Trauma Anesthesia

Joseph H. McIsaac, III

JAMA. 2010;304(16):1841-1843 (doi:10.1001/jama.2010.1548)
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Topic collections Anesthesia; Emergency Medicine

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 BOOK AND MEDIA REVIEWS
CONN’S CURRENT THERAPY 2010
Edited by Edward T. Bope, Robert E. Rakel, and Rick D. Kellerman
1309 pp, $99.95
Philadelphia, PA, Saunders/Elsevier, 2010
ISBN-13: 978-1-4160-6642-2
THIS TEXT WAS FIRST PUBLISHED IN 1949. ROBERT RAKEL BE-
came the editor in 1984 after Howard Conn’s death, and this
most recent version is edited by Rakel and fellow family phy-
sicians Edward Bope and Rick Kellerman. As a reference
book, it is not meant to be leisurely read on a sunny after-
noon on the front porch; rather, it works best if readers know
the specific condition they want to review and go directly
to the relevant chapter. This is because it is organized using
the traditional systems approach, with sections covering top-
ics such as infectious diseases, cardiology, and gastroenter-
ology. The reader faced with a patient who presents with
an unusual and as-yet-undiagnosed collection of symp-
toms will find that there is no easy way of using this text-
book to help sort out the problem.
The book is written by a series of experts, with “Method
of” formatting at the start of each chapter (eg, the “Pain”
chapter is headed “Method of Trish Palmer”; the “Nausea
and Vomiting” chapter is headed “Method of Robert Kraft,”
and so on). This implies an expert opinion approach, and I
believe it is the way Conn originally structured the book,
but it seems anathema to today’s evidence-based approach.
However, most authors do refer to the recent evidence, and
relevant articles are cited at the end of each section. The help-
ful bibliographies include references as recent as 2008 and
2009. The book is edited by family physicians, and it is rec-
ommended that it be shelved with other textbooks of fam-
ily medicine; however, its organization around diseases rather
than presentations and processes makes it feel more like a
textbook of internal medicine, more closely aligned to Har-
rison’s Principles of Internal Medicine than to Textbook of Fam-
ily Medicine by McWhinney and Freeman or even Rakel’s
own Textbook of Family Medicine.
At times, the location of various topics seems unusual.
This is because some diseases can fall into more than one
category. For example, diabetes is discussed in the “Meta-
bolic Disorders” section rather than the section titled
“The Endocrine System”; asthma is discussed in the “Dis-
eases of Allergy” section rather than the section titled
“The Respiratory System”; contraception is discussed in
the “Sexually Transmitted Diseases” section rather than
the “Obstetrics and Gynecology” section; almost all of the
infectious diseases are discussed in the “Infectious Dis-
eases” section—except histoplasmosis, blastomycosis,
and coccidioidomycosis, which are covered in the section
on the respiratory system. However, once readers find the
©2010 American Medical Association. All rights reserved.
Downloaded from www.jama.com by guest on October 26, 2010
information they are looking for, the text is useful, com-
plete, and current.
Purchasers of this reference work also receive access to
the online version through Elsevier’s ExpertConsult Web
site. The approach is the same as for all other textbooks
on that site; readers can browse using the table of contents
or the index and can search the text for words. The system
works—it already just seems so old school. Readers
now want material to be available on a variety of devices;
they want touch, want to be able to navigate using hand
gestures, want smarter search capabilities, want more
graphics. Mere online availability and searchability will not
cut it with the newly graduated physician.
One particular feature promoted on the back cover is
that purchasers are free to use any of the online graphics/
photographs/figures in presentations by simply copying and
pasting them or saving them to a computer. The problem
is there are precious few graphics and they are all black and
white. Even the 100-page section on dermatology—a spe-
cialty that is all about visuals, pattern recognition, and color—
contains only 6 small black-and-white images.
