Commotio Cordis -- Sudden Cardiac Death With Chest Wall Impact

Christopher Madias, M.D.; Barry J. Maron, M.D.; Jonathan Weinstock, M.D.; N. A. Mark Estes III, M.D.; Mark S. Link, M.D.

Disclosures

J Cardiovasc Electrophysiol. 2007;18(1):115-122. 

In This Article

Clinical Spectrum

The U.S. Commotio Cordis Registry has accrued more than 180 cases since it was initiated in 1996.[1,9] CC is being reported with increasing frequency; however, the actual incidence is unknown as many cases are likely missed because of lack of recognition and underreporting. When analyzed by year of occurrence, most of the cases in the registry (75%) are clustered from the years 1988 to present.[9] This is likely due to a lack of awareness and understanding of this phenomenon prior to the late 20th century.

CC primarily affects young males with a median age of 14 years found in the Registry.[1] This susceptibility has been attributed to the compliant chest walls in children that allow for greater transmission of impact energy to the myocardium. Only 28% of the cases were aged over 18 years, with the oldest reported in a 44-year-old woman.

Cases have been reported most commonly in the setting of organized sporting events—46 (58%) in baseball or softball and 13 (16%) in hockey games. In most of the cases that occurred during competitive sports, victims were struck by projectiles regarded as standard implements of the game. With the exception of one air-filled soccer ball, each projectile that resulted in CC had a dense solid core, such as a baseball, hockey puck, or lacrosse ball. Projectiles with a nonsolid core likely absorb much of the impact energy as they collapse on contact. In baseball, 25% of the deaths occurred owing to pitched balls, with the rest due to batted balls or balls thrown between other players. Velocities of pitched balls that resulted in CC were estimated to be 48-80 km//h (30-50 mph). Most of the chest wall blows occur to the left of the sternum, directly over the cardiac silhouette. Interestingly, 28% of the individuals competing in organized athletic activities were wearing commercially available standard chest wall protection at the time of their event. However, in 13 of these 22 individuals, the chest wall protector did not adequately cover the left chest or precordium at the time of impact.[1,25]

In addition to those mentioned earlier, CC events have been reported in a variety of other sports, as well as in a diverse spectrum of nonsports-related activities.[1,3] Many cases occurred in association with events of normal daily life that resulted in often unintentional and innocent chest wall blows. Eighteen events involved bodily contact or contact with implements regarded as toys. Some such examples included a 23-year-old man fatally striking his friend in the chest as a mutually agreed on remedy for hiccups and a 44-year-old teacher who died when she was inadvertently struck in the chest as she was trying to break up a fight between two students. In two other cases, a 2-year-old girl was incidentally struck in the chest by the head of her pet dog and a five-year-old boy died instantly after being struck in the chest by a circular plastic sledding saucer. These examples illustrate the potential dire consequences from even seemingly innocuous chest wall impacts.[1]

Initial ECG data were available in 82 patients in the U.S. Commotio Cordis Registry (as recorded in the emergency room or by emergency medical technicians).[1] This revealed 33 cases of VF, 3 with ventricular tachycardia, 3 with bradyarrhythmias, 2 with idioventricular rhythm, and 1 with complete heart block. Forty of the cases documented asystole, which was unlikely to be the initial rhythm after impact, and is more likely a result of prolonged time from event to the documentation of a rhythm. Of the more than 180 individuals reported in the U.S. Commotio Cordis Registry, the survival rate is only about 15%.[1,9,25] As with other causes of VF, the most important determinant of survival appears to be the application of early resuscitation and defibrillation. Cardiopulmonary resuscitation was known to have been performed in 106 of the individuals in the U.S. Commotio Cordis Registry. Of 68 cases in which resuscitative efforts were instituted within 3 minutes of the incident event, 17 survived (25%). In the cases where resuscitation was substantially delayed (>3 minutes), only 1 out of 38 survived (3%).[1]

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