Commotio cordis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Commotio cordis is a rare and potentially fatal condition characterized by sudden cardiac death triggered by a blunt, non-penetrating impact to the chest. It is most commonly associated with sports activities, such as baseball, ice hockey, lacrosse, and softball. However, it can also occur as a result of fistfights or other forms of physical violence.

Typically, arrhythmic deaths are caused by a low/mild force striking the chest wall, a condition known as Commotio Cordis. Many of those suffering from this condition are athletes between the ages of 8 and 18 and play sports that involve projectiles, such as baseball, hockey pucks, and lacrosse balls. When a hand strikes in martial arts, its force can alter its rhythm, causing it to become arrhythmic. If a projectile strikes the athlete’s heart in the middle of their chest with a low impact but is sufficient to cause their heart to become arrhythmic, it can also cause the athlete’s heart to become arrhythmic. In the case of commotio cordis, a poor prognosis is associated with failure to provide immediate CPR and defibrillation. This is a hazardous condition that has a very low survival rate.

The most common causes of Commotio cordis are sports that during them the chance of chest trauma with objects or the opponents is high. It can also be seen in cases of child abuse, torture, motor vehicle collisions or fights. There are several measures to reduce the incidence of commotio cordis and its complications in sports such as: having athletic trainers, teaching CPR and the usage of AED among trainers and athletics and other personnel, wearing protective equipment, avoiding weight and strength disparities among athletics.

Commotio cordis should be distinguished from cardiac contusion, which occurs when a blunt strike to the chest damages the structural heart structures. the differential diagnosis of commotio cordis includes other causes of sudden cardiac death during sport participation, such as familial hypertrophic cardiomyopathy, myocarditis, dilated cardiomyopathy, long-QT syndrome, Brugada syndrome, Wolf-Parkinson-White syndrome, Marfan syndrome, aortic valve stenosis, mitral valve prolapse, coronary artery disease, asthma, heat stroke, drug abuse, and a ruptured cerebral artery. It is important to consider the possibility of intentional acts of violence causing commotio cordis.

Commotio cordis is a very rare event, but nonetheless is often considered when an athlete presents with sudden cardiac death. Among the cardiovascular factors leading to sudden death in athletes, commotio cordis holds the second-highest occurrence rate, after hypertrophic cardiomyopathy. The incidence of commotio codis is less than 30 cases per year. The USA Commotio Cordis Registry reported 216 cases recorded by July 2012, with most of the cases occurring in Little League baseball, lacrosse and softball. The real number of cases may be much larger. Children are especially vulnerable due to their more fragile thoracic skeleton. Boys between the ages of 8 and 18 are more likely to suffer from this condition.

The risk factors for commotio cordis include the location and timing of the blow, the type of mechanical stimulus, age, chest morphology, and the hardness of the object involved in the impact. Understanding these risk factors can help in developing preventive measures and strategies to reduce the incidence of commotio cordis, especially in high-risk populations such as young athletes participating in sports with a higher potential for chest impacts. Certain sports have been identified as having a higher potential risk for commotio cordis such as Karate, Taekwondo, Judo, Kabedi, Free-style Wrestling, Cricket, baseball, hockey, lacrosse, and softball.

Almost all of the patients with commotio cordis will die without any proper intervention due to arrhythmia. More than two third of those with prompt cardiopulmonary resuscitation/defibrillation experience a full physical recovery, while the remaining patients exhibit mild to moderate residual neurological disability or cardiac impairment during the follow-up period spanning from 1 to 20 years. Commotio cordis has a poor prognosis. However, a continuous rise of survival rates due to increasing awareness of the disease and prompt intervention is evident.

Symptoms of commotio cordis may include: immediate collapse, sudden cardiac arrest and loss of consciousness.

Immediately after the incident, there may not be any obvious signs of chest trauma, such as bruises. Individuals with commotio cordis are generally appeared to be unresponsive, apneic, cyanotic, pulseless without an audible heartbeat.

There are no laboratory findings associated with commotio cordis.

