Increasing survival rate from commotio cordis

doi:10.1016/j.hrthm.2012.10.034

Heart Rhythm

Volume 10, Issue 2, February 2013, Pages 219-223

https://doi.org/10.1016/j.hrthm.2012.10.034 Get rights and content

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.

Introduction

Commotio cordis is a newly recognized cause of sudden death (SD) in which relatively innocent appearing, blunt, and nonpenetrating chest blows trigger ventricular fibrillation without structural damage to the ribs, sternum, or heart itself.1, 2, 3, 4, 5 Among the cardiovascular causes of SD in athletes, commotio cordis is second in frequency only to hypertrophic cardiomyopathy.6, 7

A series of experimental studies have provided insights into the mechanism responsible for ventricular fibrillation and commotio cordis.8, 9, 10, 11, 12 Initial reports suggested that these events were associated with very low survival rates in the range of 10%–15% despite the presence of a structurally normal heart.1, 4 More recently, we considered the possibility that the epidemiology of commotio cordis may have evolved with a change in expected mortality. Consequently, we have taken this opportunity to reassess the outcome of these events over time in our registry population.

Section snippets

Methods

The 216 cases consecutively entered into the US Commotio Cordis Registry (Minneapolis, MN) as of July 2012 constitute the present series.1, 2, 4, 5, 6 Commotio cordis events were identified prospectively and retrospectively from news media accounts, Internet searches, or other public records using the LexisNexis database, US Consumer Product Safety Commission reports, or direct submission to the registry by medical examiners or other interested parties. Each case fulfilled the following

Demographics

Ages of the 216 commotio cordis victims ranged from 0.2 to 51 years (mean age 15±9 years); 161 (75%) were<18 years; 205 (95%) were males. One hundred sixty-six were whites (77%); 24 (11%) were African Americans; and 20 (9%) were of other races, most commonly Hispanics (6 are unknown). At the time of their event, victims were engaged in organized competitive sports (n = 115; 53%), recreational sporting activities (n = 52; 24%), or routine daily activities (n = 49; 23%). Chest blows were

Discussion

As a cause of arrhythmic SD in the young, commotio cordis is relatively new to the physician and general community. Previous reports from our large registry cohort initially conveyed the distinctly unfavorable impression that commotio cordis-related ventricular fibrillation was rarely reversible by cardiopulmonary resuscitation and life support (with a reported survival rate of only about 10%–15%).1, 2, 4 Also, one case report documented the failure to resuscitate a commotio cordis victim even

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Cited by (66)

