- Email: [email protected]
Clinical toxicology.By ford, delaney, ling, and erickson. philadelphia, wb saunders, 2001, 1138 pages, $125.00.1
The Journal of Emergency Medicine, Vol 23, No 1, pp 107–108, 2002 Copyright © 2002 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/02 $–see front matter
9
PII S0736-4679(02)00469-9
Book and Other Media Reviews
e CLINICAL TOXICOLOGY. By Ford, Delaney, Ling, and Erickson. Philadelphia, WB Saunders, 2001, 1138 Pages, $125.00.
pediatric colleagues keep reminding me that children are not simply little adults, and no truer proof for this can be found than in the management of a pediatric intoxication. One particular area where this textbook excelled was in discussions of laboratory testing, especially with respect to drugs of abuse. The two chapters dedicated to this topic were thorough, and provided important information about the limitations of such testing, as well as information about commonly used adulterants. Table 15-6, “Laboratory Analytes, and Detection Levels and Times,” has been one of the most useful single pieces of information in my brief toxicology career. In fact, it was a search for just this information that first led me to discover this text. The second portion of the text, comprising 13 chapters, takes a symptom-based approach to the management of the poisoned patient. Again, the general theme is that knowledge of the specific poison is not as important as managing the clinical consequences. Specific chapters discuss the care of the patient with altered sensorium, seizures, cardiovascular instability, and peripheral neuropathy, to name but a few. There is also a very comprehensive chapter on disorders of thermal regulation. Each chapter starts with a concise “Essentials of Initial Treatment” section. The chapter on seizures, for example, contains six bulleted points, beginning with assessment and control of the airway and exclusion of hypoglycemia. Each chapter in this section delves into the toxin-mediated pathophysiology of the respective process; however, the most valuable aspect of this section are the numerous, easy to comprehend tables, providing an extensive differential diagnosis of toxic and nontoxic etiologies, and definitive treatment strategies. The third and largest section of the text, spanning 101 chapters, is subtitled “Toxins in Depth.” This section is further subcategorized into analgesics and anti-inflam-
The American Association of Poison Control Centers recorded more than 2.2 million human poison exposure cases in 1999, the last year for which data are currently available (1). Of these cases, more than 450,000 were referred to health care facilities for evaluation and management. The philosophy of Clinical Toxicology, a 1138 page tome with no fewer than 156 contributing authors, is “treat the patient, not the poison.” The editors have constructed the flow of the text to instruct the reader in managing the clinical consequences of poisoning. This is not to suggest an in-depth discussion of pharmacology, pathophysiology, and laboratory assessment is lacking. The editors are to be commended in keeping the flow of the text consistent throughout. Overall, despite a wealth of information, the textbook is both easy to read and easy to apply to clinical practice. The text is divided into three sections, and a series of appendices. The first section, containing 15 chapters, provides “General Management Principles.” It covers such standard fare as initial management of the poisoned patient, evaluation for evidence of toxidromes, and a thorough review of issues surrounding decontamination and extracorporeal removal of drugs. I was pleased to see, given the goals of the text, that airway management was discussed early, and stressed throughout the text. I was also pleased that the text contained a chapter dedicated to the care of the pregnant patient, often a troublesome issue. However, I was disappointed to find that this chapter was not as easy to digest and apply as other chapters, in part because this chapter did not follow the format of the remainder of the text. Moreover, there is no chapter dedicated to the care of the pediatric patient. My
Book and Other Media Reviews is coordinated by Edward J. Otten, Medicine, Cincinnati, Ohio.