The most common rhythm observed in commotio cordis cases is ventricular fibrillation (VF). Other arrhythmias such as polymorphic ventricular tachycardia, complete heart block, idioventricular rhythm, atrial fibrillation, ST-segment elevation, T-wave abnormalities were reported. The timing and location of the impact are crucial in the generation of VF in commotio cordis. When the impact occurs directly over the heart within a specific window during the upslope of the T wave in ventricular repolarization, it triggers a rapid increase in left ventricular intracavitary pressure, leading to VF.

Echocardiography can aid in the diagnosis of specific cardiac injuries in commotio cordis. Doppler echocardiography can be used to diagnose coronary artery rupture. whereas, transthoracic or transesophageal echocardiography can help identify pericardial effusion, pericardial tamponade and cardiac lacerations. It may reveal contusion over the left or right ventricle, indicating the presence of significant chest wall trauma. Also, Follow-up and monitoring of the resolution of pericardial effusion and assess any changes in cardiac function over time can be achieved by echocardiography. It may be helpful for risk stratification and prognosis as well. It is important to note that echocardiography should be performed promptly after the return of spontaneous circulation (ROSC) in patients who have experienced cardiac arrest.

Cardiac magnetic resonance imaging (MRI), can help assess the presence of any pre-existing or trauma-associated structural lesions in the heart. This imaging modality can provide valuable information about the structural integrity of the heart and help rule out other potential causes of sudden cardiac arrest.

Autopsy examination remains the gold standard for confirming the diagnosis of commotio cordis and excluding other structural lesions in the heart. The autopsy findings in cases of commotio cordis typically show no structural or congenital abnormalities in the heart. It is important to exclude cardiac pathology, such as contusio cordis (cardiac bruising), to ensure an accurate cause of death.

The first step in the treatment of commotio cordis is immediate recognition and activation of emergency medical services (EMS). Bystander cardiopulmonary resuscitation (CPR) should be initiated as soon as possible to maintain blood flow and oxygenation. Early defibrillation with an automated external defibrillator (AED) is also essential to restore normal heart rhythm. In cases where commotio cordis occurs in a healthcare setting or in the presence of medical professionals, advanced cardiac life support (ACLS) protocols should be followed. This includes advanced airway management, administration of medications such as epinephrine and amiodarone, and possible interventions such as cardioversion or transcutaneous pacing.

There are different measures to prevent or reduce the risk of commotio cordis. One preventive measure is the use of safety baseballs which are softer than regular balls. Other preventive measures include the use of chest wall protectors. Chest wall protectors, such as those used in ice hockey, can help soften the impact of projectiles. However, recent studies indicated that there is no clear evidence of the effectiveness of chest protectors in reducing the risk of commotio cordis. Also, ensuring the availability of defibrillators at sporting events is essential in preventing deaths from commotio cordis. Education and awareness among coaches, trainers, and participants in high-risk sports events are also important preventive strategies. the decision to return to sports after experiencing commotio cordis should be carefully evaluated on an individual basis, considering factors such as the underlying cause of the event, the severity of the injury, and the presence of any underlying cardiac conditions.

There is no cost-effectiveness of therapy for commotio cordis.

There are no future or investigational therapies for commotio cordis.

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Maryam Hadipour, M.D.[2]Cafer Zorkun, M.D., Ph.D. [3]

Typically, arrhythmic deaths are caused by a low/mild force striking the chest wall, a condition known as Commotio Cordis. Many of those suffering from this condition are athletes between the ages of 8 and 18 and play sports that involve projectiles, such as baseball, hockey pucks, and lacrosse balls. When a hand strikes in martial arts, its force can alter its rhythm, causing it to become arrhythmic. If a projectile strikes the athlete’s heart in the middle of their chest with a low impact but is sufficient to cause their heart to become arrhythmic, it can also cause the athlete’s heart to become arrhythmic. In the case of commotio cordis, a poor prognosis is associated with failure to provide immediate CPR and defibrillation. This is a hazardous condition that has a very low survival rate.

