CCU was subsequent development of myocardial infarction, of ventricular tachycardia, or ventricular fibrillation. Ninety- three percent of patients with neither prolonged chest pain nor ischemic ECG changes or only one of these had PVCs or no dysrhythmias. However, these were not associated with the de- velopment of lethal arrhythmias, allhough it is not apparent from the study whether these were treated. Therefore, the study is suspect since if not treated, these may have developed into lethal arrhythmias. Most of these patients should be admitted for definitive workup of their coronary artery dis- ease. Mitchell Leavitt, MD angina

A study of the utilization of skull radiography in nine accident and emergency units in the United King- dom. Bligh AS, Lancet 2:1234-1237, (Dec) 1980.

The use of skull radiography for victims of head injury was studied in nine medical centers in the Uni ted Kingdom. Of 5,850 pat ients receiving s k u l l radiographs, 2% had l inear skull fractures and four pat ients suffered depressed fractures. Seventeen percent had other illnesses or injuries in addition to the head injury, and this group accounted for almost ha l f the l i n e a r f r a c t u r e s detec ted . One case of i n t r a c r a n i a l aerocele and seven cases of in t racrania l hematoma occurred in the study group. In over 25% of cases, the physician order- ing the radiographs thought a fracture was definitely absent prior to viewing the x-rays, with a judgmenta l accuracy of 99%. Pat ients with head injuries not radiographed were ex- cluded from the study. (Editor's note: The cost of detecting skull fractures in patients when there was no suspicion from physical exam was three times the cost of detecting fractures where there was clinical suspicion. The costs were £975 and £360, respectively. We are sure the patient in the former group would support the aggressive use of skull radiograph despite the lower cost~benefit ratio.) Carla Janson, MD

radiography, skull

Asthma in pregnancy: Current concepts. Hernandez El Angell CS, Johnson JWC, Obstet Gyneco155"739- 743, 1980.

Pregnancy is complicated by as thma in 1% of patients. Se- vere at tacks can have major impact on the woman and her fetus. The authors review several case histories of pregnancy complicated by as thma, and suggest a stepwise order of out- patient and inpat ient management . They point out tha t pa- tients experiencing exacerbation of as thma during one preg- nancy are l ike ly to do so in subsequent pregnancies. The authors suggest t ha t no medication be given to the asympto- matic pat ient if she is not already taking any. A medication regimen is suggested for the pat ient whose as thma is in poor control. The a u t h o r s s u g g e s t s t a r t i n g w i t h a n h y d r o u s theophylline, 100 mg to 200 mg every six hours, increasing dosage un t i l m a x i m u m benef i t is obta ined or toxicity is noted. A blood level of 10 ~g/ml to 20~g/ml is the goal. Be- cause epinephrine has been associated with minor ear and eye malformations in the fetus during the first trimester, its risk/benefit must be carefully considered. Ephedrine has not been found to be teratogenic and may be a safer sympatho- mimetic t han are metaproterenol or terbutal ine, though it is less effective. Corticosteroids should be used only for pat ients with refractory symptoms. Though beclomethasone dipro- pionate has not been proven to be safe during pregnancy, only a small amount is absorbed systemically and it may allow s te ro id -dependen t p a t i e n t s to reduce t he i r dosage needs. The acu t e a t t a c k shou ld be m a n a g e d w i t h t he aforementioned in mind; however, the most significant factor affecting the fetus will be hypoxia, which war ran t s aggres- sive t r ea tment in the res is tant patient. Should the PO2 go below 60 mm Hg despite aggressive t rea tment , Cesarean sec- tion should be considered if possible. (Editor's note" Because of the rarity of the problem, this will not often be seen in the

emergency department. Two lives are at stake here, so OB- G Y N consultation should be sought early and vigorous ther- apy of asthma undertaken. This article is a good review of managing asthma in the pregnant woman.)

Frank Barber, MD asthma, in pregnancy

Cerebral herniation in bacterial meningitis in child- hood. Horwitz S J, Boxerbaum B, O'Bell J, Ann' Neurol 7:524-528, 1980.

Increased in t racrania l pressure with resul t ing cerebral her- n ia t ion complicating bacter ia l meningi t i s has been recog- nized clinically for 20 years. This retrospective study in- volved 18 cases of cerebral hernia t ion complicating bacterial meningitis. I t was hoped tha t analysis of the clinical course could be used to predict a h igh risk of herniat ion, thus iden- t i fy ing those p a t i e n t s who should be t r e a t e d ear ly and aggressively with diuretics and steroids. Diagnosis of hernia- t ion was based on clinical signs only, except in one case proven by autopsy. The clinical signs used as criteria to pre- dict hernia t ion were: fixed dilated pupils (bilateral or Uni- lateral) , hemipares i s Or decort icate/decerebrate posturing, apnea or Cheyne-Stokes respiration, and loss of oculomotor response. At least two of these had to be present simulta- neously. The authors were unable to identify any reliable predictive signs, pr imari ly due t o t h e fact tha t many pat ients with meningit is suffer seizures, and the post-ictal s tate can include all the above-mentioned signs. However, the authors concluded t h a t prolonged pupi l lary di la ta t ion and lack of reaction to l ight indicate the probabili ty of hernia t ion ra the r than the post-ictal s tate in cases of meningit is . The type of organism, cerebrospinal fluid Cell counts, and protein or glu- cose levels were not helpful in predicting herniat ion. The au- thors concluded tha t prompt use of manni tol is an impor tant mode of t rea tment to decrease cerebral edema. The use of large dosages of corticosteroids to prevent rebound edema showed no adverse effect, n o r d i d it demonstrate a distinct benefit. (Editor's note: ICP monitoring plus deep barbitu- rate-induced coma has been found useful in Reyes syndrome. One wonders if this might not be a useful modality for bac- terial meningitis.) Frank Barber, MD meningitis, bacterial

Cefaclor ® in treatment of otitis media and pharyngi- tis in children. McLinn SE, Am J Dis Child 134:560-563, (Jun) 1980.

This was a prospective, single-blind study of 130 children with otitis media and 88 children with streptococcal pharyn- gitis tha t compared t r ea tmen t with Cefaclor ® and amoxicillin t r ihydrate for t r ea tmen t of the latter. Cefaclor ~ is a new oral cephalosporin wi th in vitro act ivi ty aga ins t streptococcus pneumoniae, Hemophilus influenzae, B-hemolytic streptococ- ci, and Staphylococcus aureus. Treatment ranged from i0 days to three weeks. In general, pat ients with otitis media who were t reated with Cefaclor ® had fewer acute failures and bet ter total success t han did pat ients who received amoxicil- lin, a l though the difference was not statistically significant. Of note was the fact t ha t Cefaclor® was shown to be superior to amoxicillin against both S pneumoniae and H influenzae, the two leading causes of otitis media (54% and 25%, respec- tively) in this study group. Group A B-hemolytic strep and S aureus were causative organisms of otitis media in approx- imately 8% of this pa t ient population. These organisms are often res i s t an t to ampici l l in but susceptible to Cevaclor ®. There was no significant difference in results of t r ea tment of streptococcal pharyngi t is with Cefaclor ® versus penicillin. In addition, Cefaclor ® was found to have no serious adverse effects, and was rated more palatable than penicillin by the children studied. (Editor's note: The retail price of 150 cc pediatric suspension with 250 mg/5 cc is: Cefaclor ®, $20.80; amoxaci!lin, $6.70; Pen VK, $6.55.) Sandra Greco, MD otitis media, treatment; pharyngitis, treatment

10:6 (June) 1981 Ann Emerg Med 343/87