Biphasic Versus Monophasic Shock for External Cardioversion of Atrial Flutter: A Prospective, Randomized Trial: Mortensen K, Risius T, Schwemer TF, et al. Cardiology 2008;111:5762

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    stage 5 of the Bruce protocol before the ascent; and served astheir own controls (no dysrhythmias were demonstrated during

    The Journal of Emergency Medicine, Vol. 36, No. 3, pp. 326330, 2009Copyright 2009 Elsevier Inc.

    Printed in the USA. All rights reservedel I trauma center, reviewed 50 cases from 20002006 ofergency department thoracotomy (EDT) for penetrating ab-

    inal trauma to examine whether prelaparotomy EDT is ben-ial. The majority of patients were young men suffering fromshot wounds. Patients at the same institution who underwentT for thoracic injuries served as the comparison group. The

    the control phase). Above 5000 m, all subjects experiencedpalpitations during exercise and all subjects demonstrated sinustachycardia and marked sinus dysrhythmia. One subject dem-onstrated asymptomatic atrial flutter (4500 m, 76% oxygensaturation), one subject had asymptomatic non-conducted Pwaves (4300 m, 84% oxygen saturation), and one subject hadAbstracts

    BIPHASIC VERSUS MONOPHASIC SHOCK FOR EX-RNAL CARDIOVERSION OF ATRIAL FLUTTER: AOSPECTIVE, RANDOMIZED TRIAL. Mortensen K, Ri-s T, Schwemer TF, et al. Cardiology 2008;111:5762.This single-blinded, randomized prospective trial from Ger-ny evaluated the difference in cardioversion rates betweennophasic and biphasic defibrillators in atrial flutter. The authorsnowledged that biphasic cardioversion in atrial fibrillation hasn shown to be superior in previous studies but that none hadked at atrial flutter. Ninety-five of 135 symptomatic atrialter patients from the clinic, ward, and Emergency Departmentne academic cardiac center were prospectively enrolled. Par-

    pants were then randomly assigned to either monophasic orhasic cardioversion. On analysis, the two groups were similarh respect to age, gender, underlying cardiac disease, and use ofdications. Patients in the monophasic arm received sequentialcks of increasing energy of 100, 150, 200, 300, and 360 joules,ereas patients in the biphasic arm received sequential shocks of75, 100, 150, and 200 joules. Successful cardioversion wasned as remaining in sinus rhythm for 30 s. The resultsonstrated that 28% of the monophasic patients compared toof the biphasic patients had successful cardioversion on the

    t shock (p 0.04). Results were similar for the second higherrgy shock when delivered. The authors concluded that biphasicernal cardioversion of atrial flutter is superior to monophasicernal cardioversion.

    [Leslie Armstrong, MD,Denver Health Medical Center, Denver, CO]

    Comments: This was a very small study with an outcomet is of limited clinical value. Given the minimal clinicalnificance of both the disease and the measured outcome, it islear whether any change in practice should be made basedthese results.

    EMERGENCY DEPARTMENT THORACOTOMY:ILL USEFUL AFTER ABDOMINAL EXSANGUINA-

    N? Seamon MJ, Pathak AS, Bradley KM, et al. J Traumamary outcome of this retrospective review was neurologicallyct hospital survival. Survival to the operating room (OR),

    asyoxy

    326vival to 48 h, and intensive care unit (ICU) length of stay wereo investigated. Of the 50 patients who underwent EDT forominal exsanguination, 23 survived to the OR, none expired inICU, and the 8 who survived to 48 h also survived the entirepitalization neurologically intact. There were no statistical dif-

    ences between those who had EDT after abdominal trauma andse who sustained thoracic trauma, with the exception thatients in the latter group were less likely to have vital signssent in the ED. The authors conclude that prelaparotomy EDTabdominal exsanguination is not futile care and should there-

    e be considered in the care of a patient with penetrating ab-inal injuries. The authors hypothesize that the survival benefit

    y be a result of open cardiac massage and thoracic aorticss-clamping.

    [Maggie DiGeronimo, MD,Denver Health Medical Center, Denver, CO]

    Comment: This is a small study performed at a single centery familiar with penetrating trauma. Despite these limitations, a

    survival rate is compelling and suggests that prelaparotomyT for critical abdominal injuries should be considered as anion in management of these patients at qualified centers.

    HIGH-ALTITUDE DYSRHYTHMIAS. Woods DR,en S, Gardiner D, et al. Cardiology 2008;111:23946.This study sought to investigate the cause and nature ofpitations occurring at high altitude. Nine healthy male vol-eers had implantable loop recorders (ILR) implanted sub-aneously in the left pectoral region. The study subjects flewt to Kathmandu (1250 m), then to Lukla (2800 m) beforemencing an ascent and descent profile to high altitude

    00 m to 6325 m, depending on subject). The ILR wasotely activated with any episode of palpitations and duringrcise, rest, and sleep. Arterial oxygen saturation via pulsemetry was measured concomitantly with device activation.9 subjects were free of cardiac morbidities and had nevererienced palpitations; they all underwent cardiovascularminations, two-dimensional echocardiograms, and at least

    0736-4679/09 $see front mattermptomatic marked ST-segment depression (6300 m, 59%gen saturation). The authors conclude that significant dys-

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