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The management of head injuries—a practical guide for the emergency room. 2nd edition.
  1. Ian Swann
  1. Consultant in Accident and Emergency Medicine, Glasgow Royal Infirmary

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    By D Currie, E Ritchie, S Scott. (Pp 196; £26.95). Oxford University Press, 2000. ISBN 0-192-63078-4.

    In this second edition David Currie, a Scottish neurosurgeon, has been joined by two anaesthetists to provide a handy guide for the management of patients with head injuries aimed at junior doctors and nurses working in the emergency room and ward setting. A welcome addition is the excellent chapter on the disturbed patient, which will be appreciated by nurses on wards that are often under staffed. Advice with which most A&E specialists would agree includes “observation should ideally be undertaken on a neurosurgery ward”.

    There could be more detail on the practical issues of how the “frontline” staff can safely and efficiently sort out difficult patients with complex problems. When they arrive in A&E, patients rarely have “isolated head injury” stamped on their foreheads yet I believe this is the way neurosurgeons would like to receive them. The management of potential alcohol withdrawal deserves more than a mention.

    I am concerned about the use of a contraction of the 15 point GCS score to a total of 14—this could create confusion in clinical discussions if the score is used without clarifying the denominator, for example, GCS < 8 instead of < 9 is given as the criterion for intubation and ventilation. The importance of describing the levels of the three responses and avoiding numbers should be emphasised.

    It is good that ATLS principles are espoused and there is an expanded chapter on cervical spine injuries but the inappropriate term “traction” is still used rather than “in line immobilisation”. Scalp “lacerations” should be differentiated from “incised wounds”—an important clue to the likely mechanism. Some typographical errors and mislabelling are retained and, in my copy, the clarity of some photographs has deteriorated compared with first edition.

    Possibly because of the timing of this edition, it excludes the guidelines for the initial management of head injuries by the Society of British Neurological Surgeons (1998), which, for example, recommend computed tomography within four hours for GCS 15 patients with skull fracture.

    This book about a common A&E presentation is written mainly for A&E staff by non-A&E specialists. To justify its title there needs to be a greater focus on what really happens in the emergency room everyday and an up to date view of what we should be doing in the future.