A B S T R A C T S

eclampsia; labetalol; dihydralazine

Malignant ventricular arrhythmias in eclampsia: A comparison of labetalol with dihydralazine Bhorat IE, Naidoo DP, Rout CC, et al Am J Obstet Gynecol 168.1292-1296 Apt 1993

The aim of this study was to assess the effect of labetalol compared with dihydralazine on the incidence and severity of ventricular arrhyth- mias in eclamptic subjects. Constant labetalol infusion or intermittent dihydralazine injections were given to 40 antepartum eclamptic patients to control blood pressure. All patients also were given magnesium sulfate and delivered by cesarean section within six to eight hours of admiss'ion. The subjects' blood pressure, heart rate, and continuous ECG monitoring were recorded for 24 hours. Both treatment groups achieved adequate control of blood pressure before delivery. However, the dihydralazine group showed a statistically significant increase in heart rate after the treatment (118 to 126), while the labetalol group showed a decrease (119 to 95). Ventricular arrhythmias were screened by a cardiologist blinded to the study and graded according to the Lown classification. The inci- dence of serious ventricular arrhyth- mias was significantly higher in the dihydralazine group (81%) compared with the labetalol group (17%). Neonatal outcome and Apgar scores were similar in the two groups. Three neonates in the labetalol group exhibited transient bradycar- dia within 30 minutes of delivery that resolved without treatment. The authors conclude that g-adrenergic blockade in the peripartum hyperten- sive management of eclampsia sig- nificantly reduces the incidence of dangerous ventricular arrhythmias.

Scott Paul& MD

meningitis; lumbar puncture

Cerebral herniation during bacterial meningitis in children Rennick G, Shann F, de Campo J Br Med J 306.953-955 Apr 1993

The authors reviewed the records of 157 children to determine the inci- dence of cerebral herniation after lumbar puncture (LP) and reviewed the results of computed tomography (CT) performed near the time of LP. All children had a diagnosis of bac- terial meningitis and had died, had been admitted to the ICU, or had cranial CT performed. Twenty-one episodes of cerebral herniation occurred in 19 children; in 19 of the episodes an LP was performed. Four herniations occurred before an LP, eight herniations occurred within three hours after LP, and 12 hernia- tions occurred within 12 hours after LP. Of 14 CT scans performed near the time of herniation, five were normal. The authors conclude that LP can cause cerebral herniation in some patients and that normal cranial CT does not exclude this possibility. They suggest that in children who are so ill that they will be admitted and given antibiotics, even if the initial LP is normal, LP should be delayed several days until their condition improves and a normal CT scan has been obtained. [Editor's note: Although this study raises concerns, assuming a causal association from a temporal relation- ship based on retrospective data is tenuous at best.]

Paul Lane, MD

trauma, blunt

Blunt trauma in children: Causes and outcomes of head versus extracranial injury tescohier I, OiScala C Pediatrics 91.721-725 Apt 1993

The authors analyzed a subset of the National Pediatric Trauma Registry to describe causes and outcomes of blunt trauma among children less than 15 years old. This subset of 8,639 children was divided into three groups according to the injured body region. Almost half (4,266) had extracranial injury only (ECI), about one-fourth (2,132) had head injury only (HI), and the remainder (2,241) had both head injury and extracra- nial injury (HI + ECI). The three groups were compared with respect to demographic characteristics, external cause of injury, injury sever- ity, and outcomes. Boys accounted for approximately two-thirds of the cases in each group. A greater pro- portion of young children fell in the HI group versus the ECI or HI + ECI group. Falls were the predominant cause of injury in the HI group. Traffic-related injuries predominated in the ECI and HI + ECI groups with pedestrian injuries being the major contributor. The highest proportion of severe injuries and in-hospital deaths were observed in the HI + ECI group, and the lowest in the ECI group. Functional impairments at discharge were most frequently noted in the ECI group (60%). In contrast, impairments resulting from head injury affected a smaller pro- portion (6%), but tended to produce a more significant disability. [Editor's note. The finding that pedestrian rather than motor vehicle occupant injuries predominated in the traffic-related injury category suggests that child injury prevention strategies should be refocused on pedestrian safety.]

Kathy Kroshus, MD

myocardial infarction

Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction Zehender M, Kasper W, Kauder E,

etal N Engl J Med 328.981-988 Apr 1993

This German study prospectively evaluated 200 consecutive patients admitted with acute inferior myocar- dial infarction. The diagnostic accu- racy of ST-segment elevation in right precerdial lead V4R (107 of 200 patients) was found to be predictive of right ventricular infarction (sensi- tivity, 88%; specificity, 78%). Right ventricular infarction was confirmed with one of four modalities: autopsy, ventriculography, technetium scan- ning, or invasive hemodynamic mea- surements. The prognostic implica- tion of right ventricular infarction also was evaluated. Logistic regres- sion analysis revealed V4R ST-seg- ment elevation to be the most pre- dictive clinical finding available at the time of admission for assessing the risk of in-hospital mortality (rela- tive risk, 7.7) and major complica- tions (relative risk, 4.7). The mortality rate for patients with V4R ST-segment elevation was 31% as compared with a rate of 6% for those patients without this finding. Similarly, the major complication rate was 64% in patients with V4R ST-segment elevation and 28% in the rest of the study population. The authors conclude that right ventricu- lar infarction associated with acute inferior myocardial infarction can be diagnosed reliably by the finding of ST-segment elevation in lead V4R. This subset of patients comprises a high-risk group for major complica- tions and in-hospital mortality. The authors recommend routine right precordial ECG assessment for all

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