Development of the NOCSAE Standard to Reduce the Risk of Commotio Cordis.

BACKGROUND: Commotio cordis, sudden cardiac death (SCD) caused by relatively innocent impact to the chest, is one of the leading causes of SCD in sports. Commercial chest protectors have not been demonstrated to mitigate the risk of these SCDs. METHODS: To develop a standard to assess chest protectors, 4 phases occurred. A physiological commotio cordis model was utilized to assess variables that predicted for SCD. Next, a surrogate model was developed based on data from the physiological model, and the attenuation in risk was assessed. In the third phase, this model was calibrated and validated. Finally, National Operating Committee on Standards for Athletic Equipment adopted the standard and had an open review process with revision of the standard over 3 years. RESULTS: Of all variables, impact force was the most robust at predicting SCD. Chest wall protectors which could reduce the force of impact to under thresholds were predicted to reduce the risk of SCD. The correlation between the experimental model and the mechanical surrogate ranged from 0.783 with a lacrosse ball at 30 mph to 0.898 with a baseball at 50 mph. The standard was licensed to National Operating Committee on Standards for Athletic Equipment which initially adopted the standard in January 2018, and finalized in July 2021. CONCLUSIONS: An effective mechanical surrogate based on physiological data from a well-established model of commotio cordis predicts the reduction in SCD with chest protectors. A greater reduction in force provides a great degree of protection from commotio cordis. This new National Operating Committee on Standards for Athletic Equipment standard for chest protectors should result in a significant reduction in the risk of commotio cordis on the playing field.

Advancing Commotio cordis Safety Standards Using the Total Human Models for Safety (THUMS).

Commotio cordis is one of the leading causes of sudden cardiac death in youth baseball. Currently, there are chest protector regulations regarding the prevention of Commotio cordis in baseball and lacrosse; however, they are not fully optimized. For the advancement of Commotio cordis safety, it is vital to include various age groups and a variety of impact angles in the testing process. This study employed finite element models and simulated Commotio cordis-inducing baseball collisions for different velocities, impact angles, and age groups. Commotio cordis risk response was characterized in terms of left ventricular strain and pressure, chest band and rib deformation, and force from impact. Normalized rib and chest band deformation when correlated with left ventricular strain resulted in R2 = 0.72, and R2 = 0.76, while left ventricular pressure resulted in R2 = 0.77, R2 = 0.68 across all velocities and impact angles in the child models. By contrast, the resultant reaction force risk metric as used by the National Operating Committee on Standards for Athletic Equipment (NOCSAE) demonstrated a correlation of R2 = 0.20 in the child models to ventricular strain, while illustrating a correlation to pressure of R2 = 0.74. When exploring future revisions to Commotio cordis safety requirements, the inclusion of deformation-related risk metrics at the level of the left ventricle should be considered.

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.

Sobre las características de los supervivientes de muerte súbita cardiaca extrahospitalaria / On the characteristics of out-of-hospital sudden cardiac death survivors

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Safety baseballs and chest protectors: a systematic review on the prevention of commotio cordis.

OBJECTIVE: To determine whether chest protectors and/or safety baseballs reduce the incidence of commotio cordis during sport through a review of the best available evidence. DATA SOURCES: PubMed, Ovid Medline, and Embase databases from 1950 to 2009. We selected articles according to "death, sudden, cardiac," "commotio cordis," "sports equipment," and "protective devices." We identified 17 articles in the systematic literature search. Of these, 7 articles met inclusion criteria. Three independent reviewers reviewed the articles. The study results and generated conclusions were extracted and agreed on. RESULTS: The softest safety baseball shows statistically significant reductions in the incidence of ventricular fibrillation (VF) at all velocities compared with standard baseballs in the 3 studies that evaluated their use. Different degrees of softness did not show statistically significant reductions in VF. In the 3 studies that evaluated the use of chest protectors against controls, there was an increase in protection against fatal arrhythmias; however, this was only statistically significant for 1 chest protector. CONCLUSIONS: This systematic review shows strong supportive evidence toward a decreased rate of commotio cordis with safety baseballs when compared with standard balls. Based on the results of our systematic review, the rate of induction of VF was at its lowest when chest protection was used.