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

Commotio Cordis: Treatment & Medication

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

Treatment

Medical Care

The treatment of commotio cordis (CC) is not different from any other cardiopulmonary emergency associated with asystole. Attention to airway maintenance, chest compressions, and ventilation are key. Current guidelines recommend immediate defibrillation (if available) following a sudden, witnessed collapse. Chest compressions and ventilation (30:2 ratio) should be used for 5 cycles (about 2 min) prior to defibrillation when the collapse is unwitnessed. One shock should be administered and then followed immediately by cardiopulmonary resuscitation (CPR), starting with chest compressions, for 5 cycles before checking the rhythm. 

The relatively low rate of survival from commotio cordis is probably caused by the delay in instituting effective CPR measures because bystanders frequently fail to appreciate the severity of the event, lack knowledge of commotio cordis, or mistakenly believe that the trauma was insignificant. Many observers have commented that they believed that the wind was knocked out of the person. Experience suggests that survival is associated with resuscitation efforts begun within 1-3 minutes of collapse.

  • Electrical defibrillation
    • The hallmark of effective resuscitation is rapid, direct current defibrillation. Time to defibrillation is probably the single most important determinant of survival in cardiac arrest. The likelihood of successful defibrillation decreases rapidly over time, in part because ventricular fibrillation generally evolves to asystole within a few minutes. Experimental data gathered using the commotio cordis swine model suggest that defibrillation within 1 minute of ventricular fibrillation onset results in a 100% survival rate and that defibrillation after 2 minutes results in an 80% survival rate. In animals in which ventricular fibrillation was present for more than 4 minutes, the survival rate was 0% unless CPR was instituted after defibrillation (in which case, the likelihood of survival increased to 65%). In humans, every 1-minute delay in defibrillation beyond the first 3 minutes decreases the likelihood of survival by approximately 10%.
    • Because emergency paramedical technicians cannot be expected to arrive at the scene of a cardiac arrest in less than 5 minutes, the expanded use of automated external defibrillators (AEDs) may save the lives of countless young people who go into arrest due to blunt trauma to the precordium. AEDs, even when used by persons with minimal training, can recognize and automatically terminate fatal arrhythmias. AEDs are now approved for use in children as young as 1 year. Ideally, AEDs should have a specific "low-output" setting or a special pediatric pad and cable set which attenuates the charge for use in children aged 1-8 years. Even without these, all AEDs can be used in children of any age older than 1 year.
  • Precordial thump
    • Use of the precordial thump during CPR is controversial. No prospective studies have evaluated the efficacy of precordial thump in resuscitation. Recently, limited studies in animals and humans have shown precordial thumps to be ineffective in terminating ventricular fibrillation.6 The guidelines mention that one immediate precordial thump may be considered after a witnessed cardiac arrest if a defibrillator is not immediately available.
    • Precordial thump is not mentioned at all as an option in pediatric CPR or pediatric advanced life support (PALS). Because a single thump can be delivered quickly, its use as emergency therapy for pediatric commotio cordis, in which the child is pulseless and no defibrillator or cardiac monitor is immediately available, should be reinvestigated. If used in this setting, it should never be allowed to delay electrical defibrillation and should always be followed by standard CPR modalities.

Medication

  • Medications may be required to treat arrhythmia following basic cardiopulmonary resuscitation (CPR), electrical defibrillation, or both.
  • Follow current American Heart Association (AHA) guidelines.

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

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  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.

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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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