New Address: Mayo Clinic 200 First Street SW Rochester MN 55905 e-mail: [email protected] 107
MD,
of the University of Cincinnati College of
108
matory agents, nonprescription medications, cardiovascular drugs, other therapeutic agents, drugs of abuse, industrial and occupational agents, pesticides and agricultural products, natural toxins, and household products. Each chapter once again begins with a series of bulleted “essentials.” A brief introduction is followed by an indepth discussion of pathophysiology and toxicology. Clinical presentation, differential diagnosis, and management strategies are stressed. Information on current antidotal therapies is provided, including the use of octreotide in sulfonylurea intoxication and glucose-insulin in calcium channel antagonist intoxication. One particularly useful section in each chapter describes disposition for the specific intoxication. This is particularly helpful in the emergency department setting, especially when access to a clinical toxicologist is limited. The content is remarkably up-to-date for such a comprehensive text, especially one with so many contributors. As an example, the chapter on anticholinergics and antihistamines contains a discussion on the use of physostigmine in anticholinergic toxicity. Although this would be expected from any toxicology reference text, the author includes a study published in April 2000 in the discussion (2). On the other hand, the rare omission is made all the more obvious. A discussion about valproic acid-induced hyperammonemia, and the potential role of L-carnitine, is curiously absent. The final section of the textbook is a series of six appendices, ranging from a description of nontoxic agents, to a table of therapeutic and toxic drug levels, to legal issues surrounding patient refusal of treatment and patient transfer. A convenient appendix on drug and
The Journal of Emergency Medicine
antidote dosing is provided. No textbook is perfect, and Clinical Toxicology has some minor flaws, some of which have already been discussed. Most are subtle nuisances rather than serious problems. The most significant is a relative paucity of information on pharmacokinetics and toxicokinetics. While I understand that the purpose of the text is to address clinical management issues, a more in-depth discussion of this topic would be helpful for readers attempting to gain more understanding of overdose and should be expected from a reference toxicology textbook. Another shortcoming is a relative lack of figures. In contrast to the excellent tables, figures are few and far between. Despite its occasional shortcomings, Clinical Toxicology is a thorough and excellent textbook. Both easy and enjoyable to read, it is a useful addition for any departmental library and should be strongly considered by any individual wishing to own a general reference work in clinical toxicology. Matthew D. Sztajnkrycer, MD, PhD Department of Emergency Medicine University of Cincinnati Cincinnati, Ohio REFERENCES 1. Litovitz TL, Klein-Scwartz W, White S, et al. 1999 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2000;18;517– 4. 2. Burns MJ, Linden CH, Graudins A, et al. A comparison of physostigmine and benzodiazepines for the treatment of anticholinergic poisoning. Ann Emerg Med 2000;35:374 – 81.
9
PII S0736-4679(02)00469-9
Book and Other Media Reviews
e CLINICAL TOXICOLOGY. By Ford, Delaney, Ling, and Erickson. Philadelphia, WB Saunders, 2001, 1138 Pages, $125.00.
pediatric colleagues keep reminding me that children are not simply little adults, and no truer proof for this can be found than in the management of a pediatric intoxication. One particular area where this textbook excelled was in discussions of laboratory testing, especially with respect to drugs of abuse. The two chapters dedicated to this topic were thorough, and provided important information about the limitations of such testing, as well as information about commonly used adulterants. Table 15-6, “Laboratory Analytes, and Detection Levels and Times,” has been one of the most useful single pieces of information in my brief toxicology career. In fact, it was a search for just this information that first led me to discover this text. The second portion of the text, comprising 13 chapters, takes a symptom-based approach to the management of the poisoned patient. Again, the general theme is that knowledge of the specific poison is not as important as managing the clinical consequences. Specific chapters discuss the care of the patient with altered sensorium, seizures, cardiovascular instability, and peripheral neuropathy, to name but a few. There is also a very comprehensive chapter on disorders of thermal regulation. Each chapter starts with a concise “Essentials of Initial Treatment” section. The chapter on seizures, for example, contains six bulleted points, beginning with assessment and control of the airway and exclusion of hypoglycemia. Each chapter in this section delves into the toxin-mediated pathophysiology of the respective process; however, the most valuable aspect of this section are the numerous, easy to comprehend tables, providing an extensive differential diagnosis of toxic and nontoxic etiologies, and definitive treatment strategies. The third and largest section of the text, spanning 101 chapters, is subtitled “Toxins in Depth.” This section is further subcategorized into analgesics and anti-inflam-
