What Is It, Causes, Treatment, and More
Author: Anna Hernandez, MD
Editors: Alyssa Haag, Kelsey LaFayette, DNP, ARNP, FNP-C
Illustrator: Jessica Reynolds, MS
Copyeditor: David G. Walker
What is commotio cordis?
Commotio cordis, Latin for “agitation of the heart,” refers to a rare form of cardiac injury that occurs when blunt chest wall impact leads to a life-threatening arrhythmia, like ventricular fibrillation, which often leads to sudden cardiac arrest. As a result, the individual may collapse suddenly and lose consciousness. It is most often associated with sports-related injuries, but can occur during other activities, such as falls, motor vehicle accidents, or violent assaults.Until recently, commotio cordis was rarely reported despite being described in literature since the 18th century. In the last two or three decades, however, more cases of commotio cordis have been recognized due to a greater awareness of the condition. It is estimated that around 10 to 20 cases are added to the Commotio Cordis Registry every year.
What causes commotio cordis?
Commotio cordis occurs due to a sudden blow to the chest area overlying the heart, called the precordium. The energy from the blow is transmitted through the chest wall to the heart, thereby disturbing the cardiac rhythm. For commotio cordis to occur, the heart must be struck with blunt force during a specific part of the heart cycle where the ventricles, or the lower chambers of the heart, are about to contract. If the force occurs during this window, a life-threatening disturbance of the heart rhythm called ventricular fibrillation can occur. During ventricular fibrillation, the heart’s muscle fibers are not contracting simultaneously, which results in failure to pump oxygenated blood to the brain. Within minutes, sudden cardiac death can result.Commotio cordis can occur with any kind of impact to the chest wall; however, it is most often associated with sports-related injuries, where a small high-velocity projectile (e.g. baseball, lacrosse ball, or ice hockey puck) impacts directly on the chest wall. As a result, it is the second leading cause of sudden death in young athletes. More rarely, it can result from trauma due to motor vehicle accidents or violent assaults as well as after falls. Young individuals are particularly at an increased risk of commotio cordis because their chest walls are more thin, compliant, and allow for greater transmission of impact energy to the heart.
What are the signs and symptoms of commotio cordis?
The most common clinical manifestation of commotio cordis is cardiovascular collapse, which occurs almost immediately after the traumatic blow due to ventricular fibrillation. Ventricular fibrillation prevents the heart from pumping blood effectively to the rest of the body, resulting in severe hypotension and decreased blood supply to vital organs, like the brain. As a result, the individual may collapse suddenly and lose consciousness. If resuscitation is not started immediately, death can occur within minutes. Although it is uncommon, individuals may present with other signs and symptoms prior to collapsing, including precordial bruises, difficulty breathing, urinary incontinence, and convulsions. Typically, commotio cordis occurs in young, healthy individuals without underlying cardiovascular disease. It is more common in those who are assigned male at birth with an average age of 15 years.
How is commotio cordis diagnosed?
Commotio cordis is suspected when there is a loss of consciousness immediately after a blunt chest wall impact in the absence of any underlying heart disease. If available, an electrocardiogram (ECG) may reveal ventricular fibrillation, which can be recognized by the presence of irregular waves corresponding to an area of the ventricle depolarizing on its own. Unfortunately, diagnosis of commotio cordis is often confirmed following an autopsy as there are no diagnostic tests that can be done at the time of the event.
It is important to note that there is no structural damage to the heart associated with commotio cordis, which differentiates it from a cardiac contusion (i.e., contusio cordis), a condition where blunt chest trauma causes structural damage to the heart.
How is commotio cordis treated?
Treatment of commotio cordis is the same as that of any other form of cardiac arrest and involves initiating resuscitation measures as soon as possible. Cardiopulmonary resuscitation (CPR), which combines chest compressions and artificial ventilation to maintain blood flow to the brain while the heart is not pumping blood effectively, should be started immediately. As soon as a cardiac monitor or automated external defibrillator (AED) is available, using it becomes the most important step. The cardiac monitor assesses the heart rhythm on the ECG, and if it senses a shockable rhythm like ventricular fibrillation, it will deliver a high-energy shock to the heart. This allows the sinus node, or the heart’s main pacemaker, to take control and restore normal heart rhythm.Even with timely and appropriate resuscitation, commotio cordis has a high mortality rate. It is therefore essential to establish preventive measures to decrease its occurrence. For example, it is important to train young athletes in techniques to avoid a direct hit to the chest wall, such as turning quickly from blunt objects. Additionally, using safety baseballs with extra cushioning or chest wall protectors, such as protective padding used in ice hockey, can soften the impact of the blow.
What are the most important facts to know about commotio cordis?
Commotio cordis is a rare cause of sudden cardiac death that mainly affects young athletes participating in high-risk sports like baseball, lacrosse, and hockey. It occurs when a sudden blow to the chest results in life-threatening arrhythmias like ventricular fibrillation, eventually leading to cardiac arrest. Unfortunately, the chance of survival is low if cardiopulmonary resuscitation (CPR) and defibrillation are not initiated immediately. Therefore, preventive measures, such as wearing chest wall protectors and the widespread use of safety baseballs, are strongly recommended to those who participate in high risk activities.
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Resources for research and reference
Commotio cordis is extremely rare; quick action essential: call 911, begin CPR and use AED. (2023). In American Heart Association. Retrieved July 11, 2023, from https://newsroom.heart.org/news/commotio-cordis-is-extremely-rare-quick-action-essential-call-911-begin-cpr-and-use-aed
Lee, R. N., Sampaio Rodrigues, T., Gan, J. T., Han, H.-C., Mansour, R., Sanders, P., Farouque, O., & Lim, H. S. (2023). Commotio Cordis in non–sport-related events. JACC: Clinical Electrophysiology. DOI: 10.1016/j.jacep.2023.01.010
Link, M. S. (2012). Commotio cordis: ventricular fibrillation triggered by chest impact-induced abnormalities in repolarization. Circulation: Arrhythmia and Electrophysiology, 5(2): 425–432. DOI: 10.1161/CIRCEP.111.962712
Menezes, R. G., Fatima, H., Hussain, S. A., Ahmed, S., Singh, P. K., Kharoshah, M. A., Madadin, M., Ram, P., Pant, S., & Luis, S. A. (2017). Commotio cordis: a review. Medicine, Science, and the Law, 57(3): 146–151. DOI: 10.1177/0025802417712883Okorare, O., Alugba, G., Olusiji, S., Evbayekha, E. O., Antia, A. U., Daniel, E., Ubokudum, D., Adabale, O. K., & Ariaga, A. (2023). Sudden cardiac death: an update on commotio Cordis. Cureus, 15(4): e38087. DOI: 10.7759/cureus.38087