Commotio cordis in non-sports-related injury: A scoping review
2024, Current Problems in Cardiology
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
2023, American Journal of Cardiology
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 Non–Sport-Related Events: A Systematic Review
2023, JACC: Clinical Electrophysiology
Commotio cordis is an increasingly recognized cause of sudden cardiac death. Although commonly linked with athletes, many events occur in non–sport-related settings.
The goal of this study was to characterize and compare non–sport-related vs sport-related commotio cordis.
PubMed and Embase were searched for all cases of commotio cordis from inception to January 5, 2022.
Of 334 commotio cordis cases identified, 121 (36%) occurred in non–sport-related contexts, which included assault (76%), motor vehicle accidents (7%), and daily activities (16%). Projectiles were implicated significantly less in non–sport-related events (5% vs 94%, respectively; P < 0.001). Nonprojectile etiologies in non–sport-related events mostly consisted of impacts with body parts (79%). Both categories affected similar younger aged demographic (P = 0.10). The proportion of female victims was significantly higher in non–sport-related events (13% vs 2%, respectively; P = 0.025). Mortality was significantly higher in non–sport-related events (88% vs 66%, respectively; P < 0.001). In non–sport-related events, rates of cardiopulmonary resuscitation (27% vs 97%, respectively; P < 0.001) and defibrillation (17% vs 81%, respectively; P < 0.001) were both lower and resuscitation was more commonly delayed beyond 3 min (80% vs 5%, respectively; P < 0.001).
Commotio cordis occurs across a spectrum of non–sport-related settings including assault, motor vehicle accidents, and daily activities. Both categories affected a younger and male-predominant demographic. Mortality is higher in non–sport-related commotio cordis, likely owing to lower rates of cardiopulmonary resuscitation, defibrillation, automated external defibrillator availability, and extended time to resuscitation. Increased awareness of non–sport-related commotio cordis is essential to develop a means of prevention and mortality reduction, with earlier recognition and prompt resuscitation measures.
Ice hockey
2023, The Youth Athlete: A Practitioner's Guide to Providing Comprehensive Sports Medicine Care
Ice hockey is a fast-paced game combining speed, skill, finesse, and power. Physical maturity and the introduction of body checking into the game during adolescence significantly increase the risk of injury in the young hockey athlete. Injury risk factors can be divided into intrinsic and extrinsic, with severity ranging from contusions, minor sprains, and strains to rare, catastrophic injuries, including cervical spine fracture, laryngeal trauma, skate blade lacerations to the neck, and commotio cordis. This chapter reviews the history and rules of ice hockey, the epidemiology and risk factors for ice hockey injuries, and injury prevention strategies for youth hockey athlete.
Blunt Trauma to the Heart: A Review of Pathophysiology and Current Management
2022, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Thus, when the impact occurs during the upslope of T-wave (repolarization) morphology, an ‘R-on-T’ phenomenon causes a polymorphic ventricular tachycardia that can degenerate quickly into ventricular fibrillation.30 Early cardiopulmonary resuscitation (CPR) is vital to survival, as 40% of patients who receive early CPR (within 3 minutes) survive, while only 2% of those who do not receive early CPR (after 3 minutes) survive.31 Over the last 3-to-4 years, there has been a trend toward improved survival, as the increased availability of automated electrical defibrillators at sporting events and better recognition of commotio cordis have allowed for prompt defibrillation and resuscitation.28
Blunt cardiac injury (BCI), defined as an injury to the heart from blunt force trauma, ranges from minor to life-threatening. The majority of BCIs are due to motor vehicle accidents; however, injuries caused by falls, blasts, and sports-related injuries also can be sources of BCI. A significant proportion of patients with BCI do not survive long enough to receive medical care, succumbing to their injuries at the scene of the accident. Additionally, patients with blunt trauma often have coexisting injuries (brain, spine, orthopedic) that can obscure the clinical picture; therefore, a high degree of suspicion often is required to diagnose BCI. Traditionally, hemodynamically stable injuries suspicious for BCI have been evaluated with electrocardiograms and chest radiographs, whereas hemodynamically unstable BCIs have received operative intervention. More recently, computed tomography and echocardiography increasingly have been utilized to identify injuries more rapidly in hemodynamically unstable patients. Transesophageal echocardiography can play an important role in the diagnosis and management of several BCIs that require operative repair. Close communication with the surgical team and access to blood products for potentially massive transfusion also play key roles in maintaining hemodynamic stability. With proper surgical and anesthetic care, survival in cases involving urgent cardiac repair can reach 66%-to-75%. This narrative review focuses on the types of cardiac injuries that are caused by blunt chest trauma, the modalities and techniques currently used to diagnose BCI, and the perioperative management of injuries that require surgical correction.
Commotio Cordis Resulting from Sibling Rivalry
2021, American Journal of Cardiology
Citation Excerpt :
Commotio cordis most commonly afflicts young male athletes with a mean age of 15 years-old. It is also reported that 95% of victims are male and up to 20% of cases occur in adults.3,4 The presented case is particularly interesting in that the patient is female and it did not involve athletic activity.
A 17-year-old girl with no significant medical, surgical, or family history presented to the emergency department following an episode of sudden cardiac arrest after being punched in the chest by her brother. Bystander CPR was immediately initiated, and she was found to be in ventricular fibrillation by emergency services. The patient had return of spontaneous circulation after one defibrillation event. No other significant injuries were found, and she eventually experienced a complete neurologic recovery and was discharged with no other identified cause for her arrest. The objective of this clinical case report is to highlight this unusual and rare injury to increase awareness and avoid incorrect diagnosis.

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Increasing survival rate from commotio cordis

Background

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Demographics

Discussion

Heart Rhythm

Am J Cardiol

Heart Rhythm

Heart Rhythm

JAMA

Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities

N Engl J Med

Commotio cordis

N Engl J Med

An experimental model of sudden death due to low-energy chest-wall impact (commotio cordis)

N Engl J Med

Clinical profile and spectrum of commotio cordis

JAMA