Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology

Volume 2, Number 2, July-December 2001

Technical Books Section

(Page 9)

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 Trauma Secrets, 1^st Edition by Gideon P. Naudé, Frederic S. Bongard and Demetrios Demetriades
Hanley & Belfus, Medical Publishers, 210 South 13th Street, Philadelphia, PA 19107; xviii + 297 pages: ISBN 1-56053-256-4. Library of Congress Control No. 98-27476. Publication Date October 1998: Price, $39.95 (US), $44.95 (Foreign).

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Test Yourself on Trauma! The book is packed with interesting information on trauma. Here are some questions you should be able to answer after reading this book. You may want to try these questions now. For answers see the box below and to the left. Qu 1. List several scoring systems currently available? (From Chapter 2, entitled "Trauma Scoring Systems") Qu 2. What is rapid sequence intubation (RSI), and why is it performed? (From Chapter 3, entitled "Airway Management in Trauma") Qu 3. Is splenic injury only associated with severe trauma? (From Chapter 20, entitled "Splenic Injuries") Qu 4. What is the prognosis of thyroid storm? (From Chapter 30, entitled "Endocrine Problems in Trauma") Qu 5. Must you remove the nail to evaluate a nail bed injury? (From Chapter 31, entitled "Plastic Surgery") Qu 6. List the differential diagnosis of child abuse? (From Chapter 38, entitled "Family Violence: Child abuse, domestic violence, and elder abuse") Qu 7. At what age does the driver mortality rate for motor vehicle crashes exceed that of the 16-19 age group? (From Chapter 41, entitled "Trauma in the elderly") Qu 8. Is there a genetic predisposition to alcohol abuse? (From Chapter 42, entitled "Alcohol and acute withdrawal") Qu 9. Will ultrasound replace CT scanning in the evaluation of blunt abdominal trauma? (From Chapter 44, entitled "Ultrasound in Trauma") Qu 10. What is the SAD PERSONS scale? (From Chapter 46, entitled "Psychiatric aspects of Trauma")

Ask any medical student, how he would like his information to be presented to him: in text form or in question-answer form, and the chances are he would opt for the latter. And there are good reasons for him thinking so. However much information he may acquire, his ultimate aim is to be able to answer all his theory and viva questions and to be able to pass the exams with good grades. Another of his worries is the extremely limited time that he has at his disposal. A graduate student spends most of his time in the school, and a postgraduate student in the hospital. What is top most in his mind is to be able to cover the whole course in shortest possible time.

Books in a question and answer format serve his needs extremely well. Hanley and Belfus has come out with an excellent "secret series", in which authentic information is imparted to the student in a question-answer form. The book under review is one in that series.

Trauma is a subject which encompasses many specialties - surgery, orthopedics, burns, forensic pathology and emergency medicine, being some of them. Students - and even younger doctors - are in dire need of a text which can answer their questions in a jiffy, without them being forced to read excessive text. Written by three experts in their fields, the book under review does this task admirably well. It "trims" lots of unnecessary text so to say, and presents the information in no-nonsense straightforward style.

The book is divided into 48 chapters arranged in fifteen sections. The sections include almost all topics related to trauma. There are sections on trauma basics, head and neck trauma, thoracic trauma, gastrointestinal trauma, endocrinology, surgical issues and so on. I as a forensic pathologist found several chapters of interest. Take for example Chapter 5 entitled "Mechanisms of wounding ballistics", which is full of interesting questions. Sample these questions: What is ballistics? Why must surgeons have a working knowledge of ballistics? What are the three principles of wound ballistics? What makes shotgun injuries so unique? What is the difference between low-velocity and high velocity missiles? And so on..

