anaesthetist in this team is emphasized from the outset and
there is a major central chapter given over to the prioritizing of
surgery for the trauma patient. Here the anaesthetist plays an
essential role as the 'gatekeeper' of the operating theatre, and has
a large responsibility for ensuring correct resuscitation measures
have been taken and that surgery for life-threatening injuries is
conducted first.
The early chapters of the text concern the assessment and early
management of the trauma patient and follow essentially the wellestablished protocols set out by the ATLS course developed by the
American College of Surgeons. Despite the relative clinical
rigidity of this approach, there is sensible council about the need
for dynamic and integrated assessment and resuscitation, and
advice on when it is necessary to break the rules of the ATLS
system.
Airway and ventilation management are rather loosely entwined
in the text and greater emphasis could have been given to the need
for effective ventilation as an immediate reflex following
establishment of the airway. Techniques of IPPV are given only
cursory treatment and confined to the use of the bag valve mask.
The valuable role of the portable automatic ventilator is absent,
possibly because it has been more widely used in emergency
medicine in countries other than the United States.
Airway management is rightly given detailed treatment with
good discussion of devices such as the LMA* and Combitube.
Curiously, the essential technique of cricothyroidotomy is

relegated to the practice of the emergency physician, but should

be firmly within the capabilities of the trauma anaesthetist.
Cervical spine management is given careful treatment in the
airway section.
There follows a good overview of the theoretical and practical
aspects of the management of traumatic shock, with a clinical
discussion covering early and late resuscitation and the importance of treatment before irreversibility sets in. A section on fluid
replacement follows a discussion of the pathogenesis of traumatic
shock, and moves the debate beyond the usual impasse of
crystalloid vs colloid, emphasizing the key goal of oxygen
delivery.
The central pivotal chapter on the role of the anaesthetist in
overall management provides a logical approach to the management of the airway, control of haemorrhage, traumatic brain
injury, the realities of thoracic trauma, and finally, limbthreatening injury and time-dependent systemic infection. This
chapter will be a valuable tool for the anaesthetist involved in the
overall management of surgical priorities. They take serious
decisions on who must make risk-benefit analyses for each case,
allowing for potential complications from a delay in surgery.
The remainder of the book is given over to a clear account of
the management of closed head injuries and a collection of
chapters devoted to the pathophysiology of trauma, spinal cord
injury, trauma in the young, pain, and burns management. There is
a very useful chapter on the management of post-traumatic
respiratory failure and an analysis of the management of ARDS in
the light of the findings of the 2000 consensus conference held in
Barcelona.
This monograph should find a very useful place as a source
reference for all anaesthetists involved in trauma for many years
to come. The editors and publisher are to be congratulated in
producing a definitive text at a very affordable price. Although
certain sections, particularly the chapter on mediators of tissue
injury, may appear rather indigestible, repeated reading will reveal
a rich source of useful information for those anaesthetists who will
be increasingly involved in the front line management of trauma.
D. J. Baker
Paris
France

Book Reviews

Handbook of Obstetric Anaesthesia. C. M. Palmer, R. d'Angelo

and M. J. Paech. Published by BIOS Scientific Publishers
Ltd, Oxford. Pp. 266; indexed; illustrated. Price 60.00. ISBN
1-85996-232-7.
This book is designed as a guide to practical obstetric anaesthesia
and aims to be a quick reference for trainees and consultant
anaesthetists working in this area. The contents section shows
clearly the chapters together with their relevant subsections, and
this simplifies matters for the anaesthetist seeking help on a
particular topic. The content is easily readable and there are a
plethora of tables, charts and diagrams in each section which
summarize the accompanying text. This makes for quick, easy
reference. The sections are nicely balanced and cover essentially
all areas of relevance to the obstetric anaesthetist. At 260 pages, it
is easy to read through and use to revise concepts before
examinations.
There is a good introductory section that summarizes the
development of obstetric anaesthesia. Thereafter, there are
excellent chapters on obstetric physiology, neonatal physiology,
and neuroanatomy and neuropharmacology which anyone revising
for examinations would find invaluable. The chapter on antenatal

