Edited by Andrew D. Rosenberg, Ralph L. Bernstein, and Christopher M. Grande. Problems in Anesthesia. Volume 8. Number 3. Philadelphia, J. B. Lippincott Company, 1994. Pages: 218. Price:$40.00.
This issue of Problems in Anesthesia was prepared under the auspices of the International Trauma Anesthesia and Critical Care Society, and all the royalties derived from its sale are donated to this organization. As specified in the preface, this monograph provides an indepth examination of the perioperative and critical care management of orthopedic injuries by anesthesiologists. Most of the contributors to this book are trauma anesthesiologists from the United States, with two from Norway and one from the United Kingdom.
The volume is organized logically, starting with the epidemiology of orthopedic injuries. The author reminds us that, in the developed world, trauma is the fifth most common cause of death, with a large number of these fatalities the result of motor vehicle accidents or falls. This chapter is well written and well illustrated with tables and figures to help interpret the many statistical data reported. Almost all of these data are from the developed countries, particularly the United States, because "data from most of the countries in the developed world are unreliable." A flaw in this chapter is the omission of page numbers in some references.
The second chapter, on prehospital care of orthopedic injuries, is interesting to readers in the United States. It describes a prehospital system in which anesthesiologists ride on rescue vehicles and provide initial care at the trauma scene (including induction of anesthesia and treatment of pain). Reading about this system, which is widespread in Europe, should encourage more involvement of trauma anesthesiologists in the prehospital settings in this country. The prehospital evaluation and management of the trauma patient suggested in this chapter are derived from the guidelines of the Advanced Trauma Life Support of the American College of Surgeons, with modifications reflecting the presence of the anesthesiologist in the field. This chapter contains two interesting case reports and valuable practical information for the examination and management of orthopedic injuries, including care of amputated parts.
The three chapters that follow deal with the perioperative care of specific orthopedic problems. The one on spine injuries provides a clear picture of the diagnosis (particularly helpful is the section on evaluation of x-rays), early management, and anesthetic concerns in patients with this condition. The part on succinylcholine and hyperkalemia is not as thorough as the rest of this chapter, and the legend to an important table (expiratory parameters in quadriplegic patients) is incomplete. The chapter on pelvic, acetabular, and long bone fractures briefly reviews the literature in support of early fixation of these fractures and then concisely describes management of these orthopedic injuries (particularly well written is the part on pelvic fractures). The chapter on the elderly patient with a hip fracture reviews in depth the epidemiology, pathophysiology, morbidity and mortality, and anesthetic considerations related to this common orthopedic injury. It is exhaustive and well written.
Regional anesthesia for orthopedic trauma is the topic of the following chapter, which starts with an informative case report and then presents benefits of and concerns with this anesthetic modality (the benefits are covered superficially). The chapter continues with excellent and detailed description of various regional anesthesia techniques, complemented by good illustrations. Next, a comprehensive review of some of the most common pulmonary, cardiac, and renal complications, which may occur in the operating room or in the intensive care unit, is presented. The subsequent chapter covers four special problems in orthopedic trauma: fat embolism syndrome, compartment syndrome, tourniquet use, and use of methylmethacrylate cement. It is well written and includes interesting case reports (however, more pathophysiology should have been described for compartment syndrome). Pathophysiology, diagnostic procedures, and treatment modalities for thromboembolic phenomena in the perioperative period are discussed in the next chapter in detail, with the exception of inferior vena cava interruption techniques, which I would have liked to see described.
The last two chapters deal with post-traumatic pain and with anesthetic problems during diagnostic evaluation and in-hospital transport. In the former, valuable practical information and numerous references are provided about analgesic techniques for acute and chronic pain (e.g., phantom limb pain and reflex sympathetic dystrophy) after trauma. In the latter, an important but often neglected topic is discussed in depth: essential information about common diagnostic imaging techniques so that the anesthesiologist (who may accompany the patient to the radiology suite) can adapt to each situation and environment. Of particular value is the description of an organized approach to monitoring and treating a critically ill patient during the dangerous time spent in transport (with an informative table on capnograms).
This monograph is a well written source of practical information that includes a good number of up-to-date references. It is remarkable that no significant redundancy is present in the text, despite the many collaborators. This book can be used effectively as an introductory text by residents in training or as a reference by practicing anesthesiologists.
Massimo Ferrigno, MD, Assistant Professor, Department of Anesthesiology, University of South Alabama, 2451 Fillingim Street/MSTN 610, Mobile, Alabama 36617