Answers Here are the answers to the questions asked in the box above Ans 1. CRAMS (Circulation, Respiration, Abdomen, Motor, Speech Scale), Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), Trauma Index (TI), Abbreviated Injury Severity (AIS), Injury Severity Score (ISS), TRISS (RTS or TS combined with ISS), ICD-9-CM (International Classification of Diseases, 9thRevision, Clinical Modification, Acute Physiology and Chronic Health Evaluation (APACHE), Pediatric Trauma Score (PTS) (Page 7) Ans 2. RSI is the sequential administration of a sedative or anesthetic along with a neuromuscular blocking agent to facilitate endotracheal intubation. This combination of sedation and brief paralysis provides the best environment for emergency airway management. Advantages of RSI include adequate sedation, full muscle relaxation to facilitate vocal cord visulization atraumatically and decreased risk of pulmonary aspiration. (Page 16) Ans 3. No. The injury is occasionally so trivial that the patient presents without a history of trauma. (Page 113) Ans 4. Untreated, the mortality is almost 100%. With aggresive treatment, it is currently about 20%. (Page 174) Ans 5. Yes! The treatment of fingernail injuries involves removal of the entire nail with exploration of all portions of the eponychial laceration. (Page 192) Ans 6. Trauma related to birth (e.g. cephalhematoma, clavicle fractures), Musculoskeletal disorders (e.g. osteogenesis imperfecta, rickets, scurvy, syphilis), Bleeding disorders, blood dyscrasias, and vasculitis, folk remedies (e.g. cupping, Cia Gao, or coining), Blistering skin lesions (e.g., erythema multiforme, staphylococcal scalded skin syndrome), Mongolian spots, Malabsorption syndromes, Sudden Infant Death Syndrome, Cardiopulmonary resuscitation.(Page 232-233) Ans 7. The rate begins to increase at age 70 (1.2 per 100 crashes). The rate increases for those drivers 80 years old to 4 per 100 crashes, exceeding the rate in the youngest population. A decrease in cognitive skills is believed to be related to this rate increase.(Page 249) Ans 8. It is thought that there is a genetic predisposition to alcoholism in about half of all alcoholics.(Page 251) Ans 9. CT scanning is still superior to ultrasound in detecting a solid organ injury and in grading its severity. In most surgeons' hands, ultrasound is limited to detecting abdominal fluid but is not particularly accurate in demonstrating which organ is injured. Currently, ultrasound should be considered an alternative to diagnostic peritoneal lavage in the evaluation of blunt abdominal trauma.(Page 262) Ans 10. This suicide risk assessment mnemonic stands for Sex, Age, Depression, Previous attempt, Ethanol abuse, Rational thinking loss, Social supports lacking, Organized plan, No spouse and Sickness.(Page 268)

The answers range from just one or two lines to a full length discussion bordering on one full page length. Diagrams, photographs and tables appear at appropriate places. Take for instance question number 15 on page 157 (from Chapter 27 entitled "Vascular Trauma"). The question is: What is the optimal exposure for an injury to the subclavian artery? Its answer runs to almost one full page and includes a diagram too.

Two CT images of Epidural hematoma

On page 46, the authors ask a question: Describe the etiology and radiographic appearance of epidural hematomas? The authors not only give a detailed explanation, but also give two photographs showing epidural hematomas in two different patients. In the first photograph the patient has a right middle fossa (temporal hematoma) and in the second photograph the patient shows left frontal fossa hematoma. Both hematomas are limited in their extension by the coronal suture. Such photographs increase the comprehension, and occur throughout the book.

At other places clear line diagrams appear. On page 260, a question is asked: What is the FAST exam for trauma? FAST actually stands for Focused Abdominal Sonogram for Trauma. It is designed to detect fluid (i.e. blood) in the pericardium or abdomen after trauma. Performing FAST is fast (seems like an interesting pun to me!), generally done in 2-3 minutes by experienced examiners, and involves looking at four areas in the supine trauma patient. The authors go on to explain not only in the text, but give a very clear line diagram, which should be very easy for the students to remember.

Mnemonics appear at several places making the job of the student much easier. Take for example question 42 on page 28 (from Chapter 4 entitled "Shock and Resuscitation"). The question is: What is the initial management of hemorrhagic shock? And the answer is - ABCDE! Intrigued? Well, it translates like this Airway, Breathing, Circulation, Disability and Exposure. Of course the authors gives explanations along with these. But this is a clever way of remembering which the students are going to love.

Four areas of scanning in a FAST scan

After giving the answers to some of the questions, the authors give relevant websites too for further exploration in the related areas. Take for example two questions appearing on page 29. The questions are What is ATLS? And What is AAST? ATLS actually is Advanced Trauma Life Support course designed and sponsored by the American College of Surgeons. The authors advise to go to the site http://www.facs.org for further information. Similarly AAST stands for the American Association for the Surgery of Trauma. For further information, the reader is advised to visit their site at http://www.aast.org. The authors have thus tried to rope in the latest web information in their answers too, which is a welcome change.

I think this is an excellent book for students appearing not only for their surgery or orthopedic examinations, but also for several other examinations such as pediatrics, radiology etc. I as a forensic pathologist thoroughly enjoyed this book, and I would imagine even forensic pathologists would find this book very valuable. Besides students appearing for various examinations, the book should be very valuable for young doctors doing the rounds in wards and manning emergency departments. Surely this book would solve several of their questions at odd hours when none of the senior doctors could be contacted immediately. Having this book would be like having a senior surgery advisor at your elbow round the clock!

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-Anil Aggrawal

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