eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology

Commotio Cordis: Follow-up

Author: Steven M Yabek, MD, FAAP, FACC, Pediatrix Cardiology Associates of New Mexico (a Division of Mednax Medical Group), Presbyterian Hospital Medical Center
Contributor Information and Disclosures

Updated: Sep 4, 2009

Follow-up

Deterrence/Prevention

  • The recently published 36th Bethesda Conference on Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities had a number of recommendations regarding commotio cordis (CC).7
    • Children and adolescents aged 13 years and younger should use age-appropriate safety baseballs.
    • Although commercial chest wall protectors prevent traumatic injury in some instances, the construction of many products is not sufficient to prevent transmission of blows to the heart in all instances. In a recent review, 18% of commotio cordis events occurred in individuals wearing a chest protector.3
    • All sports venues should have immediate access (within 5 min) to an automated external defibrillator (AED).
    • Survivors of commotio cordis should undergo a thorough cardiac evaluation, including a 12-lead ECG, ambulatory Holter monitoring, and complete echocardiography.
    • Eligibility for returning to competitive sports following a commotio cordis episode is, at present, a decision left to individual clinical judgment.
  • Because risk is proportional to the hardness and compactness of the object that strikes the precordium, consideration may be given to the use of specially designed, softer-than-normal safety baseballs in recreational and Little League baseball.

Prognosis

  • Survival from a commotio cordis event is the exception. Based on the most recent US Commotio Cordis Registry data, only 24% of individuals have survived a commotio cordis episode. Overall, survival trends following exercise-related sudden cardiac arrest from all causes in young athletes continues to be dissapointing.8
  • Despite greater awareness of sudden cardiac death in athletes and the increasing availability of AEDs at athletic venues, overall successful resuscitation and survival from 2000-2006 was only 11%. Most resuscitation failures have been attributed to delayed onset of cardiopulmonary resuscitation (CPR) and defibrillation. Survival has usually been associated with effective CPR efforts that are begun within 1 minute of the collapse. However, in a report of 9 witnessed and sudden cardiac arrests among intercollegiate athletes, only 1 survived, despite initiation of CPR within 1 minute in 8 of the 9 cases and defibrillation at an average of 3 minutes in 7 of 9 cases.9 Two of the individuals had a commotio cordis event. In 6 cases, a cardiac abnormality was identified.   
  • Failure of timely resuscitation efforts may relate to several factors, the most important of which is the presence of structural heart disease. In those with an anatomically normal heart suffering a commotio cordis event, the duration and intensity of exercise prior to arrest, higher than normal endogenous catecholamine levels and a decrease in systemic vascular resistance may all play a role in limiting the success of resuscitation.9
  • Standard chest compressions following electrical defibrillation may predispose to episodes of repeated refibrillation, thereby limiting the effectiveness of resuscitation. Studies have demonstrated that chest compressions result in electrical capture of the ventricles which, under certain conditions, can lead to so-called "long-short" electrical sequences that initiate fibrillation.10

Miscellaneous

Medicolegal Pitfalls

  • Although mortality from commotio cordis (CC) is seemingly a chance event and clearly accidental in almost every instance, criminal charges have been pursued in some cases. Several cases reported to the US Commotio Cordis Registry (occurring on and off the athletic field) have resulted in murder or manslaughter convictions. This may be primarily related to the lack of understanding of how blunt chest impact can result in an unintended electrophysiologic cardiovascular catastrophe.
  • In 1998, a man from Washington, DC, was sentenced to a prison term of up to 18 years following the sudden death of his 11-year-old son immediately following 2 seemingly innocuous, but punitive, chest blows. The Cook County Chicago Office of the Medical Examiner recently reported deaths involving 2 boys, aged 3 years and 14 months. In both instances, deliberate fatal blows were delivered to the anterior chest with a closed fist. Both children collapsed immediately, were found to be in ventricular fibrillation by paramedics, and could not be resuscitated.
 


More on Commotio Cordis

Overview: Commotio Cordis
Differential Diagnoses & Workup: Commotio Cordis
Treatment & Medication: Commotio Cordis
Follow-up: Commotio Cordis
Multimedia: Commotio Cordis
References
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References

  1. Maron BJ. Sudden death in young athletes. N Engl J Med. Sep 11 2003;349(11):1064-75. [Medline].

  2. Link MS, Wang PJ, Pandian NG, et al. An experimental model of sudden death due to low-energy chest-wall impact (commotio cordis). N Engl J Med. Jun 18 1998;338(25):1805-11. [Medline].

  3. Maron, BJ: Clinical Features of Commotio Cordis. Presentation of Registry Data at Heart Rhythm Society Scientific Sessions [database online]. Boston, Massachusetts: May 15, 2009.

  4. Animal Model of Commotio Cordis: Presentation at Heart Rhythm Society Annual Scientific Sessions [database online]. Boston, Masachusetts: Link MS; May 15, 2009.

  5. Link MS, Maron BJ, Wang PJ, et al. Upper and lower limits of vulnerability to sudden arrhythmic death with chest-wall impact (commotio cordis). J Am Coll Cardiol. Jan 1 2003;41(1):99-104. [Medline].

  6. Amir O, Schliamser JE, Nemer S, Arie M. Ineffectiveness of precordial thump for cardioversion of malignant ventricular tachyarrhythmias. Pacing Clin Electrophysiol. Feb 2007;30(2):153-6. [Medline].