Conn’s Current Therapy 2010 is true to its roots. It is a tra-
ditional textbook of medicine, formatted in the traditional
way. For the reader who needs to brush up on a given medi-
cal condition, it is a good resource. Readers can have the
feel of a real textbook or, if they prefer, can search and read
the text online. Readers who already have a favorite medi-
cal reference will have no compelling reason to switch to
Conn’s Current Therapy; those seeking a favorite should con-
sider it.
Marshall Godwin, MD
Department of Family Medicine
Primary Healthcare Research Unit
Memorial University of Newfoundland
St John’s, Newfoundland, Canada
godwinm@mun.ca
Financial Disclosures: None reported.
TRAUMA ANESTHESIA
Edited by Charles E. Smith
606 pp, $99
New York, NY, Cambridge University Press, 2008
ISBN-13: 978-0-5218-7058-0
THE PRINCIPLES OF TRAUMA ANESTHESIA ARE THE SAME AS
those for routine anesthesia but also include the added
stresses of urgency, uncertainty, and reduced control.
Administering an anesthetic involves the controlled,
Book and Media Reviews Section Editor: John L. Zeller, MD, PhD, Contributing Editor.
(Reprinted) JAMA, October 27, 2010—Vol 304, No. 16 1841
BOOK AND MEDIA REVIEWS
reversible poisoning of the nervous system to allow the
performance of a therapeutic or diagnostic procedure
without pain, anxiety, awareness, recall, movement, or
cardiovascular response. Disruption of the normal
homeostatic mechanisms produces adverse effects
ranging from apnea and hypotension to positioning inju-
ries and falls unless specific efforts are directed to pre-
vent these complications. In routine anesthesia, a
single organ system is disturbed by the surgery, and anes-
thesia is achieved in an orderly manner. In contrast,
the trauma patient usually presents with multiple life-
threatening insults and displays a spectrum of physiologi-
cal dysfunctions. Time is of the essence. History and
laboratory data are sparse. Airway establishment, ventila-
tion, and hemorrhage control become the dominant,
time-critical issues—usually under disadvantageous con-
ditions.
Trauma Anesthesia begins with a discussion of trauma
mechanisms and demographics, followed by a thorough dis-
cussion of airway management. Advanced techniques such
as rigid and flexible bronchoscopy, surgical airways, and ven-
tilation of the patient fitted with a cervical collar are well
described.
The text covers hemorrhage, shock, and coagulopathy in
great detail from multiple vantage points. Hypothermia, sys-
temic inflammatory response, hemodilution, and acidosis
all lead to coagulopathy. Five well-written chapters dis-
cuss establishing protocols for administering massive trans-
fusion while keeping systemic blood pressure low to re-
duce hemorrhage and coagulation disorders and to prevent
dislodging a thrombus. Competing comorbid conditions,
such as head injury accompanying major hemorrhage, de-
mand subtle compromises and are discussed in detail. Ra-
tional therapy using fresh-frozen plasma, platelets, cryo-
precipitate, and recombinant factor VIIa, based on recent
clinical research and experience in combat, provide a valu-
able and pragmatic depth of technical knowledge and prac-
tical advice.
Orthopedic injuries are quite common and often are
accompanied by neurologic complications resulting from
head or spinal trauma. Elevated intracranial pressure and
spinal cord pathology both require careful, specialized
management during surgery and into the postoperative
period to maximize tissue survival and function. Six
chapters define the state of the art. Blunt and penetrating
thoracoabdominal trauma, along with associated vascular
disruption, represent another commonly seen class of
injury. The anesthesiologist needs to be familiar with
operative as well as nonoperative and radiological man-
agement strategies.
The text is enhanced by coverage of special topics.
