Commotio cordis in non-sports-related injury: A scoping review.

Commotio cordis is a rare but life-threatening condition characterized by sudden cardiac arrest resulting from a blunt chest impact. While commotio cordis has traditionally been associated with sports-related activities, a significant proportion of cases occur in non-sport-related settings, such as assaults, motor vehicle accidents (MVAs), and daily activities. This critical review examines the epidemiology, clinical characteristics, and outcomes of non-sports-related commotio cordis cases, highlighting the need for increased awareness and improved management in these contexts. The review analyzes existing literature, drawing attention to the demographics of non-sports-related cases, which predominantly affect adolescents and young adults, with males being the primary demographic. In contrast to sport-related cases, non-sports-related commotio cordis cases exhibit a wider age range and a higher proportion of female subjects. Mortality rates are significantly higher in non-sports-related commotio cordis cases, largely due to lower rates of cardiopulmonary resuscitation (CPR), limited access to automated external defibrillators (AEDs), and delayed initiation of resuscitative efforts compared to sport-related incidents. This underscores the critical importance of increasing awareness and preparedness in non-sport-related settings. To mitigate the risks associated with non-sports-related commotio cordis, efforts should focus on early recognition of the condition, timely administration of CPR, and the widespread availability and accessibility of AEDs in various environments. Enhanced awareness and education can potentially lead to a reduction in mortality and improved outcomes for individuals affected by commotio cordis outside of sports-related activities. In conclusion, commotio cordis is not exclusive to sports and presents a significant health risk in non-sport-related scenarios. This review emphasizes the urgent need for increased awareness, preparedness, and resuscitation measures in non-sports contexts to address the higher mortality associated with these cases.

Commotio Cordis Returns When We Least Expected It: Cardiac Arrest in A Professional Football Player.

For the first time in 52 years, an American professional football player (Damar Hamlin) collapsed in cardiac arrest during a game, viewed in real-time on national television. The cause of this profound event was commotio cordis, that is, blunt non-penetrating chest blow-initiated ventricular fibrillation triggered by physical contact not considered unusual for football. The athlete survived because of timely cardiopulmonary resuscitation and defibrillation provided by first responders organized by the National Football League. Commotio cordis, albeit rare, was most prominently identified initially in competitive and also recreational sports participants. More recently it became apparent that similar events could occur in almost any circumstance involving a chest blow, such as during everyday activities around the home and with innocent play. The determinant of a commotio cordis event is a blow over the heart in a narrow vulnerable electrical window during dispersion of repolarization. Survival from these events has increased substantially to >60% due to enhanced recognition and prompt resuscitation/defibrillation. In conclusion, in this commentary, we take a timely opportunity to describe in detail the relevant demographics, mechanism/pathophysiology, and clinical course of commotio cordis.

Commotio Cordis in 2023.

Since the nationally televised cardiac arrest of American National Football League player Damar Hamlin in January 2023, commotio cordis has come to the forefront of public attention. Commotio cordis is defined as sudden cardiac arrest due to direct trauma to the precordium resulting in ventricular fibrillation or ventricular tachycardia. While the precise incidence of commotio cordis is not known due to a lack of standardized, mandated reporting, it is the third most common cause of sudden cardiac death in young athletes, with more than 75% of cases occurring during organized and recreational sporting events. Given that survival is closely tied to how quickly victims receive cardiopulmonary resuscitation and defibrillation, it is crucial to raise awareness of commotio cordis so that athletic trainers, coaches, team physicians, and emergency medical personnel can rapidly diagnose and treat this often-fatal condition. Broader distribution of automated external defibrillators in sporting facilities as well as increased presence of medical personnel during sporting events would also likely lead to higher survival rates.

Don't Forget Commotio Cordis.

Non-penetrating chest blows can occasionally trigger fatal ventricular tachyarrhythmias and sudden death (commotio cordis). Such events were initially reported in association with sporting activities and projectiles such as baseball/lacrosse balls. However, similar potentially fatal chest blows, seemingly incapable of causing death, can occur during a variety of other circumstances such as when delivered during a fight (by a fist) such as in the accompanying paper. Notably, commotio cordis events can be reversed by resuscitation and defibrillation.

Commotio cordis and L-type calcium channel mutation: Is there a link?

Commotio cordis is a rare phenomenon when ventricular fibrillation and sudden death occurs with a blunt, nonpenetrating blow to the chest. Individual susceptibility to commotio cordis has been demonstrated in swine models, and might be present in humans as well. We report a case of commotio cordis in an adolescent with a heterozygous mutation on the gene CACNA1C, encoding for an L-type calcium channel expressed in the heart. This genetic mutation has been previously associated with a phenotype of long-QT syndrome; however, this was not demonstrated in our patient despite extensive investigations. To the best of our knowledge, this is the first report of commotio cordis in which an ion-channel gene mutation involved in repolarization abnormalities has been documented. This finding might corroborate the hypothesis that a genetic predisposition plays a role in the individual susceptibility to this rare cause of cardiac arrest.

Ventricular Tachycardia: A Rare Commotio Cordis Presentation.

Commotio cordis is a rare event caused by an unfortunately timed blunt anterior chest wall impact that most commonly presents in young male adolescents and is the second leading cause of death in young athletes. The most common initial presenting dysrhythmias are ventricular fibrillation and asystole, although other rare dysrhythmias have been reported-predominantly in animal models. To our knowledge, this is the first telemetry-confirmed case of commotio cordis with a presenting cardiac rhythm of ventricular tachycardia. While prompt recognition of commotio cordis and early cardiopulmonary resuscitation and defibrillation (if applicable) are still the treatment in these cases, our case offers potential insight into the underlying commotio cordis process.

