Introduction
Commotio cordis is a Latin term that translates as agitation of the heart. Commotio cordis occurs primarily in children and young adults, most often while participating in certain recreational or competitive sports. It rarely occurs while doing normal, routine daily activities. Cases of commotio cordis are rare, with fewer than 30 cases annually. However, survival can happen similarly to other cases of ventricular fibrillation by receiving prompt treatment.
What Is Commotio Cordis?
Commotio cordis comprises ventricular fibrillation (a type of cardiac arrhythmia) by an event of nonpenetrating and often an innocent-appearing unintended blow to the chest without injury to the sternum, ribs, or heart and in the absence of any underlying cardiovascular disease. An absence of structural cardiac injury differentiates commotio cordis from a cardiac contusion because, in the case of cardiac contusion, high-impact blows lead to traumatic injury to myocardial tissue and the thorax.
What Are the Causes of Commotio Cordis?
Commotio cordis most commonly results from a hit to the left chest with a hardball, such as a baseball or a football, being struck in the chest by a hockey puck during sports activity. Seemingly innocuous things, such as sledding saucers and plastic toy bats, can become lethal when struck at small children, even at lower speeds.
The sudden focal distortion of the myocardium leads to ventricular fibrillation, resulting in a sudden cardiac arrest in a structurally normal heart. Therefore, it is distinguishable from traumatic damage to the heart, like cardiac rupture, contusion, or penetrating chest traumas.
What Is the Mechanism of Commotio Cordis?
Commotio cordis is an immediate arrhythmic event that happens when the mechanical energy developed by a blow is specified to a small area of the chest and to the front wall of the heart, which profoundly changes the electrical stability of the muscles of the heart, resulting in ventricular fibrillation.
The impact energy, about 50 joules, is sufficient to cause ventricular depolarization. A thrown baseball quickly gains this energy level, and the risk for commotio cordis peaks around 40 miles per hour. However, the higher speed with more energy is more likely to result in structural damage to the chest wall and heart rather than sole ventricular fibrillation. In addition, small balls carry a higher risk for commotio cordis due to their impact being concentrated on a less surface area. The mechanical force resulting from the impact causes a stretch in cardiac muscle cell membranes, which probably activates ion channels. If these channels are in a weak repolarization period, resultant depolarization may lead to ventricular fibrillation.
What are the symptoms?
Symptoms of commotio cords include:
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Immediate Collapse after getting hit in the chest.
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Cardiac arrest.
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Unconsciousness.
How Is Commotio Cordis Diagnosed?
History:
There is a history of immediate cardiac arrest following a sudden impact on the anterior chest overlying the heart. However, such individuals generally do not have a history of structural heart conditions to justify the dysrhythmia.
1. Physical Examination:
Physical findings may show
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A contusion over the chest area of the heart may often take time to develop.
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A pulse is absent with ventricular fibrillation.
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Evidence of impaired organ perfusion, that is, unconsciousness, is present.
2. Imaging:
The following types of imaging can help in diagnosing commotio cordis,
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Rhythm strip analysis can help to guide interventions.
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Ultrasound may help exclude concomitant injuries such as pneumothorax, pericardial effusion, and tamponade.
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Troponin and echocardiogram may help determine the presence of myocardial contusion.
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An echocardiogram may help identify other underlying structural abnormalities.
3. Stress Testing or Cardiac Catheterization:
They can evaluate for coronary artery disease.
4. Pharmacological Testing:
It can diagnose long-QT syndrome and Brugada syndrome.
How Is Commotio Cordis Managed?
Resuscitation From Cardiac Arrest:
The initial management line includes closed chest compressions and early defibrillation. Rescue ventilation and medications such as Epinephrine are given in case of prolonged arrest to improve coronary perfusion pressure. Stabilization of the electrical activity is the only necessary intervention for isolated blunt cardiac traumas. The American Heart Association and the American College of Cardiology strongly recommend that after prompt resuscitation with commotio cordis, a complete evaluation for underlying cardiac conditions and susceptibility to arrhythmias is considerable.
Considering other forms of traumatic arrest is appropriate depending on the clinical situation. These include cardiac or coronary laceration, hemorrhagic shock, tension pneumothorax, cardiac tamponade, great vessel injury or pulmonary laceration, traumatic valvular injury, or extrathoracic injuries, depending on the mechanism of injury.
What Is the Differential Diagnosis of Commotio Cordis?
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Myocardial infarction.
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Ventricular fibrillation.
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Hypertrophic cardiomyopathy.
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Viral myocarditis.
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Prolonged QT syndrome.
How to Prevent Commotio Cordis?
Prevention remains a significant consideration.
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Successful resuscitation measures for commotio cordis victims, such as training staff, players, coaches, parents, and others to provide prompt recognition, also helps to notify emergency medical services and institutions.
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Use age-appropriate safety baseballs to decrease the risk of injury and commotio cordis.
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Rules controlling athletics and coaching techniques to lower chest blows can help lessen the probability of commotio cordis.
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Promote all coaches and officials to undergo training in cardiopulmonary resuscitation (CPR), first aid, and automatic external defibrillator (AED) use.
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Proper arrangement and access to AED units at sports facilities.
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Educate coaches and officials on the need for immediate CPR and AED because the more prolonged the delay, the greater the probability of death.
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Establish an emergency measure plan involving all officials, players, and parents at all athletic platforms.
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Using sport-specific chest protectors while practicing and playing games, which decreases the individual's risk of traumatic chest injury.
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Teach all players to safeguard themselves and avoid being struck on the chest by objects such as baseball, hockey pucks, and lacrosse balls.
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Encourage the use of softer baseballs and pucks.
Conclusion
Commotio cordis occur in healthy and active young individuals, generally during recreational and competitive sports. However, if the blow is delivered at a specific moment in the cardiac cycle, then even an innocent-appearing blow to the left front side of the chest can trigger ventricular fibrillation and may result in fatal commotio cordis events. Efforts to prevent these avoidable deaths by providing better-designed athletic equipment such as chest-wall protectors, broader access to AEDs at athletic event venues, and more education related to commotio cordis prevention and prompt management are paramount. These strategies can result in a safer sports environment for everyone playing sports.