• Commotio cordis occurs due to sudden blunt force trauma to the chest, causing sudden death without damage to the heart. It does not occur simply by striking the chest. The blow must occur just at the right time during the heartbeat and must hit close to the left ventricle.
• In the event of an impulsive blow to the chest, you may suffer from hypertension, in which the lower chambers of your heart beat abnormally fast. This may be dangerous if you are struck again, in the same manner, a few minutes later.
• Commotio cordis should be distinguished from a condition called a cardiac contusion, which occurs when a blunt strike to the chest damages the structural heart structures. Motor vehicle accidents are an example of such a case. ^[1]

There are many possible causes of commotio cordis, including the impact of being hit by an object:^[2]

• baseball
• hockey puck
• lacrosse ball
• softball

The following factors increase the chance of commotio cordis^[3][4]:

• Direction of impact over the precordium (precise area, angle of impact)
• Total applied energy (area of impact versus energy, i.e., speed of the projectile multiplied by its mass)
• Impact occurring within a specific 10-30 millisecond portion of the cardiac cycle. This period occurs in the ascending phase of the T wave, when the ventricular myocardium is repolarizing, moving from systole to diastole (relaxation).

The small window of vulnerability explains why it is a rare event. Considering that the total cardiac cycle has a duration of 1000 milliseconds (for a base cardiac frequency of 60 beats per minute), the probability of a mechanical trauma within the window of vulnerability is 1 to 3% only. That explains also why the heart becomes more vulnerable when it is physically strained by sports activities:

• The increase in heart frequency (exercise tachycardia) may double the probability above (e.g., with 120 beats per minute the cardiac cycle shortens to 500 milliseconds without fundamentally altering the windows of vulnerability size)
• Relative exercise-induced hypoxia and acceleration of the excito- conductive system of the heart make it more susceptible to stretch-induced ventricular fibrillation.

The cellular mechanisms of commotio cordis are still poorly understood, but probably related to the activation of mechano- sensitive proteins, ion channels.

It is estimated that impact energies of at least 50 joules are required to cause cardiac arrest, when applied in the right time and spot of the precordium of an adult. Impacts of up to 130 joules have already been measured with hockey pucks and lacrosse balls, 450 joules in karate punches and an incredible 1028 joules in boxer Rocky Marciano’s punch. The 50 joules threshold, however, can be considerably lowered when the victim’s heart is under ischemic conditions, such as in coronary artery insufficiency^[5].

There is also an upper limit of impact energy applied to the heart; too much energy will create structural damage to the heart muscle as well as causing electrical upset. This condition is referred to as ”contusio cordis” (from Latin for bruising of the heart). On isolated guinea pig hearts, as little as 5 mJ was needed to induce release of creatine kinase, a marker for muscle cell damage.^[6] Obviously one should take into account that this figure does not include the dissipation of energy through the chest wall, and is not scaled up for humans, but it is indicative that relatively small amounts of energy are required to reach the heart before physical damage is done.

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Maryam Hadipour, M.D.[2]Cafer Zorkun, M.D., Ph.D. [3]

The most common causes of Commotio cordis are sports that during them the chance of chest trauma with objects or the opponents is high. It can also be seen in cases of child abuse, torture, motor vehicle collisions or fights. There are several measures to reduce the incidence of commotio cordis and its complications in sports such as: having athletic trainers, teaching CPR and the usage of AED among trainers and athletics and other personnel, wearing protective equipment, avoiding weight and strength disparities among athletics.

Many sports may result in commotio cordis, including athletic competitions, swimming, and rugby, among others:

• baseball
• cricket
• hockey
• lacrosse
• softball
• Martial arts

Commotio cordis may occur also in other situations, such as in children who are punished with blows over the precordium, cases of torture, frontal collisions of motor vehicles (the impact of the steering wheel against the thorax, although this has decreased substantially with the use of safety belts and air bags).

Cases of commotio cordis have been recorded in people who were shot by firearms over the precordium and were using body armour^[1], thus stopping the bullet but causing a mechanical impact to the thorax (the so-called Behind Armour Blunt Trauma or BABT); or after being hit by less-lethal crowd control firearm shots using rubber bullets or plastic bullets^[2].