Major burns, for example, can be devastating, and few
anesthesiologists outside of burn centers have extensive
experience managing the care of burn patients. Burns
affect every aspect of care: pain control, fluid administra-
1842 JAMA, October 27, 2010—Vol 304, No. 16 (Reprinted)
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tion, infection, and pharmacology all require specialized
attention. Pregnancy is another special topic of interest to
the trauma anesthesiologist. Surgical delivery when the
mother cannot be resuscitated, management of abruption
in blunt abdominal trauma, and prioritization of care
(mother first) are discussed. Pediatric and geriatric
patients represent other special populations. Children are
not just miniature adults; they have different physiolo-
gies, injury spectra, and presentations. Considerations for
elderly persons are similar. Each topic is nicely pre-
sented.
Much of what the anesthesiologist does involves
applied pharmacology, whether anesthesia is adminis-
tered systemically or locally at a peripheral nerve. This
theme is covered extensively. The pharmacology of anes-
thetics and muscle relaxants in the patient with hypoten-
sion, bleeding, massive transfusion, or burns poses con-
cerns that can differ greatly from the routine. Pain
management, especially in the postoperative period, can
alter outcome. Regional anesthesia, frequently guided by
ultrasound imaging, has enhanced the safety and efficacy
of local anesthetics. A separate chapter on ultrasound,
both diagnostic and for anatomical precision in nerve
blockade, provides an in-depth review of the state of the
art. A chapter on combat trauma and pain control on the
battlefield and in the intensive care unit is also included.
Surgery for damage control and surgical considerations in
austere environments—topics likely unfamiliar to civilian
physicians—are eloquently discussed.
Several criticisms of this multiauthored work require
mention. The chapter on oromaxillofacial injuries pro-
vides an excellent overview of facial trauma from a surgi-
cal perspective. However, the only reference to anesthesi-
ology in that chapter is a brief mention of surgical
airways and fiber-optic intubation. More insight into
anesthesia in patients with oromaxillofacial injuries
would be helpful. Orthopedic, cardiothoracic, burn, and
spinal trauma each comprise 2 chapters written by differ-
ent authors, the first chapter being a surgical overview
and the second intended to cover management of anes-
thesia. A substantial amount of redundancy could be
avoided by combining these discussions into unified
chapters. Major gaffes in editing are a further problem.
The chapter on eye trauma presents the considerations
for open- and closed-globe management well. Substitu-
tion of the word “rapture” for “rupture” in the figure for
the Birmingham Eye Trauma Terminology System algo-
rithm is confusing. The figure also is not credited but
appears to be taken from another publication (with the
exception of the substituted word). Chapter 31, “Trauma
and Regional Anesthesia,” is well written but incom-
pletely edited—all text references to figures are cited as
“(??),” leaving readers to fend for themselves. The book
is printed in black and white except for a color-plate
insert in its center. This requires searching for photo-
©2010 American Medical Association. All rights reserved.

graphs and figures in another section of the text. Such
maneuvering can be time-consuming and aggravating to
the reader.
Despite a few blemishes, Trauma Anesthesia provides
an expansive, in-depth review of an emerging subspe-
cialty of anesthesiology. The material is well written but
dense. Like any technical work, it requires careful read-
ing. I especially liked the editor’s broad treatment of the
subject. Not only is acute operative care presented but
critical care and long-term pain-management issues are
thoroughly discussed. Systems and team interaction,
good communication being most important, are treated
in 2 chapters that tie it all together. Trauma Anesthesia
provides guidance for trainee, generalist, and experienced
specialist alike. Overall, this text is a valuable contribu-
tion to the field and well worth the price.
Joseph H. McIsaac III, MD, MS
Department of Anesthesiology
Hartford Hospital
Hartford, Connecticut
Department of Biomedical Engineering
University of Connecticut
Storrs
jmcisaa@harthosp.org
Financial Disclosures: Dr McIsaac reported that he has no relevant financial dis-
closures but that he is a member of the American Society of Anesthesiologists Com-
mittee on Trauma and Emergency Preparedness and knows 4 of the 68 contribu-
tors to Trauma Anesthesia; he is also a graduate of Case Western Reserve University,
the editor’s home institution.
