Commotio Cordis
Description
Commotio Cordis refers to the sudden arrhythmic death caused by a low/mild chest wall impact. Commotio Cordis is seen mostly in athletes between the ages of 8 and 18 who are partaking in sports with projectiles such as baseballs, hockey pucks, or lacrosse balls. These projectiles can strike the athletes in the middle of the chest with a low impact but enough to cause the heart to enter an arrhythmia. Martial arts is a sport in which a strike of a hand can also cause the heart to change it's rhythm. Without immediate CPR and defibrillation the prognosis of commotio cordis is not very good. This condition is extremely dangerous with rare survival.
Cause
In victims of commotio cordis, the impact of a blunt object on the anterior chest wall leads to ventricular fibrillation, a disorganized rhythm of the ventricles that result in ineffective pumping of the heart, and a marked fall in the blood pressure. We've learned from investigations in animal models that the susceptibility to ventricular fibrillation occurs during a very specific, very short period (perhaps just 20 msec) during the cardiac cycle that corresponds to the initial upstroke of the T-wave on the ECG.
It’s like hitting the bulls-eye, but with a baseball or other flying object. The impact on the anterior chest wall must occur at just the precise moment to produce the fatal arrhythmia.
Symptoms
Look for these symptoms in athletes when commotio cordis is suspected:
Athlete was struck in the chest by an object such as a baseball, baseball bat, lacrosse ball, hockey puck
Athlete will typically stumble forward for a few seconds, followed by unconsciousness
No breathing
No pulse
Ventricular fibrillation is indicated on AED reading
Treatment
Use an AED and defibrillate as quickly as possible. For every minute delay in shocking with AED, chance of survival decreases by 10%.
Immediately activate EMS and the schools Emergency Action Plan (EAP)
Continue AED use and CPR until EMS arrives and takes over.
Commotio cordis is usually fatal. With increasing attention paid to this condition, though, the survival rate has increased from about 15% to about 35% over the past decade. The only effective treatment for individuals with ventricular fibrillation due to commotio cordis is prompt defibrillation. We know that survivors have received prompt CPR and defibrillation within the first few minutes after collapsing. The survival rate may be less than 5% for victims in whom CPR/defibrillation is delayed more than 3 minutes.
These statistics point to the importance of staffing a Certified Athletic Trainer, having Coaches trained in CPR/AED and the availability of automatic external defibrillators (AEDs) for use by coaches and bystanders before trained medical personnel can arrive on the scene.
Recovery/Rehabilitation
Before returning to play, that athlete must have a cardiac evaluation & ECG by a cardiologist and must have final medical clearance by the schools chief medical officer. The schools medical staff, including the Athletic Trainer, School Nurse, and School Physician should use clinical judgement before return to play and should carefully watch the athlete to ensure a cardiac episode does not occur. Adjustments will be made to practice by adding personal protection such as additional chest padding or switching to safety balls to decrease chances of another episode.