  7. Maron BJ, Estes NAM, Link MS. 36th Bethesda Conference: Eligibility recommendations for competitive athletes with cardiovascular abnormalities. Task Force 11: Commotio Cordis. J Am Coll Cardiol. Apr 19 2005;45(8):1371-3. [Medline].

  8. Drezner JA, Chun JS, Harmon KG, Derminer L. Survival trends in the United States following exercise-related sudden cardiac arrest in the youth: 2000-2006. Heart Rhythm. Jun 2008;5(6):794-9. [Medline].

  9. [Guideline] Drezner JA, Rogers KJ. Sudden cardiac arrest in intercollegiate athletes: detailed analysis and outcomes of resuscitation in nine cases. Heart Rhythm. Jul 2006;3(7):755-9. [Medline].

  10. Osoria J, Dosdall DJ, Robichaux Jr RP, Tabereaux PB, Ideker RE. In a Swine Model, Chest Compressions Cause Ventricular Capture and, By Means of a Long-Short Sequence, Ventricualar Fibrillation. Circ Arrhythmia Electrophysiol. 2008/10;1:282 - 9.

  11. Abrunzo TJ. Commotio cordis. The single, most common cause of traumatic death in youth baseball. Am J Dis Child. Nov 1991;145(11):1279-82. [Medline].

  12. Futterman LG, Lemberg L. Commotio cordis: sudden cardiac death in athletes. Am J Crit Care. Jul 1999;8(4):270-2. [Medline].

  13. Link MS, Bir C, Dau N, Madias C, Estes NA 3rd, Maron BJ. Protecting our children from the consequences of chest blows on the playing field: a time for science over marketing. Pediatrics. Aug 2008;122(2):437-9. [Medline].

  14. Link MS, Estes NA 3rd. Mechanically induced ventricular fibrillation (commotio cordis). Heart Rhythm. Apr 2007;4(4):529-32. [Medline].

  15. Link MS, Ginsburg SH, Wang PJ, et al. Commotio cordis: cardiovascular manifestations of a rare survivor. Chest. Jul 1998;114(1):326-8. [Medline].

  16. Link MS, Maron BJ, VanderBrink BA, et al. Impact directly over the cardiac silhouette is necessary to produce ventricular fibrillation in an experimental model of commotio cordis. J Am Coll Cardiol. Feb 2001;37(2):649-54. [Medline].

  17. Link MS, Wang PJ, VanderBrink BA, et al. Selective activation of the K(+)(ATP) channel is a mechanism by which sudden death is produced by low-energy chest-wall impact (Commotio cordis). Circulation. Jul 27 1999;100(4):413-8. [Medline].

  18. Maron BJ, Gohman TE, Kyle SB. Clinical profile and spectrum of commotio cordis. JAMA. Mar 6 2002;287(9):1142-6. [Medline].

  19. Maron BJ, Link MS, Wang PJ, Estes NA 3rd. Clinical profile of commotio cordis: an under appreciated cause of sudden death in the young during sports and other activities. J Cardiovasc Electrophysiol. Jan 1999;10(1):114-20. [Medline].

  20. Maron BJ, Strasburger JF, Kugler JD, et al. Survival following blunt chest impact-induced cardiac arrest during sports activities in young athletes. Am J Cardiol. Mar 15 1997;79(6):840-1. [Medline].

  21. Vincent GM, McPeak H. Commotio cordis: a deadly consequence of chest trauma. Phys Sportsmed. Nov 2000;28(11):31-9. [Full Text].

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Further Reading

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Keywords

commotio cordis, CC, low-impact chest trauma, cardiac concussion, ventricular fibrillation, cardiac arrest, sudden cardiac death, myocardial infarction, heart attack, anomalous origin of a coronary artery, hypertrophic cardiomyopathy, congenital prolongation of the QTc interval, asystole, automated external defibrillators, AED, blunt chest impact, precordium, arrhythmogenic right ventricular cardiomyopathy, primary electrical disorders, catecholaminergic ventricular tachycardia, primary electrical phenomenon, coronary artery vasospasm, myocardial contusion, precordial trauma, trauma to the precordium, precordial thump, precordial blunt trauma, treatment, diagnosis

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Contributor Information and Disclosures

Author

Steven M Yabek, MD, FAAP, FACC, Pediatrix Cardiology Associates of New Mexico (a Division of Mednax Medical Group), Presbyterian Hospital Medical Center
Steven M Yabek, MD, FAAP, FACC is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, Heart Rhythm Society, New Mexico Pediatric Society, Society for Pediatric Research, and Western Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Ira H Gessner, MD, Professor Emeritus, Pediatric Cardiology
Ira H Gessner, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Hugh D Allen, MD, Professor, Department of Pediatrics, Division of Pediatric Cardiology and Department of Internal Medicine, Ohio State University College of Medicine
Hugh D Allen, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, American Society of Echocardiography, Society for Pediatric Research, Society of Pediatric Echocardiography, and Western Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Gilbert Z Herzberg, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College; Consulting Staff, Department of Pediatrics, Sound Shore Medical Center
Gilbert Z Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD, Professor of Pediatrics, Division of Cardiology, Medical College of Wisconsin; Chief of Pediatric Cardiology, Medical Director of Pediatric Heart Transplant Program, Medical Director of The Heart Center, Children's Hospital of Wisconsin
Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

 
 
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