INFECTIOUS DISEASES OF THE FEMALE GENITAL TRACT
By Richard L. Sweet and Ronald S. Gibbs
5th ed, 469 pp, $139
Philadelphia, PA, Wolters Kluwer/Lippincott Williams & Wilkins,
2009
ISBN-13: 978-0-7817-7815-2
THIS IS THE FIFTH EDITION OF INFECTIOUS DISEASES OF THE FE-
male Genital Tract, and to use the authors own words, it “comes
at a critical time in obstetrics and gynecology and in medi-
cine. The number one priority in medical care is patient safety,
and chief among the priorities is the prevention and treat-
ment of serious infections . . . and expanded concerns about
emerging infections and antibiotic resistance.”
The current edition has 25 chapters, all easy to read
and up to date, with a plethora of visuals. The chapters
provide pertinent information about public health at the
national, international, and global levels, including dis-
ease prevalence as well as health care burden and impli-
cations for prevention. Sections on pathophysiology are
detailed enough to provide an up-to-date review for the
recent medical school graduate but simple enough that
even seasoned practitioners who have been away from
basic science for some time can understand and refresh
their memory and glean new insight into the evolving
©2010 American Medical Association. All rights reserved.
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BOOK AND MEDIA REVIEWS
basic science understanding of some disease processes or
treatment modalities. Some chapters are organized with
the practitioner in mind and almost emulate the practice
bulletins from the American Congress of Obstetricians
and Gynecologists, in which key clinical questions are
asked and answered. Importantly, all sections include a
specific portion dealing with pregnancy implications, risk
of vertical transmission, and potential treatment (if appli-
cable) during pregnancy.
The current edition has made extensive revisions to up-
date chapters pertaining to human papillomavirus, herpes
simplex virus, hepatitis, human immunodeficiency virus
(HIV)/AIDS, and perinatal infections. The chapters related
to preterm birth, premature rupture of membranes, and intra-
amniotic infection reflect the current state of the science and
integrate research findings into a meaningful way for the
practicing clinician. Suggestions for practice are clear and
explicit. The chapter on HIV/AIDS provides a wonderful sum-
mary of the HIV/AIDS epidemic, historical landmarks re-
lated to diagnosis and treatment, and pertinent studies lead-
ing to decreased mother-to-child transmission of HIV in the
United States and also discusses the pathophysiology of evolv-
ing HIV/AIDS in the setting of highly active antiretroviral
therapy. The authors conclude the chapter with a caution
about the need for vigilance concerning emerging resis-
tance. Important distinctions are made between develop-
ing and developed countries both with regard to epidemi-
ology and treatment options. Given the widespread pandemic
in third-world countries, it is clear that there will remain a
persistent large reservoir of the virus until simple cost-
effective treatment options (vaccines) can be developed and
distributed worldwide.
The new “Infection as a Cause of Neonatal Brain Dam-
age” chapter is a must read for any reader interested in
understanding the models and mechanisms believed
associated with neonatal brain damage. The authors sim-
ply and eloquently describe the various theories involv-
ing the complex interaction between inflammation,
coagulation, genetics, and epigenetic phenomena. Per-
haps the only criticism would be the authors’ decision to
not include citations within the text but rather to refer
the reader to a “Suggested Readings” section at the end of
each chapter, thus making it difficult to follow up on
selected topics for further study.
The authors have made an online version available, and
it is anticipated that this will be a welcome convenience for
students, residents, and consultants who travel to different
clinical sites. It is easy to use, especially when viewing full
text. However, the search option brings up a series of pas-
sages that can be a little confusing. The printed text refers
to sections only available online and therefore difficult to
locate. These minor shortcomings aside, Infectious Diseases
of the Female Genital Tract will be a welcome addition to
the library of every busy clinician. I wanted to skim through
the book, reviewing certain chapters and looking for spe-
(Reprinted) JAMA, October 27, 2010—Vol 304, No. 16 1843