Medical Care

The treatment of commotio cordis is not different from any other cardiopulmonary emergency associated with a nonperfusing cardiac rhythm. For victims of witnessed ventricular fibrillation arrest, as occurs in commotio cordis, early cardiopulmonary resuscitation (CPR) and rapid defibrillation can significantly increase the chances of survival.

The 2010 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommend early CPR that emphasizes chest compressions immediately after the emergency response system has been activated. The guidelines deemphasize the importance of rescue breaths and pulse checks. Although a chest compression to ventilation ratio of 30:2 and a compression rate of at least 100 per minute are still recommended for adults and children (above age 1 y), bystander "hands-only" CPR (compression only) also significantly improves survival compared with no bystander CPR. Rapid defibrillation significantly increases the chances for survival to hospital discharge. CPR, beginning with chest compressions, should resume immediately after a shock and should continue for 2 minutes before a rhythm or pulse check is conducted.

Performing CPR while the AED or defibrillator is readied for use is strongly recommended. A shorter time interval between the last chest compression and the shock is directly correlated with the success of defibrillation.

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 public-access automated external defibrillators (AEDs) may save the lives of countless young people who experience cardiac 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.^[18]The 2010 AHA Guidelines for adult ACLS mention that one immediate precordial thump may be considered after a witnessed cardiac arrest if an AED or defibrillator is not immediately available. Precordial thump is not mentioned at all as an option in pediatric CPR or pediatric advanced life support (PALS).

Medication

Medications may be required to treat arrhythmias following basic cardiopulmonary resuscitation (CPR), electrical defibrillation, or both.

Prevention

The 36th Bethesda Conference on Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities had a number of recommendations regarding commotio cordis, including the following^[19]:

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. Among professional athletes who suffered a commotio cordis event, 1/3 were wearing commercially available chest protectors.
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. No evidence suggests that survivors of commotio cordis have a greater risk of future arrhythmic events. The role of subclinical long QT syndrome as a potential cause for increased susceptibility, as suggested by animal studies, needs further investigation.
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.

In February, 2022, USA Lacrosse, the National Federation of State High School Associations (NFHS), and National Collegiate Athletic Association (NCAA) required all goalies in girls’ and boys’ lacrosse to wear chest protectors that meet the National Operating Committee on Standards for Athletic Equipment (NOCSAE) standard to protect against commotio cordis.^[14]

Shang G. Commotio cordis: an under-appreciated cause of sudden cardiac death (SCD) in young athletes. Heart Matters. 2017 Apr. 8(1):
[Guideline] Link MS, Estes NAM 3rd, Maron BJ, American Heart Association Electrocardiography and Arrhythmias Committee of Council on Clinical Cardiology, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 13: Commotio Cordis: a scientific statement from the American Heart Association and American College of Cardiology. Circulation. 2015 Dec 1. 132(22):e339-42. [QxMD MEDLINE Link]. [Full Text].
Maron BJ. Sudden death in young athletes. N Engl J Med. 2003 Sep 11. 349(11):1064-75. [QxMD MEDLINE Link].
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. 1998 Jun 18. 338(25):1805-11. [QxMD MEDLINE Link].
Maron BJ, Haas TS, Ahluwalia A, Garberich RF, Estes NA 3rd, Link MS. Increasing survival rate from commotio cordis. Heart Rhythm. 2013 Feb. 10(2):219-23. [QxMD MEDLINE Link].
Nazer D, Kannikeswaran N, Schmidt C. Commotio cordis: a case report of a fatal blow. J Forensic Sci. 2022 Jan. 67(1):384-6. [QxMD MEDLINE Link].
Humble JR, Surrey A, Taylor L. Commotio cordis resulting from sibling rivalry. Am J Cardiol. 2021 Oct 1. 156:132-3. [QxMD MEDLINE Link].
Maron BJ, Link MS. Don't forget commotio cordis. Am J Cardiol. 2021 Oct 1. 156:134-5. [QxMD MEDLINE Link].
Krexi L, Sheppard MN. Blow/trauma to the chest and sudden cardiac death: commotio cordis and contusio cordis are leading causes. Med Sci Law. 2018 Apr. 58(2):93-6. [QxMD MEDLINE Link].
Mu J, Zhang J, Liu L, Dong H. Homicidal commotio cordis caused by domestic violence: a report of two cases. Med Sci Law. 2016 Apr. 56(2):138-41. [QxMD MEDLINE Link].
Link MS, Maron BJ, Wang PJ, VanderBrink BA, Zhu W, Estes NA 3rd. Upper and lower limits of vulnerability to sudden arrhythmic death with chest-wall impact (commotio cordis). J Am Coll Cardiol. 2003 Jan 1. 41(1):99-104. [QxMD MEDLINE Link]. [Full Text].
Madias C, Maron BJ, Dau N, Estes NAM 3rd, Bir C, Link MS. Size as an important determinant of chest blow-induced commotio cordis. Med Sci Sports Exerc. 2018 Sep. 50(9):1767-71. [QxMD MEDLINE Link]. [Full Text].
Link MS. Commotio cordis: ventricular fibrillation triggered by chest impact-induced abnormalities in repolarization. Circ Arrhythm Electrophysiol. 2012 Apr. 5(2):425-32. [QxMD MEDLINE Link].
National Operating Committee on Standards for Athletic Equipment. Performance Standard to Protect Against Commotio Cordis. October, 2021. NOCSAE. Available at https://nocsae.org/wp-content/uploads/2021/10/NOCSAE_Performance-Standard-to-Protect-Against-Commotio-Cordis-Fact-Sheet_October-11-2021.pdf. Accessed: November 29, 2022.
Drezner JA, Rao AL, Heistand J, Bloomingdale MK, Harmon KG. Effectiveness of emergency response planning for sudden cardiac arrest in United States high schools with automated external defibrillators. Circulation. 2009 Aug 11. 120(6):518-25. [QxMD MEDLINE Link].
Drezner JA, Rogers KJ. Sudden cardiac arrest in intercollegiate athletes: detailed analysis and outcomes of resuscitation in nine cases. Heart Rhythm. 2006 Jul. 3(7):755-9. [QxMD MEDLINE Link].
Osorio J, Dosdall DJ, Robichaux RP Jr, Tabereaux PB, Ideker RE. In a swine model, chest compressions cause ventricular capture and, by means of a long-short sequence, ventricular fibrillation. Circ Arrhythm Electrophysiol. 2008 Oct. 1(4):282-9. [QxMD MEDLINE Link]. [Full Text].
Amir O, Schliamser JE, Nemer S, Arie M. Ineffectiveness of precordial thump for cardioversion of malignant ventricular tachyarrhythmias. Pacing Clin Electrophysiol. 2007 Feb. 30(2):153-6. [QxMD MEDLINE Link].
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. 2005 Apr 19. 45(8):1371-3. [QxMD MEDLINE Link].
Maron BJ, Estes NA 3rd. Commotio cordis. N Engl J Med. 2010 Mar 11. 362(10):917-27. [QxMD MEDLINE Link].
De Gregorio C, Magaudda L. Blunt thoracic trauma and cardiac injury in the athlete: contemporary management. J Sports Med Phys Fitness. 2018 May. 58(5):721-6. [QxMD MEDLINE Link].
Lear A, Patel N, Mullen C, et al. Incidence of sudden cardiac arrest and death in young athletes and military members: a systematic review and meta-analysis. J Athl Train. 2022 May 1. 57(5):431-43. [QxMD MEDLINE Link]. [Full Text].