ABSTRACTS

emergency treatment of severe, acute asthma?" Three hun- dred forty-seven reports were reviewed, with only 13 meet- ing the inclusion criteria of controlled trials of W ami- nophylline therapy in severe, acute asthma. Five studies compared aminophylline as a single-drug regimen against another single-drug regimen, five others compared a given regimen against the same regimen with the addition of ami- nophylline, and three compared albuterol with steroids against the use of aminophylline with steroids. The results of these 13 studies did not agree. Seven reported no dif- ference in spirometric values between aminophylline and the control regimens, while three favored the control, and three found aminophylline to be superior. It was concluded that overall there was no difference between the ami- nophylline-treated groups and the control groups. For sin- gle-drug therapy alone, aminophylline is not as effective as other bronchodilators, and although a trend was detected favoring the addition of aminophylline to injected beta ago- nists, the evidence does not persuasively demonstrate that this common practice is beneficial.

Mark W Elliott, M D

methotrexate, corticosteroids, asthma

Methot rexate in the t rea tment of cor t icosteroid .dependent as thma Mullarkey MF, Blumenstein BA, Andrade WP, et al N Engl J Med 318:603-607 Mar 1988

A prospective, double-blind, randomized, crossover trial comparing low-dose methotrexate, an antagonist of folic acid and an anti-inflammatory agent when given in low doses (7.5 to 15 mg/wk), with placebo was conducted to ob- serve the effects on corticosteroid requirements in severe asthma. Fourteen patients with steroid-dependent asthma of 12 to 180 months duration and an average prednisone re- quirement of 173.5 + 107 mg/wk (range, 70 to 420 mg/wk) completed the study. The patients received either metho- trexate (15 mg/wk) or placebo for 12 weeks, after which crossover to the other agent was performed. Patients were encouraged to reduce their prednisone by 5 mg every five days if asthma symptoms improved during the study and to increase prednisone intake or seek medical attention if symptoms worsened. Patients kept a diary of symptoms, and all other medication regimens were unchanged. Thir- teen of 14 patients reduced their daily prednisone require- ments during methotrexate therapy (P < .002) by an average of 36.5% (range, 16.2 to 73.5%). One patient was able to discontinue prednisone during the study (as were four of nine additional patients who continued to take methotrex- ate after the study formally ended). Measured forced vital capacities and forced expiratory volumes at one second dur- ing the two treatment periods were not statistically differ- ent. Morbidity of methotrexate included mild nausea in three patients and a self-limited pruritic rash in one. It was concluded that this trial provides preliminary evidence of

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the short-term efficacy of methotrexate as a steroid-sparing agent in asthma patients who have corticosteroid-related morbidity. [Eddtor's note: This criticod review of the existing literature seriously calls into question the efficacy of the routine administration of IV aminophyll ine in the emer- gency department treatment of asthma.]

Michael Hunt, MD

CPR, carbon dioxide; cardiac arrest, blood flow

End-tidal carbon dioxide concentrat ion during cardiopulmonary resuscitat ion Falk JL, Rackow EC, Weil MH N Engl J Med 318:607-611 Mar 1988

Ten critically ill, manually ventilated patients were pro- spectively monitored for changes in end-tidal carbon diox- ide concentration (ETCO2) during CPR for cardiac arrest. Prior to arrest, the ETCO 2 was 1.4 + 0.9%. Within one minute of arrest, ETCO2 dropped to 0.4 + 0.4% but in- creased to 1.0 + 0.5% after 30 seconds of chest compres- sion. Successful resuscitation was heralded by the return of spontaneous circulation and a coincident increase in the ETCO 2 to 3.7 + 2.1% after eight minutes. The ETCO 2 of unsuccessfully resuscitated patients remained steady at 0.7 + 0.4%. IV sodium bicarbonate administration during CPR produced a transient ETCO 2 increase that dissipated within two minutes. Because ETCO2 is principally influenced by CO 2 production, alveolar ventilation, and pulmonary perfu- sion, this parameter is postulated to be an accurate indica- tor of blood flow. It was concluded that during chest com- pressions the ETCO2 is a reliable, noninvasive gauge of CPR efficacy and that an abrupt increase in the ETCO 2 un- der conditions of reasonably constant ventilation provides the earliest evidence of successful resuscitation. [Editor's note: A l l patients in this s tudy were in a critical care unit in tubated on a ventilator wi th continuous ETCO 2 monitor- ing prior to their cardiac arrests. I f ETCO 2 moni tor ing could be extended to the prehospita] and emergency de- par tmen t areas i t would have tremendous usefulness not only as to the efficacy of CPR but as an indicator of proper endotrachea] tube placement.]

Michael Hunt, MD

spinal cord injury, pediatric

Pediatr ic spinal injury: The very young Ruge JR, Sinson GP, McLone DG, et al J Neurosurg 68:25-30 Jan 1988

Seventy-one of 2,598 (2.7%) cases of spinal cord injuries (SCI) in children 12 years or younger were reviewed retro-

Annals of Emergency Medicine 17:7 July 1988