Commotio cordis: Difference between revisions

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==Background==
==Background==
*Sudden cardiac arrest resulting from blunt chest trauma in absence of underlying cardiac disease<ref name="Yousef">Yousef R, Carr JA. Blunt cardiac trauma: a review of the current knowledge and management. Ann Thorac Surg. 2014 Sep;98(3):1134-40. doi: 10.1016/j.athoracsur.2014.04.043.</ref>
*Sudden [[cardiac arrest]] from blunt, non-penetrating chest wall impact in the absence of underlying cardiac disease or structural damage<ref>Menezes RG, et al. Commotio cordis: A review. Med Sci Law. 2017 Jul;57(3):146-151. PMID 28587536</ref>
*50% of cases due to competitive sports<ref name="Yousef" />
*50% of cases occur during competitive sports (baseball is most common)
**Baseball is most common culprit
*Most commonly affects young males (median age 14)<ref>Lee RN, et al. Commotio Cordis in Non-Sport-Related Events: A Systematic Review. JACC Clin Electrophysiol. 2023 Aug;9(8 Pt 1):1321-1329. PMID 37558288</ref>
*Autopsy usually shows normal cardiac anatomy with no evidence of damage to heart or other intrathoracic structures<ref name="Ngai">Ngai KY, Chan HY, Ng F. A patient with commotio cordis successfully resuscitated by bystander cardiopulmonary resuscitation and automated external defibrillator. Hong Kong Med J. 2010 Oct;16(5):403-5.</ref>
*Autopsy shows structurally normal heart with no myocardial contusion, rib fracture, or other thoracic injury


===Pathophysiology<ref name="Ngai" />===
{{Background BCI}}
*Primary electrical event resulting in induction of Vfib
 
*Likely due to blow occurring 10-30ms before peak of T wave, although this theory is disputed<ref name="Yousef" />
===Pathophysiology===
*Strike directly over cardiac silhouette ↑ risk of developing commotio cordis
*Primary electrical event: blow to precordium during the vulnerable period of repolarization (10-30 ms before T-wave peak) triggers [[ventricular fibrillation]]
*Younger patients more at risk - compliant chest wall allows transmission of more energy to the heart.
*Risk factors for commotio cordis:
**Impact directly over the cardiac silhouette
**Young, compliant chest wall (transmits more energy)
**Velocity of projectile 30-50 mph (neither too slow nor too fast)
**Small, hard projectile (baseball, hockey puck, lacrosse ball)


==Clinical Features==
==Clinical Features==
*Cardiac arrest (usually ventricular fibrillation)
*Witnessed collapse immediately after chest wall impact
*[[Cardiac arrest]] — usually [[ventricular fibrillation]]
*No external signs of significant chest wall injury


==Differential Diagnosis==
==Differential Diagnosis==
{{Thoracic trauma DDX}}
{{Thoracic trauma DDX}}


==Diagnosis==
==Evaluation==
*Clinical
*Clinical diagnosis based on witnessed event and mechanism
*Post-resuscitation workup if ROSC achieved:
**[[ECG]]: may show ST changes or arrhythmias
**Troponin (to evaluate for myocardial injury)
**[[Echocardiography]]: should be structurally normal (distinguishes from [[blunt cardiac injury]])
**CT chest to rule out other traumatic injuries


==Management==
==Management==
*Standard [[Adult Pulseless Arrest|adult]] or [[Pediatric Pulseless Arrest|pediatric]] cardiac arrest management
*Immediate [[CPR]] and early defibrillation — standard [[Adult Pulseless Arrest|ACLS]] or [[Pediatric Pulseless Arrest|PALS]] cardiac arrest management
*Prognosis is poor, with only 16% survival rate<ref name="Ngai" />
*'''Early defibrillation is key:''' survival rates improve significantly with prompt AED use
*Overall survival ~25% (improving with increased bystander CPR and AED availability)