In contrast, the precordial thump (hard blows given over the precordium with a closed fist in order to revert cardiac arrest) is a sanctioned procedure for emergency resuscitation by trained health professionals witnessing a monitored arrest when no equipment is at hand, endorsed by the latest guidelines of the International Liaison Committee on Resuscitation. It has been discussed controversially, as – in particular in severe hypoxia– it may cause the opposite effect (i.e., a worsening of rhythm- commotio cordis). In a normal adult, the energy range involved in the precordial thump is 5-10 times below that associated with commotio cordis^[3].

Although sports-related chest injuries cannot be prevented, some measures can be taken to reduce complications associated with cardiotio cordis, such as death, and avoid automobile accidents resulting in chest injuries.^[4][5]

To reduce the incidence of complications of commotio cordis among youth teams and leagues, there are some key steps youth organizations can take:

• It is essential to have an athletic trainer present whenever there is a practice or a game
• It is important that AEDs are available at all athletic facilities, as well as being taught to coaches and other personnel involved in the sport how to use when it is needed
• Training trainers, coaches, parents, and athletes in recognition, CPR, and the use of AEDs in times of commotio cordis.

To reduce the likelihood of a chest injury occurring, a variety of efforts have been made, such as:

• Wearing the right kind of protective equipment, such as pads, consistently and properly
• Educating athletes on how to avoid getting struck with a ball puck or another implement that has the potential to cause these kinds of injuries
• In every case that can be avoided, athletes should avoid weight and strength disparities between themselves
• Using a safety baseball or hockey puck that has been cushioned to prevent injuries

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Maryam Hadipour, M.D.[2]

Commotio cordis should be distinguished from cardiac contusion, which occurs when a blunt strike to the chest damages the structural heart structures. the differential diagnosis of commotio cordis includes other causes of sudden cardiac death during sport participation, such as familial hypertrophic cardiomyopathy, myocarditis, dilated cardiomyopathy, long-QT syndrome, Brugada syndrome, Wolf-Parkinson-White syndrome, Marfan syndrome, aortic valve stenosis, mitral valve prolapse, coronary artery disease, asthma, heat stroke, drug abuse, and a ruptured cerebral artery. It is important to consider the possibility of intentional acts of violence causing commotio cordis.

Commotio cordis should be distinguished from a condition called a cardiac contusion, which occurs when a blunt strike to the chest damages the structural heart structures. Motor vehicle accidents are an example of such a case. The differential diagnosis of commotio cordis includes other causes of sudden cardiac death during sport participation, such as^[1][2]:

• Familial hypertrophic cardiomyopathy
• Myocarditis
• Dilated cardiomyopathy
• Long-QT syndrome
• Coronary artery anomalies
• Brugada syndrome
• Wolf-Parkinson-White syndrome
• Marfan syndrome
• Aortic valve stenosis
• Mitral valve prolapse
• Asthma
• Heat stroke
• Drug abuse
• Ruptured cerebral artery

In addition to accidental causes, commotio cordis can also be caused by intentional acts of violence. There have been reported cases of homicidal commotio cordis caused by domestic violence^[3].

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Maryam Hadipour, M.D.[2]Cafer Zorkun, M.D., Ph.D. [3]

Commotio cordis is a very rare event, but nonetheless is often considered when an athlete presents with sudden cardiac death. Among the cardiovascular factors leading to sudden death in athletes, commotio cordis holds the second-highest occurrence rate, after hypertrophic cardiomyopathy. The incidence of commotio codis is less than 30 cases per year. The USA Commotio Cordis Registry reported 216 cases recorded by July 2012, with most of the cases occurring in Little League baseball, lacrosse and softball. The real number of cases may be much larger. Children are especially vulnerable due to their more fragile thoracic skeleton. Boys between the ages of 8 and 18 are more likely to suffer from this condition.

