Pediatric Trauma Anesthesia & Critical Care. Edited by J. K. Hall and Jeffrey M. Berman. Futura Publishing, 1996. Pages: 507. Price:$98.00.
Do we really need a whole book devoted to pediatric trauma? More to the point, do we really need a whole book devoted to pediatric trauma anesthesia care? Although I am a pediatric anesthesiologist and there may be some bias in my response, the answer is clearly “yes.” Pediatric trauma is the leading cause of death in children older than 1 yr in this country. Despite the overwhelming nature of this problem, relatively little attention has been focused on this major source of sickness and death for children. For example, although the automobile is arguably the most dangerous object in the child's universe, we teach very little in our field about the specific differential of problems to expect when a victim of a traumatic encounter with an automobile is brought to the emergency room. It is the stated goal of this work by Drs. Jeffrey Berman and John Hall to present the necessary elements of pediatric trauma to not only understand the problems unique to pediatric patients, but also the elements necessary to build a local system to improve the care of these patients. With any book with this wide a scope, there must be a balance between presenting general principles of management and enumerating the details that differentiate pediatric and adult care. Although there are chapters with greater emphasis on practical matters than others, the book as a whole accomplishes its goal “to provide clinicians with physiological and clinical principals (that)… will allow them to better assimilate clinical data and plan the care of trauma victims.”
The first of the 20 chapters is entitled “Pediatric Trauma and Injury Patterns.” This chapter offers excellent background statistical information on incidences and outcomes of various types of trauma. This overview provides a focus for the rest of the book. The chapter on airway management, however, is not as satisfying. Because airway management has consistently been shown to be a significant factor in improving outcome, it is especially important for anesthesiologists to have a clear and broad understanding of this area. The authors present a good discussion of anatomic and physiologic differences between children and adults, followed by a presentation of routine and specialized airway equipment. However, both discussions could have been more detailed, especially given the intended audience. The chapter would also have been strengthened by greater use of illustrations. Finally, the issue of succinylcholine use is controversial. Although the authors (and I) are strong proponents of its use, this opinion is not universal. There is some confusion in the anesthesia community about current guidelines, especially because of changes in the manufacturers' recommendations for use in children. This deserves comment in the chapter, as well as discussion of alternative techniques. The third chapter, “Vascular Access and Initial Resuscitation,” covers vascular access well, but seemed a bit weak in covering initial resuscitation. However, the next chapter on fluid management was thorough and adequately supplemented with excellent tables and illustrations.
There are actually three different chapters devoted to transport. The first, “Pediatric Emergency Medical Systems,” is focused on information that is of historical interest, but probably would be minimally useful to most practitioners. The next chapter on transport to the hospital contained more practical information. However, it is disturbing to me that the chapter did not include a table showing the Glasgow Coma Scale or Pediatric Trauma Score (or both). Because these scales are an intricate part of ongoing monitoring during this phase of care, attention should be drawn to them. The chapter on intrahospital transport was very timely; it is rare for any hospital involved in trauma care not to have had difficulties or critical incidents occur in this circumstance where the patient is away from staff, who are primarily focused on trauma care. This chapter is a well-reasoned approach to the issue.
For me, the most fascinating chapter was on envenomation by Dr. George Lederhaas. Initially I did not know what this was about: the study of injuries caused by venom from land or water-based creatures. We learn that coral snake injuries differ significantly from those of other land-based snakes, with neurotoxicity and respiratory paralysis occurring in severe cases. I also discovered that the dreaded tarantula is less dangerous than the black widow or brown recluse spider. Similarly, the chapter on poisoning was comprehensive and well written.
The chapter “Anesthesia for Minor Procedures” provoked controversy by tackling one of the hottest topics around, sedation practices. The author states that “conscious sedation will almost always be the goal for children with minor injuries.” Although this statement is true, most pediatric anesthesiologists would probably agree that conscious sedation is difficult, if not impossible, to achieve consistently in children. Children who are anxious and in pain often require deep sedation, with risks that can be similar to general anesthesia, to obtain satisfactory conditions. The author of this chapter believes that chloral hydrate is a safe drug. Although this drug has been used for many years in many venues, it is increasingly recognized that serious mishaps have occurred with its use, particularly with large doses. The recommendation of the DPT (Demerol/Phenergan/Thorazine) or “lytic cocktail” regimen is somewhat disconcerting, especially because the author shows that the duration of sleep averages 4.7 h, with return to baseline an average of 19 h. It seems to me that there are few situations in which this would be the most appropriate method of sedation, especially for minor procedures.
The chapters devoted to some of the major issues in pediatric trauma-head trauma, near-drowning, and burns-are all well worth reading. It is good to see burns covered, because this area is often given only cursory coverage in the trauma literature. Each of the authors approached their topic with a scientific point of view and clearly outline the pathophysiology of the injuries. A minor area of controversy, in my opinion, was the suggestion that propofol was a suitable alternative to opioids or ketamine in patients with burns. This is appropriate only if adequate baseline analgesia is also provided. The chapter on thoracoabdominal trauma contained algorithms that strengthened the discussion considerably.
The final three chapters of the book discuss risk-benefit analysis, rehabilitation, and the team approach to trauma. These are important issues in developing a systematic approach to trauma, although many practitioners may gloss over them in an effort to find “clinically relevant” material. The authors are correct in including these chapters because the building of a system to care for children is clinically relevant.
This text is an excellent source for the uninitiated or occasional pediatric practitioner. The major important topics are covered in an easy-to-read manner, with good references and tables. The cost of $98.00 is a reasonable price to pay to have this in one's personal library. Where else can one, for $98.00, learn not only about burns, intraosseous fluids, and cervical traction but also about rattlesnake bites?
Tetsu Uejima, M.D.
Attending Anesthesiologist; Assistant Professor of Anesthesia; Department of Pediatric Anesthesia; Children's Memorial Hospital; 2300 Children's Plaza; Chicago, Illinois 60614