Ellenhorn's medical toxicology

Book ReviewBook Review Ellenhorn’s Medical Toxicology: Diagnosis and Treatment of Human Poisoning, 2nd ed. Matthew J. Ellenhorn, Seth Schonwald, Gary Ordog, and Jonathan Wasserberger. Baltimore, MD: Williams and Wilkins, 1997, 2047 pp., $199, ISBN 0–683-30031–8. Thomas G. Rosano Published February 1998 The field of medical toxicology has expanded rapidly in new information and toxins since Ellenhorn and Barceloux wrote the first edition of Medical Toxicology: Diagnosis and Treatment of Human Poisoning. The second edition, written by Matthew Ellenhorn and published posthumously with the assistance of only a few coauthors, is clearly an authoritative work that has been renamed in recognition of the primary author. The new version has been completely rewritten and now spans 67 chapters, 2047 pages, and more than 13 000 references. The text, organized into five sections, gives a national and international approach to principles of poison management, individual drugs, intoxicants in the home, chemical poisons, and natural toxins. For the laboratorian, the first section on poison management offers a clinician’s insight to management of the intoxicated patient. Ellenhorn reaches into both his clinical experience and access to poison control data as he tabulates the toxic syndromes and causative agents. He also provides a practitioner’s perspective on diagnostic procedures that, while lacking in technical detail, outlines the interdisciplinary scope of services used in the workup of an intoxicated patient. The series of chapters in gut decontamination, elimination enhancement, antidotes, and supportive care cover treatment approaches that may appear to be beyond the laboratory boundaries but avail the laboratorian of baseline knowledge that is essential for an effective interface with the emergency medicine practitioner. The chapter on toxicokinetics presents principles adequately, with emphasis on breast milk kinetics and drugs in the elderly. An entire chapter is also dedicated to management of the pregnant patient. Clinical laboratorians seeking current information on therapeutic and abused drugs will find the second section on drug classes and individual agents a useful reference source. In addition to the agents covered in the first edition, the text has been expanded to include chapters on new analgesics, drugs for treatment of AIDS, antiviral agents, blood and blood-forming drugs, cytokines, plasma volume expanders, vasodilators, lipid-lowering drugs, immunotoxicology, respiratory drugs, and receptor-modulating drugs. The presentation on each therapeutic drug is consistent in format, including structure, classification, formulation where important, use, mechanism of action, therapeutic dose, toxic dose, toxicokinetics, clinical presentation, laboratory, and treatment. The introduction to drugs of abuse offers a broad overview of current abuse patterns with elaboration on the major agents in subsequent chapters. The section emphasizes emergency intoxication, but information on subacute or chronic intoxication such as cyclosporine-induced nephrotoxicity may not always be presented. Clearly the strengths of this major section of the textbook include the scope of coverage for therapeutic agents, the recent citations, and the prolific use of tables, summaries, and quick-to-learn facts. The extent of topical coverage is driven by new studies, requiring the clinical chemist to look to other sources for the more basic or previously established information. The final sections on poisons in the home, chemical intoxicants, and natural toxins were written primarily for the poison control and clinical practitioner, but these sections abound with reference information and insights for the laboratory-based toxicologist, especially those serving poison control centers or involved in medicolegal investigations. The coverage of over-the-counter stimulants and cold medications deserves reading. From the mechanism of gastric rupture by baking soda to intoxication with cosmetics, the rest of the home products section also makes interesting reading. The chemical agent section includes a wealth of information on alcohols, hydrocarbons, anesthetics, antiseptics, metals, pesticides, contrast media, and chemotherapeutic agents, and the chapter on chemical disasters gives a global overview of disaster planning in the prehospital and hospital phases. The natural toxin section stands as another valuable reference source for agents ranging from snake bites to mushroom poisons to traditional medicines. The laboratory aspects of the textbook are addressed from the clinical perspective, with abbreviated coverage of analytical issues. For example, in Chapter 10, Acetaminophen (Paracetamol), the authors effectively link the laboratory work-up with clinical findings. Rapid point-of-care drug testing is emphasized, and the nomographic interpretation of acetaminophen values is well covered. Ellenhorn also includes current information on glutathione S-transferase, a clinically sensitive index of acetaminophen-induced centrolobular damage of the liver. There is also a useful discussion of ancillary tests for renal function, hypoglycemia, and electrolyte balance. The information on acetaminophen assays, however, is very abbreviated and is handled better in other textbooks such as Tietz Textbook of Clinical Chemistry. In Chapter 55, Alcohols and Glycols, only rapid tests for ethanol are cited, and the reader must look to other sources for information on well-established enzymatic and chromatographic methods. While coverage of toxicologic methods may be limited, the role of the laboratory is integrated with other clinical and toxicokinetic issues, and the citations often allow the reader to obtain more in-depth information. Ellenhorn’s work stands among a number of major textbooks on the field of medical toxicology. Bryson’s recent edition of Comprehensive Review in Toxicology for Emergency Clinicians was written primarily for the practicing clinician and Goldfrank’s Toxicologic Emergencies uses a case-oriented approach with multiple contributing authors. While each of the major textbooks have value to laboratorians responsible for integrating analytical toxicology with clinical practice, Ellenhorn’s work stands out as a valuable state-of-the-art review of the many facets of medical toxicology and, therefore, serves as a valuable reference textbook for laboratorians involved in therapeutic, emergency, abuse, or medico-legal toxicology. Ellenhorn’s contribution to future editions will be missed, and his coauthors should be encouraged to carry on his tradition. • © 1998 The American Association for Clinical Chemistry