==Disposition==
==Disposition==
*Admit to ICU if ROSC is achieved
*Admit to ICU if ROSC achieved
*See [[Post Cardiac Arrest]]
*Post-arrest care per [[Post cardiac arrest]] protocol
*Cardiology consult for monitoring and risk stratification
*Consider ICD discussion if recurrent arrhythmias post-resuscitation
 
==Prevention==
*Chest protectors (limited efficacy — cannot fully prevent commotio cordis)
*Safety baseballs (softer core) reduce risk
*AED availability at all youth sporting events


==See Also==
==See Also==
[[Thoracic Trauma]]
*[[Blunt cardiac injury]]
*[[Thoracic trauma]]
*[[Post cardiac arrest]]
*[[Ventricular fibrillation]]


==References==
==References==
<References/>
<references/>


[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Trauma]]
[[Category:Trauma]]

Latest revision as of 10:59, 22 March 2026

Background

  • Sudden cardiac arrest from blunt, non-penetrating chest wall impact in the absence of underlying cardiac disease or structural damage[1]
  • 50% of cases occur during competitive sports (baseball is most common)
  • Most commonly affects young males (median age 14)[2]
  • Autopsy shows structurally normal heart with no myocardial contusion, rib fracture, or other thoracic injury


Blunt cardiac injury

Spectrum of Blunt Cardiac Injury
  • A spectrum of disease due to blunt trauma to the chest wall
  • Ranges from cardiac contusion to infarction to cardiac rupture and death.[3]
    • Commotio cordis is sudden cardiac arrest resulting from blunt chest trauma, in absence of underlying cardiac disease[4]
    • Up to 20% of all MVC deaths are due to blunt cardiac injury

Pathophysiology

  • Primary electrical event: blow to precordium during the vulnerable period of repolarization (10-30 ms before T-wave peak) triggers ventricular fibrillation
  • Risk factors for commotio cordis:
    • Impact directly over the cardiac silhouette
    • Young, compliant chest wall (transmits more energy)
    • Velocity of projectile 30-50 mph (neither too slow nor too fast)
    • Small, hard projectile (baseball, hockey puck, lacrosse ball)

Clinical Features

Differential Diagnosis

Thoracic Trauma

Evaluation

  • Clinical diagnosis based on witnessed event and mechanism
  • Post-resuscitation workup if ROSC achieved:
    • ECG: may show ST changes or arrhythmias
    • Troponin (to evaluate for myocardial injury)
    • Echocardiography: should be structurally normal (distinguishes from blunt cardiac injury)
    • CT chest to rule out other traumatic injuries

Management

  • Immediate CPR and early defibrillation — standard ACLS or PALS cardiac arrest management
  • Early defibrillation is key: survival rates improve significantly with prompt AED use
  • Overall survival ~25% (improving with increased bystander CPR and AED availability)

Disposition

  • Admit to ICU if ROSC achieved
  • Post-arrest care per Post cardiac arrest protocol
  • Cardiology consult for monitoring and risk stratification
  • Consider ICD discussion if recurrent arrhythmias post-resuscitation

Prevention

  • Chest protectors (limited efficacy — cannot fully prevent commotio cordis)
  • Safety baseballs (softer core) reduce risk
  • AED availability at all youth sporting events

See Also

References

  1. ↑ Menezes RG, et al. Commotio cordis: A review. Med Sci Law. 2017 Jul;57(3):146-151. PMID 28587536
  2. ↑ Lee RN, et al. Commotio Cordis in Non-Sport-Related Events: A Systematic Review. JACC Clin Electrophysiol. 2023 Aug;9(8 Pt 1):1321-1329. PMID 37558288
  3. ↑ El-Menyar A, Al Thani H, Zarour A, Latifi R. Understanding traumatic blunt cardiac injury. Ann Card Anaesth. 2012 Oct-Dec;15(4):287-95. doi: 10.4103/0971-9784.101875.
  4. ↑ Yousef R, Carr JA. Blunt cardiac trauma: a review of the current knowledge and management. Ann Thorac Surg. 2014 Sep;98(3):1134-40. doi: 10.1016/j.athoracsur.2014.04.043.
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