Critical Care Toxicology. Edited by Jeffrey Brent, M.D., Ph.D., Kevin L. Wallace, M.D., Keith K. Burkhart, M.D., F.A.C.M.T., F.A.C.C.T., F.A.C.E.P., Scott D. Phillips, M.D., F.A.C.P., F.A.C.M.T., and J. Ward Donovan, M.D. Philadelphia, Elsevier Mosby, 2005. Pages: 1,690. Price: $175.00.
“Everything is poison. Nothing is poison. The poison is the dose,” as Paracelsus (1493–1541) said. Intoxications, both voluntary and iatrogenic accidents, are a frequent cause of admission in critical care units. Most of them have a good prognosis, requiring only supportive treatment and the occasional use of an antidote. Some may develop a nonspecific complication that the critical care physician is accustomed to treating (such as aspiration pneumonia or rhabdomyolysis). However, there are several unique features in the treatment of these patients. But because we are all facing “so many pathologies, so little time,” extensive knowledge about these features may be hard to come by. There have been many textbooks about intoxications, some by toxicologists, some by emergency physicians, but no English-language reference book addresses the specific needs of the critical care specialist in such details as Brent, Wallace, Burkhart, Phillips, and Donovan’s Critical Care Toxicology .
As can be expected from a book directed at critical care physicians, the authors’ aim was not just to give the reader the tools to deal with intoxications in general and specific intoxications in particular. They have tried to present the pathophysiologic aspects of intoxications, the various options for treatment, the evidence, and the therapeutic controversies and to give ample references for the reader to make up his or her mind. There is a definitive clinical orientation to this book, which is directed to clinicians more than laboratory toxicologists. So, how does this book fare as a textbook about intoxications in general, as a reference about specific intoxications, and as a general critical care book for nonspecific complications of intoxications?
If you want a book about general toxicology, pharmacokinetics, and pharmacodynamics, you certainly can find a better deal by looking elsewhere. The authors of this hefty, 1,690-page textbook have decided to concentrate on what they know best, the clinical approach to intoxication, and do not attempt to compete in a field where more knowledgeable laboratory toxicologists have already published definitive textbooks on pharmacology. They succeed admirably in their goal, providing an in-depth presentation of many specific toxic syndromes as well as how to deal with intoxications in general (diagnosis, supportive treatment, the role of the toxicology laboratory, gastrointestinal decontamination, and so forth). Some of the subjects are very well covered, with clear indication of the clinical benefits to be expected from the intervention (e.g. , gastrointestinal decontamination). Others are less precise about the real clinical benefits or the absence of data about certain procedures (e.g. , the role of the extracorporeal removal of toxic substances). The chapters about certain categories of patients (e.g. , elderly people, pregnant women, workers) are a welcome addition. The antidotes are covered with chapters ranging from adequate to excellent. For the majority of these antidotes, though, there are few data provided regarding their efficacy in terms of morbidity/mortality. This is especially regrettable for antidotes such as flumazenil or naloxone, where the decision of antagonization versus intubation is not always obvious. Overall, the chapters about antidotes are more about the “hows” than about the “whys.”
The sections describing the care of specific intoxications are where this book really shines. With contributions from established specialists from all over the world, there is (nearly) not a single intoxication that is not covered by an author who is deeply knowledgeable about the subject, its controversies, and recent developments. There are a few regrettable omissions, such as extracorporeal circulation for severe membrane-stabilizing agent intoxication, but this is inevitable for a book of this scope and magnitude. There is the obligatory chapter on agents of chemical and biologic terrorism, some of it belonging more to an infectious diseases textbook than a toxicologic reference book. One appreciable aspect of the chapters about specific intoxications is that they do not limit themselves to intoxications in one particular part of the world but are really an international effort and can be of use to clinicians everywhere. In addition to these specifics, this book also achieves expectations as a general reference for the general care of critically ill intoxicated patients. For most subjects, the authors give a brief and up-to-date overview of general therapies for nonspecific complications, such as acute respiratory distress syndrome, and skim over the more controversial aspects (such as the use of diuretics in oliguric acute renal failure). The coverage is usually adequate for most critical care patients.
The chapters in this book are clearly presented, with abundant tables and figures. There are 16 pages of color figures, although some will probably be of limited use to most practitioners, such as blisters after prolonged coma, anatomopathology plates of Wegener granulomatosis, snakes and mushrooms, and victims of smallpox. Color might have been used more effectively on a few diagrams and algorithms on the diagnosis of intoxication depending on the toxidrome, for example.
Overall, this textbook is a worthy addition to any critical care physician’s library. Whether you want to improve your general care of the intoxicated patient or need to know how to treat an obscure intoxication arriving at 5:00 am in your intensive care unit, and wherever you are in the world, you will find a precise, clear, up-to-date, and clinically relevant answer to your question. This book fills a need for critical care toxicology and fills it quite well.
Centre Hospitalo-Universitaire Pitié-Salpêtrière, Assistance-Publique Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France. samuel.delerme@psl.aphp.fr