• Among the cardiovascular factors leading to sudden death in athletes, commotio cordis holds the second-highest occurrence rate, surpassed only by hypertrophic cardiomyopathy^[1][2].
• The incidence of commotio codis is less than 30 cases per year.^[3] This could be due to public ignorance of the condition. Since the public is not educated about this condition, it is more common that more cases occur without being reported as commotio cordis. It is estimated that about 50% of cases are related to competitive sports. Another 25% of events are related to recreational activities, especially for those younger than 10 years old. Contrasty, the other percent of cases are related with another kind of chest trauma.^[4]
• The USA Commotio Cordis Registry reported 216 cases recorded by July 2012, with most of the cases occurring in Little League baseball, lacrosse and softball^[5]..
• Boys between the ages of 8 and 18 are more likely to suffer from the condition for various reasons, one of them being the lesser development of their chest walls compared to older people.
• Children are especially vulnerable due to their more fragile thoracic skeleton.

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Maryam Hadipour, M.D.[2]

The risk factors for commotio cordis include the location and timing of the blow, the type of mechanical stimulus, age, chest morphology, and the hardness of the object involved in the impact. Understanding these risk factors can help in developing preventive measures and strategies to reduce the incidence of commotio cordis, especially in high-risk populations such as young athletes participating in sports with a higher potential for chest impacts. Certain sports have been identified as having a higher potential risk for commotio cordis such as Karate, Taekwondo, Judo, Kabedi, Free-style Wrestling, Cricket, baseball, hockey, lacrosse, and softball.

Certain sports have been identified as having a higher potential risk for commotio cordis. Baseball, hockey, lacrosse, softball and combat sports such as Karate, Taekwondo, Judo, Kabedi, Free-style Wrestling, and Cricket have been associated with an increased risk of commotio cordis^[1].

• The impact to the chest should be in a specific area and occur during a vulnerable phase of the cardiac cycle.
• The precise timing of the impact is crucial in determining whether ventricular fibrillation, the main arrhythmia associated with commotio cordis, occurs^[2].

• Smaller, more compact objects that concentrate their energy on a smaller surface area (like a baseball or hockey puck) have been shown to increase the risk of mechanically induced arrhythmia^[3].

• Young age and a thin, undeveloped chest cage increase the vulnerability to this condition.
• The chest wall of children and young adults is more compliant and less able to absorb the impact, making them more susceptible to cardiac arrest^[4].

• Softer baseballs have been shown to decrease the risk of commotio cordis compared to regulation balls.
• Safety baseballs, specifically designed to reduce the risk of commotio cordis, have been shown to be effective in experimental models^[2][3].

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Maryam Hadipour, M.D.[2]

Almost all of the patients with commotio cordis will die without any proper intervention due to arrhythmia. More than two third of those with prompt cardiopulmonary resuscitation/defibrillation experience a full physical recovery, while the remaining patients exhibit mild to moderate residual neurological disability or cardiac impairment during the follow-up period spanning from 1 to 20 years. Commotio cordis has a poor prognosis. However, a continuous rise of survival rates due to increasing awareness of the disease and prompt intervention is evident.

Almost all of the patients with commotio cordis will die without any proper intervention due to arrhythmia. Prompt cardiopulmonary resuscitation and defibrillation are the main interventions which increase the survival rates^[1].

• Generally, it is assumed that if commotio cordis is successfully treated and recovered, no further heart complications will develop in most of the cases.
• A study demonstrated that out of the total cases of commotio cordis with particularly prompt cardiopulmonary resuscitation/defibrillation, 71% experienced a full physical recovery, while the remaining 29% exhibited mild to moderate residual neurological disability or cardiac impairment (noted through a decrease in left ventricular ejection fraction) during the follow-up period spanning from 1 to 20 years^[1].

• Commotio cordis has a poor prognosis with only a small number of these victims surviving after immediate resuscitation. A continuous rise of survival rates due to commotio cordis is evident, shifting from 10%–15% before the year 2000 to more than 50% in 2012 l^[2].

• There is a 10 percent decline in survival rate in the first minute following the loss of consciousness. Five percent decline in survival rate in each following minute following the loss of consciousness^[2].

Template:WH Template:WS