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Cardiac Emergencies: A Pocket Guide

Article  in  Emergency Medicine Journal · November 1999

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acquired their medical knowledge from books JANE FOTHERGILL tal cardiac arrests vary so widely. He then pro-
such as this, rather than from ER! Consultant in Accident and Emergency Medicine, vides a "community survival checklist" to
London assess the likelihood of successful resuscita-
ZUL MIRZA (RICHARD BIRAM, Senior House Officer in Accident tion, and to suggest where improvements
Specialist Registrar in and Emergency Medicine; SHEILA PROUDFOOT, could be made. This includes the question
Accident and Emergency Medicine, London Nurse Practitioner; ELIZABETH SINCLAIR, General "Does the EMT unit with a defibrillator have
Practitioner) a response time of four minutes or less?". How
many of us would be able to tick "Yes"?
Minor Injuries Unit Handbook. By This well researched, and amply referenced,
Matthew Cooke, Ellen Jones, Conor Kelly. Life in the Balance: Emergency book is engagingly written. It tells a fascinat-
(Pp 182; C13.99.) Butterworth-Heinemann, Medicine and the Quest to Reverse ing story and introduces the reader to some
1998. ISBN 0-77506-3451. Sudden Death. By Mickey S Eisenberg. (Pp remarkable and inspiring medical pioneers.
304; £19.99.) Oxford University Press, 1997. Anyone providing CPR would find this book a
This book is a little gem for the practitioners ISBN 0-19-510179-0. good read, but it would be especially useful to
for whom it has been produced: accident and all those who teach it. Having read this book
emergency (A&E) senior house officers, emer- their teaching should be far more entertain-
You have probably performed cardiopulmon- ing.
gency nurse practitioners, and general practi- ary resuscitation (CPR) more times than you
tioners. I know because they have reviewed it can remember, but have you ever wondered BERNARD FOEX
for me and what follows is a distillation of where it all came from? Specialist Registrar in
their views. In Life in the Balance: Emergency Medicine Emergency Medicine, Bolton
This is a very useful pocket reference book and the Quest to Reverse Sudden Death Mickey
that is full of the "bread and butter" problems Eisenberg, Professor of Medicine at the
with which patients attend A&E departments Management of Acute and Chronic Pain.
University of Washington, provides many of Edited by Narinder Rawal. (Pp 231; £25.)
and minor injuries units. the answers. In this book, aimed at the lay
For many junior doctors or nurses the reader, Eisenberg traces the path from the for- BMJ Publishing Group, 1998. ISBN
bewildering variety of relatively "minor" mation of the Society for the Recovery of 0-72790-1193-7.
conditions facing them can be unsettling or Drowned Persons (Amsterdam Rescue Soci-
challenging, being poorly described or absent ety), in 1767, to the training of paramedics The effective relief of pain has always been a
from A&E textbooks, perhaps being thought and later emergency medical technicians primary aim of medical care but it is often
of as too trivial to include. These conditions (EMTs) in the 1970s and 1980s. poorly managed despite increasing knowledge
are of course very important to the patient, so In one of the early chapters he points out of pain pathophysiology, and the development
the ability swiftly to diagnose, manage, and that resuscitation was largely an alien concept of new drugs and drug delivery systems.
advise does wonders to reassure them and in ancient and medieval times, when life and Management of Acute and Chronic Pain con-
maintain their confidence. death were considered the province of the sists of a series of reviews written by an inter-
The book's 182 pages are divided into four divinity. With the Enlightenment came the national panel of specialists. The book has
sections covering wounds and wound care, first serious attempts to revive the drowned. introductory chapters on the anatomy, physi-
minor trauma, minor medical conditions, and The practices of the time included bloodlet- ology, and pharmacology of pain followed by
managerial matters. The layout is very good ting, rectal or oral fumigation with tobacco reviews of the management of postoperative
which allows for quick reference; in less than smoke, and the use of domestic bellows or the and obstetric pain. The management of acute
one minute it is possible to glean enough rescuer's mouth for artificial respiration. The paediatric pain, chronic low back pain, and
knowledge to allow confident diagnosis, care- latter was soon supplanted by far less intimate, cancer pain is also covered.
ful exclusion of more serious or life threaten- but far less effective techniques, until the work The authors demonstrate an enthusiasm for
ing conditions, and sensible management of Elam, Gordon, and Safar in the 1940s and their subject and attention is given to the
strategies with clear advice for patients in the 50s finally proved the effectiveness of mouth- clinical, organisational, and clinical risk issues
majority of cases. Key points to look out for or to-mouth resuscitation. Convincing the world of pain management. The book is well
points of interest are listed for each condition, involved demonstrations on volunteers se- referenced except for the introductory chap-
helping to differentiate patients who can safely dated and paralysed to mimic patients in ters, which disappointed by providing only a
be treated and sent home from those who are respiratory arrest! limited selected reading list. Multiauthor texts
more likely to need admission or further The discovery that electricity could stimu- produce challenges for the editor in ensuring
investigation. There are no diagrams or late muscles led, in 1818, to macabre attempts consistency of style, presentation, and con-
photos and I think it is all the better for that- to resuscitate a recently hanged murderer. tent. In general these challenges are well met.
easier to read, and of course it keeps the price The chest movements elicited provided con- There is some repetition between chapters
down! vincing evidence that electricity could be a key and a few typographical errors of drug dosage
The book is very comprehensive, covering to reviving the dead. And so it proved, but for units need correcting.
all manner of wounds with advice on skin clo- the fibrillating heart, rather than for restoring It is a pity that the book does not contain a
sure techniques and after care. General ventilation. From the early history of electric- chapter dedicated to the management of pain
principles are followed by discussion of more ity the author takes an entertaining digression in emergency medicine. A brief mention is
difficult wounds (intraoral or pretibial lacera- into the world of "electroquackery", before given to the use of the femoral block in
tions). The vast majority-if not all-of the tackling the development of defibrillation. It children with a fractured femoral shaft but
minor ailments seen are included. was during a defibrillation study that Knicker- otherwise references to the management of
Lacking in this book is a more in-depth bocker and Kouwenhoven noticed that by acute trauma pain are limited. The chapter on
approach such that the more experienced applying pressure to the closed chest arterial chronic low back pain will be of interest to
A&E senior house officer or nurse practitioner pressure increased momentarily. From a accident and emergency specialists.
will find it over simplified at times. Occasion- chance observation external chest compres- The book will be of value to trainee
ally it is too specific-for example it has no sions were added to the resuscitation protocol. anaesthetists and intensivists and those with a
section on "red eye" but only separate ones on Having explained the development of the special interest in pain management.
conjunctivitis and arc eye, leaving out more key components of CPR Eisenberg then KAREN ILLINGWORTH
worrying conditions such as iritis. Also for covers the story of Frank Pantridge, the Leeds
brevity some conditions are not covered in Belfast ambulance, and the importance of
enough detail, such as headache. pre-hospital defibrillation. Initially this was
I was glad to see a section on violence and provided by mobile intensive care units staffed Cardiac Emergencies: A Pocket Guide.
aggression even if it was at the end rather than by a doctor. By the early 1970s paramedics By Jim Nolan, John Greenwood, Alan
the beginning, as this is a huge problem in had started using defibrillators in several cities Mackintosh. (Pp 188; C14.99.) Butterworth-
A&E departments now. in the United States, including Seattle. Heinemann, 1998. ISBN 0-7506-3833-8.
Overall this is an excellent pocket book. I In the epilogue the author asks "Is it worth-
would expect it to be well thumbed through- while?" and quotes one of the fathers of mod-
out the first few weeks of an A&E job. How ern CPR, Peter Safar, "Resuscitation applied How quickly the memory fades. Five years
clever for an academic general practitioner without judgement and compassion is morally since I left general medicine to join those at
and two A&E consultants to tailor their infor- and economically unacceptable". The author the front door and already the inner sanctum
mation so perfectly for their proposed reader- outlines the chain of survival and ponders the of the hospital has been lost to me. Or how
ship. question of why survival rates for out of hospi- swiftly the practice of medicine is evolving and
Letters, Book reviews 465