The American Association of Poison Control Centers recorded more than 2.2 million human poison exposure cases in 1999, the last year for which data are currently available (1). Of these cases, more than 450,000 were referred to health care facilities for evaluation and management. The philosophy of Clinical Toxicology, a 1138 page tome with no fewer than 156 contributing authors, is “treat the patient, not the poison.” The editors have constructed the flow of the text to instruct the reader in managing the clinical consequences of poisoning. This is not to suggest an in-depth discussion of pharmacology, pathophysiology, and laboratory assessment is lacking. The editors are to be commended in keeping the flow of the text consistent throughout. Overall, despite a wealth of information, the textbook is both easy to read and easy to apply to clinical practice. The text is divided into three sections, and a series of appendices. The first section, containing 15 chapters, provides “General Management Principles.” It covers such standard fare as initial management of the poisoned patient, evaluation for evidence of toxidromes, and a thorough review of issues surrounding decontamination and extracorporeal removal of drugs. I was pleased to see, given the goals of the text, that airway management was discussed early, and stressed throughout the text. I was also pleased that the text contained a chapter dedicated to the care of the pregnant patient, often a troublesome issue. However, I was disappointed to find that this chapter was not as easy to digest and apply as other chapters, in part because this chapter did not follow the format of the remainder of the text. Moreover, there is no chapter dedicated to the care of the pediatric patient. My
Book and Other Media Reviews is coordinated by Edward J. Otten, Medicine, Cincinnati, Ohio.
New Address: Mayo Clinic 200 First Street SW Rochester MN 55905 e-mail: [email protected] 107
MD,
of the University of Cincinnati College of
108
matory agents, nonprescription medications, cardiovascular drugs, other therapeutic agents, drugs of abuse, industrial and occupational agents, pesticides and agricultural products, natural toxins, and household products. Each chapter once again begins with a series of bulleted “essentials.” A brief introduction is followed by an indepth discussion of pathophysiology and toxicology. Clinical presentation, differential diagnosis, and management strategies are stressed. Information on current antidotal therapies is provided, including the use of octreotide in sulfonylurea intoxication and glucose-insulin in calcium channel antagonist intoxication. One particularly useful section in each chapter describes disposition for the specific intoxication. This is particularly helpful in the emergency department setting, especially when access to a clinical toxicologist is limited. The content is remarkably up-to-date for such a comprehensive text, especially one with so many contributors. As an example, the chapter on anticholinergics and antihistamines contains a discussion on the use of physostigmine in anticholinergic toxicity. Although this would be expected from any toxicology reference text, the author includes a study published in April 2000 in the discussion (2). On the other hand, the rare omission is made all the more obvious. A discussion about valproic acid-induced hyperammonemia, and the potential role of L-carnitine, is curiously absent. The final section of the textbook is a series of six appendices, ranging from a description of nontoxic agents, to a table of therapeutic and toxic drug levels, to legal issues surrounding patient refusal of treatment and patient transfer. A convenient appendix on drug and
The Journal of Emergency Medicine
antidote dosing is provided. No textbook is perfect, and Clinical Toxicology has some minor flaws, some of which have already been discussed. Most are subtle nuisances rather than serious problems. The most significant is a relative paucity of information on pharmacokinetics and toxicokinetics. While I understand that the purpose of the text is to address clinical management issues, a more in-depth discussion of this topic would be helpful for readers attempting to gain more understanding of overdose and should be expected from a reference toxicology textbook. Another shortcoming is a relative lack of figures. In contrast to the excellent tables, figures are few and far between. Despite its occasional shortcomings, Clinical Toxicology is a thorough and excellent textbook. Both easy and enjoyable to read, it is a useful addition for any departmental library and should be strongly considered by any individual wishing to own a general reference work in clinical toxicology. Matthew D. Sztajnkrycer, MD, PhD Department of Emergency Medicine University of Cincinnati Cincinnati, Ohio REFERENCES 1. Litovitz TL, Klein-Scwartz W, White S, et al. 1999 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2000;18;517– 4. 2. Burns MJ, Linden CH, Graudins A, et al. A comparison of physostigmine and benzodiazepines for the treatment of anticholinergic poisoning. Ann Emerg Med 2000;35:374 – 81.