Blunt Cardiac Injury.

Blunt cardiac injury encompasses multiple different injuries, including contusion, chamber rupture, and acute valvular disorders. Blunt cardiac injury is common and may cause significant morbidity and mortality; a high index of suspicion is needed for accurate diagnosis. Diagnostic work-up should always include electrocardiogram and cardiac enzymes, and may include echocardiography if specific disorders (ie, tamponade or valvular disorders) are suspected. Patients with myocardial contusion should be observed for 24 to 48 hours for arrhythmias. Many other significant forms of blunt cardiac injury require surgical intervention.

Pathophysiology, prevention, and treatment of commotio cordis.

Commotio cordis is increasing described and it is now clear that this phenomenon is an important cause of sudden cardiac death on the playing field. Victims are predominantly young, male, and struck in the left chest with a ball. An animal model has been developed and utilized to explore the important variables and mechanism of commotio cordis. Impact during a narrow window of repolarization causes ventricular fibrillation. Other important variables include location, velocity, shape, and hardness of the impact object. Biological characteristics such as gender, pliability of the chest wall, and genetic susceptibility also play a role in commotio cordis. The mechanism of ventricular fibrillation appears to be an increase in heterogeneity of repolarization caused by induced abnormalities of ion channels activated by abrupt increases in left ventricular pressure. In the setting of altered repolarization a trigger of ventricular depolarization (premature ventricular depolarization caused directly by the chest blow) initiates a spiral wave that quickly breaks down into ventricular fibrillation. Prevention of commotio cordis is possible. Improved recognition and resuscitation have led to an improvement in outcome.

A case of commotio cordis treated with therapeutic hypothermia.

BACKGROUND: Therapeutic hypothermia is used as a neuroprotective strategy for patients who have persistent neurologic compromise after return of spontaneous circulation from cardiac arrest. The 2010 American Heart Association Guidelines recommend the use of therapeutic hypothermia in adult cardiac arrest patients when the initial rhythm is ventricular fibrillation. These recommendations are based on primary research in patients with a cardiac cause of their ventricular fibrillation. CASE REPORT: A 43-year-old male was brought to our emergency department (ED) with commotio cordis. He was struck in the chest with a baseball bat, after which he collapsed at the scene and was pulseless. Return of spontaneous circulation was achieved after defibrillation by treating paramedics, and the patient remained comatose on arrival to the ED. He was transferred to the intensive care unit and treated with therapeutic hypothermia at target temperature of 32-34°C. He was extubated on day 3, and discharged home on day 8 with good neurologic function. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We report a case of commotio cordis in which the adult patient was treated with therapeutic hypothermia and had a favorable outcome. To our knowledge, this is the first reported case of its kind. Evidence for the use of therapeutic hypothermia is incomplete in patients with a traumatic cause of cardiac arrest, such as commotio cordis, despite probable similarities in the pathophysiology of anoxic brain injury. Our case illustrates that there may be benefit from use of therapeutic hypothermia for a broader population than is currently recommended.

Increasing survival rate from commotio cordis.

BACKGROUND: Commotio cordis events due to precordial blows triggering ventricular fibrillation are a cause of sudden death (SD) during sports and also daily activities. Despite the absence of structural cardiac abnormalities, these events have been considered predominantly fatal with low survival rates. OBJECTIVE: To determine whether expected mortality rates for commotio cordis have changed over time, associated with greater public visibility. METHODS: US Commotio Cordis Registry was accessed to tabulate frequency of reported SD or resuscitated cardiac arrest over 4 decades. RESULTS: At their commotio cordis event, 216 study patients were 0.2-51 years old (mean age 15±9 years); 95% were males. Death occurred in 156 individuals (72%), while the other 60 (28%) survived. Proportion of survivors increased steadily with concomitant decrease in fatal events. For the initial years (1970-1993), 6 of 59 cases survived (10%), while during 1994-2012, 54 of 157 (34%) survived (P = .001). The most recent 6 years, survival from commotio cordis was 31 of 53 (58%), with survivor and nonsurvivor curves ultimately crossing. Higher survival rates were associated with more prompt resuscitation (40%<3 minutes vs 5%>3 minutes; P<.001) and participation in competitive sports (39%; P<.001), but with lower rates in African Americans (1 of 24; 4%) than in whites (54 of 166; 33%; P = .004). Independent predictors of mortality were black race (P = .045) and participation in noncompetitive sports (P = .002), with an on-site automated external defibrillator use protective against SD (P = .01). CONCLUSIONS: Survival from commotio cordis has increased, likely owing to more rapid response times and access to defibrillation, as well as greater public awareness of this condition.

Blunt cardiac injury.

Blunt chest trauma represents a spectrum of injuries to the heart and aorta that vary markedly in character and severity. The setting, signs, and symptoms of chest trauma are often nonspecific, which represents a challenge to emergency providers. Individuals with suspected blunt chest trauma who have only mild or no symptoms, a normal electrocardiogram (ECG), and are hemodynamically stable typically have a benign course and rarely require further diagnostic testing or long periods of close observation. Individuals with pain, ECG abnormalities, or hemodynamic instability may require rapid evaluation of the heart by echocardiography and the great vessels by advanced imaging.