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Commotio Cordis

Introduction

Commotio cordis is a condition in which blunt trauma to the chest triggers sudden cardiac arrest (heart stops beating). It is caused most frequently by small spherical projectiles (such as a baseball, lacrosse ball, hockey puck) and occurs most frequently in young males. Although this condition is quite rare, commotio cordis is one of the more common causes of sudden cardiac arrest in young athletes, particularly baseball players.

Basics

Commotio cordis is defined as abrupt cardiac arrest caused by blunt trauma to the chest wall which causes ventricular fibrillation (a lethal cardiac rhythm). This lethal cardiac rhythm is triggered by direct trauma to a particular area of the heart (the cardiac silhouette) at a very specific time during the heartbeat. Experimental models show commotio cordis is typically caused by harder, smaller spherical objects such as a ball and seems to be more common at velocities up to 40 mph, but less common at velocities significantly greater or significantly less than 40 mph. While the exact number of cases of commotio cordis is unknown, in the mid-1990s the National Commotio Cordis Registry was established in the United States and now over 200 confirmed cases have been studied and documented providing a relative wealth of data on this rare condition. This data shows this condition typically occurs in young people (mean age 15), 95 percent cases are in males, and 75 percent occur during competitive sports, most often those sports that involve blunt projectiles (baseball, lacrosse, hockey).

Recognition

Commotio cordis should be immediately considered in any athlete who collapses after being struck in the chest.  If the athlete is found to be unresponsive, immediately activate EMS, initiate the Emergency Action Plan and start CPR if the athlete is not breathing and/or pulseless. While there were no reported survivors in the first 25 cases recorded in the National Commotio Cordis Registry, survival has increased to 58% for cases reported between 2006-2012. This is likely due to early recognition, rapid activation of Emergency Medical Services, particularly early CPR and defibrillation. Many of these defibrillations were performed by bystanders using Automated External Defibrillators (AEDs).

Prevention

Avoidance of chest trauma with hard, blunt objects is the foundation of prevention. This is, however, inherently difficult in baseball. Nonetheless, it is interesting and important to note that softer, less dense balls in younger age groups (for example, softer baseballs in youth leagues) have been shown to decrease the incidence of commotio cordis. Interestingly, commercially available chest protectors have NOT been shown to be effective in preventing commotio cordis in the laboratory setting or in the community. In fact, some of the commotio cordis victims were wearing protective equipment at the time of their injury.

Summary

Commotio cordis is a rare but life threatening injury that can occur due to blunt chest trauma in baseball players. Recognition and rapid initiation of treatment including CPR and defibrillation are keys to survival of this injury. Accordingly, an operational, readily available AED is one of the most important pieces of equipment for any youth sports facility or league.

Key Points

  • Commotio cordis is sudden cardiac arrest caused when a blunt object strikes the chest triggering a potentially lethal heart rhythm.
  • Once universally fatal, many young athletes now can survive Commotio Cordis if they are treated with rapid initiation CPR and defibrillation. An operational, readily available AED is a crucial piece of safety equipment for youth sports complexes and leagues.
  • Commercial chest protection has not been shown to be effective in preventing commotion cordis.
  • Commotio Cordis is most common in young athletes, particularly males. 
  • While Commotio Cordis can be caused by any blunt trauma to the chest, it is most commonly caused by relatively low velocity (<40 mph) blunt trauma from a cylindrical object such as baseball, hockey puck or lacrosse ball.

References

Drewniak EI, Spenciner DB, Crisco JJ. Mechanical properties of chest protectors and the likelihood of ventricular fibrillation due to commotio cordis. J Appl Biomech 2007; 23:282.

Doerer JJ, Haas TS, Estes NA 3rd, et al. Evaluation of chest barriers for protection against sudden death due to commotio cordis. Am J Cardiol 2007; 99:857.

Kalin J, Madias C, Alsheikh-Ali AA, Link MS. Reduced diameter spheres increases the risk of chest blow-induced ventricular fibrillation (commotio cordis). Heart Rhythm 2011; 8:1578.

Link MS. Commotio Cordis. UpToDate. Accessed 2/15/2015.

Link MS. Commotio cordis: ventricular fibrillation triggered by chest impact-induced abnormalities in repolarization. Circ Arrhythm Electrophysiol 2012; 5:425.

Link MS, Maron BJ, VanderBrink BA, et al. Impact directly over the cardiac silhouette is necessary to produce ventricular fibrillation in an experimental model of commotio cordis. J Am Coll Cardiol 2001; 37:649.

Link MS, Maron BJ, Wang PJ, et al. Upper and lower limits of vulnerability to sudden arrhythmic death with chest-wall impact (commotio cordis). J Am Coll Cardiol 2003; 41:99.

Link MS, Maron BJ, Wang PJ, et al. Reduced risk of sudden death from chest wall blows (commotio cordis) with safety baseballs. Pediatrics 2002; 109:873.

Link MS, Wang PJ, Pandian NG, et al. An experimental model of sudden death due to low-energy chest-wall impact (commotio cordis). N Engl J Med 1998; 338:1805.

Madias C, Maron BJ, Weinstock J, et al. Commotio cordis--sudden cardiac death with chest wall impact. J Cardiovasc Electrophysiol 2007; 18:115.

Maron BJ, Estes NA 3rd. Commotio cordis. N Engl J Med 2010; 362:917.

Maron BJ, Haas TS, Ahluwalia A, et al. Increasing survival rate from commotio cordis. Heart Rhythm 2013; 10:219.

Weinstock J, Maron BJ, Song C, et al. Failure of commercially available chest wall protectors to prevent sudden cardiac death induced by chest wall blows in an experimental model of commotio cordis. Pediatrics 2006; 117:e656.