Commotio cordis overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Commotio cordis is a rare and potentially fatal condition characterized by sudden cardiac death triggered by a blunt, non-penetrating impact to the chest. It is most commonly associated with sports activities, such as baseball, ice hockey, lacrosse, and softball. However, it can also occur as a result of fistfights or other forms of physical violence.
Pathophysiology
Typically, arrhythmic deaths are caused by a low/mild force striking the chest wall, a condition known as Commotio Cordis. Many of those suffering from this condition are athletes between the ages of 8 and 18 and play sports that involve projectiles, such as baseball, hockey pucks, and lacrosse balls. When a hand strikes in martial arts, its force can alter its rhythm, causing it to become arrhythmic. If a projectile strikes the athlete's heart in the middle of their chest with a low impact but is sufficient to cause their heart to become arrhythmic, it can also cause the athlete's heart to become arrhythmic. In the case of commotio cordis, a poor prognosis is associated with failure to provide immediate CPR and defibrillation. This is a hazardous condition that has a very low survival rate.
Causes
The most common causes of Commotio cordis are sports that during them the chance of chest trauma with objects or the opponents is high. It can also be seen in cases of child abuse, torture, motor vehicle collisions or fights. There are several measures to reduce the incidence of commotio cordis and its complications in sports such as: having athletic trainers, teaching CPR and the usage of AED among trainers and athletics and other personnel, wearing protective equipment, avoiding weight and strength disparities among athletics.
Differential diagnosis
Commotio cordis should be distinguished from cardiac contusion, which occurs when a blunt strike to the chest damages the structural heart structures. the differential diagnosis of commotio cordis includes other causes of sudden cardiac death during sport participation, such as familial hypertrophic cardiomyopathy, myocarditis, dilated cardiomyopathy, long-QT syndrome, Brugada syndrome, Wolf-Parkinson-White syndrome, Marfan syndrome, aortic valve stenosis, mitral valve prolapse, coronary artery disease, asthma, heat stroke, drug abuse, and a ruptured cerebral artery. It is important to consider the possibility of intentional acts of violence causing commotio cordis.
Epidemiology and Demographics
Commotio cordis is a very rare event, but nonetheless is often considered when an athlete presents with sudden cardiac death. Among the cardiovascular factors leading to sudden death in athletes, commotio cordis holds the second-highest occurrence rate, after hypertrophic cardiomyopathy. The incidence of commotio codis is less than 30 cases per year. The USA Commotio Cordis Registry reported 216 cases recorded by July 2012, with most of the cases occurring in Little League baseball, lacrosse and softball. The real number of cases may be much larger. Children are especially vulnerable due to their more fragile thoracic skeleton. Boys between the ages of 8 and 18 are more likely to suffer from this condition.
Risk Factors
The risk factors for commotio cordis include the location and timing of the blow, the type of mechanical stimulus, age, chest morphology, and the hardness of the object involved in the impact. Understanding these risk factors can help in developing preventive measures and strategies to reduce the incidence of commotio cordis, especially in high-risk populations such as young athletes participating in sports with a higher potential for chest impacts. Certain sports have been identified as having a higher potential risk for commotio cordis such as Karate, Taekwondo, Judo, Kabedi, Free-style Wrestling, Cricket, baseball, hockey, lacrosse, and softball.
Natural History, Complications and Prognosis
Almost all of the patients with commotio cordis will die without any proper intervention due to arrhythmia. More than two third of those with prompt cardiopulmonary resuscitation/defibrillation experience a full physical recovery, while the remaining patients exhibit mild to moderate residual neurological disability or cardiac impairment during the follow-up period spanning from 1 to 20 years. Commotio cordis has a poor prognosis. However, a continuous rise of survival rates due to increasing awareness of the disease and prompt intervention is evident.
Diagnosis
History and Symptoms
Symptoms of commotio cordis may include: immediate collapse, sudden cardiac arrest and loss of consciousness.
Physical Examination
Immediately after the incident, there may not be any obvious signs of chest trauma, such as bruises. Individuals with commotio cordis are generally appeared to be unresponsive, apneic, cyanotic, pulseless without an audible heartbeat.
Laboratory Findings
There are no laboratory findings associated with commotio cordis.
Electrocardiogram
The most common rhythm observed in commotio cordis cases is ventricular fibrillation (VF). Other arrhythmias such as polymorphic ventricular tachycardia, complete heart block, idioventricular rhythm, atrial fibrillation, ST-segment elevation, T-wave abnormalities were reported. The timing and location of the impact are crucial in the generation of VF in commotio cordis. When the impact occurs directly over the heart within a specific window during the upslope of the T wave in ventricular repolarization, it triggers a rapid increase in left ventricular intracavitary pressure, leading to VF.
Echocardiography or Ultrasound
Echocardiography can aid in the diagnosis of specific cardiac injuries in commotio cordis. Doppler echocardiography can be used to diagnose coronary artery rupture. whereas, transthoracic or transesophageal echocardiography can help identify pericardial effusion, pericardial tamponade and cardiac lacerations. It may reveal contusion over the left or right ventricle, indicating the presence of significant chest wall trauma. Also, Follow-up and monitoring of the resolution of pericardial effusion and assess any changes in cardiac function over time can be achieved by echocardiography. It may be helpful for risk stratification and prognosis as well. It is important to note that echocardiography should be performed promptly after the return of spontaneous circulation (ROSC) in patients who have experienced cardiac arrest.
Other Imaging Findings
Cardiac magnetic resonance imaging (MRI), can help assess the presence of any pre-existing or trauma-associated structural lesions in the heart. This imaging modality can provide valuable information about the structural integrity of the heart and help rule out other potential causes of sudden cardiac arrest.
Other Diagnostic Studies
Autopsy examination remains the gold standard for confirming the diagnosis of commotio cordis and excluding other structural lesions in the heart. The autopsy findings in cases of commotio cordis typically show no structural or congenital abnormalities in the heart. It is important to exclude cardiac pathology, such as contusio cordis (cardiac bruising), to ensure an accurate cause of death.
Treatment
Medical Therapy
The first step in the treatment of commotio cordis is immediate recognition and activation of emergency medical services (EMS). Bystander cardiopulmonary resuscitation (CPR) should be initiated as soon as possible to maintain blood flow and oxygenation. Early defibrillation with an automated external defibrillator (AED) is also essential to restore normal heart rhythm. In cases where commotio cordis occurs in a healthcare setting or in the presence of medical professionals, advanced cardiac life support (ACLS) protocols should be followed. This includes advanced airway management, administration of medications such as epinephrine and amiodarone, and possible interventions such as cardioversion or transcutaneous pacing.
Primary Prevention
There are different measures to prevent or reduce the risk of commotio cordis. One preventive measure is the use of safety baseballs which are softer than regular balls. Other preventive measures include the use of chest wall protectors. Chest wall protectors, such as those used in ice hockey, can help soften the impact of projectiles. However, recent studies indicated that there is no clear evidence of the effectiveness of chest protectors in reducing the risk of commotio cordis. Also, ensuring the availability of defibrillators at sporting events is essential in preventing deaths from commotio cordis. Education and awareness among coaches, trainers, and participants in high-risk sports events are also important preventive strategies. the decision to return to sports after experiencing commotio cordis should be carefully evaluated on an individual basis, considering factors such as the underlying cause of the event, the severity of the injury, and the presence of any underlying cardiac conditions.
Cost-Effectiveness of Therapy
There is no cost-effectiveness of therapy for commotio cordis.
Future or Investigational Therapies
There are no future or investigational therapies for commotio cordis.