Brain, Vol. 124, No. 2, 445-447,
February 2001
© 2001 Oxford University Press
Book reviews |
CRITICAL CARE NEUROLOGY.
By David H. Miller and Eric C. Rapps. 1999. Oxford: Butterworth-Heinemann. Price £60. Pp. 440. ISBN 0-7506-9968-X.
Department of Neurology, University Hospital of Wales, Cardiff, UK
The Blue Book series is well regarded by neurologists and many will have one or more of the earlier volumes on their bookshelves already. This is the 22nd in the series and the smaller print topics in neurology have been reached. This book is aiming for a niche in the market, and to attract interest from both sides of the Atlantic, there is an editor from each side. However, in order to achieve any popularity it has to be special. This task is made more difficult as many neurologists, and certainly most of those in training, will already have a text on neurological emergencies and there is inevitable overlap of the subject matter in those books and this one. Anyone thinking of purchasing this book would want to know that it offered more than they could find in a book that they already own or have access to.
The book comprises 14 chapters by 24 contributors (15 from America), which cover a range of specific conditions and general problems likely to result in a patient receiving intensive care. The preface explains that the text is aimed at the non-specialist neurologist or neurologist-in-training as a practical guide to the management of clinical problems in areas where there has been a significant advance in knowledge which has translated into changed practice.
It was with these aims firmly in mind that I have used this book both as a specific reference when faced with a particular clinical problem, and for more general information over several months in my usual practice as a general hospital neurologist-in-training.
There are two common reasons why a neurologist may attend a patient on an intensive care unit. One is when a patient known to have a neurological condition deteriorates and needs critical care, either expectedly or unexpectedly; the other is when a patient on an intensive care unit is suspected of having a neurological condition. This is often because they fail to wake up after anaesthetic, or because they fail to wean from a ventilator. Of the two situations, the first is by far the most straightforward to manage and the least common. Each of these situations requires a different clinical approach and there are chapters in this book that attempt to cover the investigation and management of a patient in critical care from the standpoint of knowing what the underlying problem is and from that of having to make a new diagnosis.
The first chapter is an overview of respiratory and bulbar dysfunction in neurological disease by D. T. Laskowitz and C. O. Borel. It is a good introduction and also sets the tone of the book in that it tells the reader that the ground will be covered in both breadth and depth. It starts with an account of the functional neuroanatomy, chemoreceptor and afferent receptor contribution to respiration. Several pages of dense text follow, unrelieved by diagrams, which list in paragraphs each component and what it may do according to the cited papers in a largely unconnected manner. There is no attempt to describe the flow of events in normal respiration to which each of these components may contribute, although a sense of complexity is well conveyed. This is followed by a short piece on many of the illnesses covered in more detail later in the book. From my UK perspective, the section on the monitoring and treatment of respiratory failure in motor neurone disease (ALS) is interesting for its insight into the differences between UK and American practice.
There then follows a series of chapters covering conditions likely to pitch a patient into critical care. In Chapters 2, 3, 6 and 10, Guillain–Barré syndrome, myasthenia gravis, convulsive and non-convulsive status epilepticus and subarachnoid haemorrhage are reviewed. Each of these chapters is a well-executed but fairly standard account of a condition, with a surprisingly variable emphasis on the critical care aspects of management considering the book in which they are found.
Many of these subjects would also be covered in an emergency care text, but this book has a broader scope than those books in several areas. In particular, accounts of management go beyond the immediate emergency care and a broader range of related conditions are also considered, not all of which present acutely, and some of which are a consequence of successful emergency care and prolonged critical care. A good example of this is the chapter on coma, vegetative state and the `locked-in' syndrome by R. S. Howard and N. P. Hirsch. While the first four pages cover the usual ground seen elsewhere, there then follows an excellent section on the continuing assessment of such patients, with emphasis on the parts which can be meaningfully tested; namely the eyes. The abnormalities in function and their clinical correlates are described. Useful comments are made about drug effects and other limitations to the examination and the chapter then goes on to cover outcome from coma, the vegetative state and `locked-in' syndrome. It is all presented in a clear and very practical way, which shows the years of clinical experience that the authors have had in such situations. The final section on brainstem death is again useful but contains the United Kingdom Code of Practice recommendations without attempt to encompass practice elsewhere. There are dotted about in this text, references to practice on one side of the Atlantic or the other, usually without attempt to cover both. This is seen increasingly in textbooks and can be a little irritating if the guidance isn't appropriate to one's own practice.
Other chapters which distance this book from those on emergency care are those on chronic respiratory failure, thrombotic and vasculitic disorders and a further chapter on central vein and sinus disease. While there is some repetition inherent in a book comprising independently written chapters with overlapping subject matter, the overall effect is to provide a comprehensive view of various problems and where the same point is made from a different perspective, this may serve to reinforce important clinical tips.
The above-mentioned chapters cover their subjects largely from the perspective of knowing what the diagnosis is at the start. Chapter 4 by J. W. Teener and colleagues approaches the problem of `other causes of acute weakness in the intensive care unit' with the clinical evaluation and then progresses to the diagnosis and management. This approach is particularly useful in `real life' situations where the underlying diagnosis is not known at the outset. It deals with critical illness polyneuropathy and acute quadriplegic myopathy in detail, comparing and contrasting them. Other sections in the chapter are presented in a `frequently asked question' format with answers. This information is specific to neurology of critical care rather than to emergency neurology.
Further chapters with specific reference to the problems of critical care are Chapter 13 (central nervous system complications of critical medical illness) and Chapter 14 on paediatric neurology critical care. This last chapter is particularly useful to someone, such as myself, who treats adults with only rare excursions into paediatric neurology. It specifically highlights conditions unique to children or uncommon in adults and emphasizes areas where paediatric and adult critical care differ.
There is one chapter over which I have some reservations — Chapter 6 on convulsive and non-convulsive status epilepticus by K. G. Jordan. The content was useful and well presented; however, the reader is told that the chapter was `based on a review' written by the author 6 years ago. There are large sections which are the presumed product of cut and paste functions in a word processor. Lines have been added to expand the section on pathophysiology among other areas and several references more recent than 1994 are included. It does, however, suggest that there have been few advances in medical practice in this area since 1994 and as such is not within the spirit of the preface. This may seem to some an unreasonable criticism, especially as I felt that the content of the chapter was useful. However, I feel that substantial repetition of text produced several years earlier is probably unacceptable in a fast moving scientific field and more effort should have been made to avoid this.
This aside, my impression of the book was very favourable. Overall it provided me with a useful source of practical information. I would certainly recommend it to other trainees in the UK and I'm sure that they would not be alone in finding it a worthy addition to their bookshelf.
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