monitoring fails to mention fetal blood vessel ultrasonography and

fetal scalp electrodes.
Chapters 5-8 present anaesthesia for vaginal delivery, anaesthesia for Caesarean section, and methods of postoperative
analgesia. These chapters are less succinct but the subjects are
difficult to summarize. In this area, the book does not offer much
advantage over other books already in circulation. Also in this
section, much of the discussion is relevant to US practice and not
especially to UK practice.
The chapters on pregnancy-induced hypertension and coexisting disease are excellent, as is the section on complications of
obstetric anaesthesia and analgesia, which has a useful summary
of postpartum nerve dysfunction. A chapter on obesity is
particularly welcome. The sections on neonatal resuscitation and
medicolegal considerations are well worthwhile.
This book largely succeeds as an easy reference guide for
obstetric anaesthetists, but at 60.00 it is probably too expensive
for the trainee to buy. It is also mainly aimed at the North
American market, and has almost exclusively North American
references. Not all sections translate well into British practice.
However, it is a useful reference book to have in the department
for trainees to revise from and refer to. I can recommend it for this
purpose.
B. Loughnan
Harrow
UK

Critical Care Focus. Number 8: Blood and Blood Transfusion.

Helen F. Galley. Published by BMJ Books, London. Pp. 85;
indexed; illustrated. Price 14.95. ISBN 0727916572.
This is another in a series of short books produced in association
with the Intensive Care Society. These are not comprehensive
textbooks, but comprise concise chapters on specific topics
relevant to the critically ill. The seven chapters in this volume
cover the function of blood and administration of blood products
in the critically ill.
Two chapters describe recent large, influential studies in
intensive care and will be of considerable interest to the practising
intensivist. Martin Tweeddale gives a balanced description of the
Transfusion Requirements in Critical Care study, that showed that
restrictive transfusion practice was associated with similar
mortality to liberal use of red cells. The results of this study are
widely known and its recommendations have been adopted by
many intensive care units. What I liked about the chapter was the
description of the background and lead-up to the study, the detail
about study design, and the hints of what actually happened during
the study itself, particularly in relation to exclusions. These are less
apparent from the formal publications. Pierre-Francois Laterre
contributes a similarly balanced description of the PROWESS
study, which showed reduction in mortality in patients with severe
sepsis treated with human recombinant activated protein C. The
background information is a concise description of the confusing
area of inflammation-coagulation interaction during sepsis, which
clinicians will find helpful. The discussion of the problems of
translating study findings to the wider ICU population, particularly
with reference to bleeding risk, was also good.
The other chapters cover a mixture of topics. Machin gives a
nice overview of haemostatic problems in the ICU, with particular
reference to platelet function. There is plenty of practical advice
and I thought the section on heparin-induced thrombocytopenia
was a useful summary of a subject that causes considerable
confusion. The chapter on Transfusion Associated Lung Injury
(TRALI) is a well-written account of a poorly understood
condition that is probably often missed. The authors make
comparisons with recent advances in the understanding of

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The title 'Diseases imported from abroad' for the tropical

medicine section irked me somewhat. Abroad is a relative term.
The inclusion of HIV infection in this section would seem bizarre
to those of us based in British cities. The HIV infection we see is
locally acquired rather than imported! The chapter hardly
mentions tuberculosis, which is becoming ever more important.
The section on neck sprains is, similarly, too short. X-rays are
advised for all patients, although evidence-based guidelines exist
which identify patients who do not necessarily need an x-ray.
It must be difficult with a core handbook such as this, to
compromise between the constraints of being pocket-sized and
being comprehensive. I did not find the format attractive. The text
is dense and key information seems hidden in the middle of pages.
More diagrams and algorithms would give the presentation a more
contemporary feel. The crucial points would be more obvious.
Most junior doctors would value some spaces to include scribbles,
so as to cross reference the book's recommendations with local
practice.
There will inevitably be areas of conflict between a core
handbook, such as this, and locally developed guidelines. I
identified numerous differences with my departmental guidelines,
mainly in drug therapies. There is always a problem keeping a
published text up-to-date and the anti-tetanus policy has already
been changed in the UK to include diphtheria immunization.
Locally developed departmental guidelines may lessen the need
for a handbook such as this.
I expect that most young UK consultants relied on previous
editions of this book, or similar texts, to keep them on the right
track when they were senior house officers for the first time in
A&E. Nowadays, in most teaching hospitals, junior doctors are
better supported. I was disappointed, therefore, that the importance of calling early for senior support was not emphasized
enough in this book. Thankfully, modern emergency care is based
on experienced emergency physicians, not junior doctors working
from handbooks.
This book is a good core handbook of emergency care. Junior
doctors will find it reassuring to have a copy of this book in their
pockets when starting those first long night shifts in the emergency
department. They will not go far wrong with this book, once they
remember to call for help too.
U. Geary
Liverpool
UK