we are left behind even in subjects in which we of thrombolytic agents by A&E staff rather It is very heavy on text and short on
were once competent. Nolan and colleagues than waiting for review by busy junior medical diagrams, flow charts, or indeed anything to
have produced an informative, up to date, and doctors. interrupt the columns of text. As such it will
evidence based guide to the management of Overall, I would recommend this book to not suit all learning styles, indeed it will prob-
common cardiac conditions. The book is con- any junior physician looking after general ably only suit a minority of them. Of its
cise, readable, well referenced, and makes medical patients and it has a place within the expressed aims, therefore, I think that it is
good use of key points to emphasise important A&E department for those times when the least successful as a study text.
aspects of management. It provides clear "how cardiologists are slow to answer their pagers. The layout is not so problematic if the book
to do it" guidelines that will educate the nov- is being used for a quick review of an
ice and reassure the mature. C A EYNON
Each chapter opens with a short back- Specialist Registrar in Accident and Emergency, individual subject or as a resource for prepara-
ground to the topic. I am sure I am not the Reading tion of teaching material. Despite this criti-
only one who balks at the plethora of cism of its layout, and while it certainly is a
acronyms attached to cardiology trials. Even burdensome study tool, its content is overall
Snow White drew the line at seven. Here, Emergency Medicine: The Core very good although, understandably, North
TAMI, TIMI, GUSTO, GISSI, and the rest Curriculum. Edited by Richard V American in orientation. Each subsection of
are summarised and a clear consensus offered. Aghababian. (Pp 1490; $138.) Lippincott- each chapter follows a similar consistent
The chapters on arrhythmia management and Raven, 1998. ISBN 0-316-00753-6. layout and each subsection is followed by the
post-infarct risk stratification and treatment key references. The European literature is well
are particularly good. The protocols for resus- represented in these reference lists.
citation follow those of the European Resusci- This is a North American textbook of nearly My initial impression, based on the layout,
tation Council with the helpful addition of 1500 pages structured around, and address- was not favourable but in use I have come
suggestions to answer the question "360J, ing, the core content for emergency medicine to value the text and commend it as a text
360J, 360J, now what?" The advice on when of the American College of Emergency Physi- that meets its own expressed aims, outlined
to stop resuscitation attempts is welcome. cians. above.
The book disappoints in one or two key Its principal aims are to provide a struc- It is best as a quick review text and for
areas: 2% to 4% of patients with an acute tured study text for trainees preparing for preparation of teaching material but despite
myocardial infarct are discharged from the their higher examination, to provide a depart- my reservations about its style I would
accident and emergency (A&E) department. mental reference to assist in acute manage- commend it to any trainee studying for the
The book provides no pointers as to how to ment, to provide a resource for preparation of Edinburgh Part B in Accident & Emergency
improve this and leaves out simple diagnostic instruction material for medical students and or indeed for the FFAEM exit examination.
aids such as chest pain protocols and multi- junior staff, and to provide a list of key
lead electrocardiograms. The newer cardiac references to allow greater study. In all of these ALISTAIR McGOWAN
markers are also not included. Door-to-needle aims I believe it achieves its purpose well. It Consultant in Accident and Emergency Medicine,
time may be accelerated by the administration does this despite its layout. Leeds

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