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

Electrocardiogram

Treatment

Medical Therapy

References

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