POPULATION-SPECIFIC CONCERNS

Malissa Martin, EdD, ATC, CSCS, Report Editor

CommotioCordis in the Athlete

jane S, Kim California State University, Long Beach
PPROXIMATELY 350,000 cases of sudden cardiac death (SCD) occur in the United States each year, ' The incidence of SCD during various types of athletic activity varies, Maron et al,2 estimated that 1 in 200,000 high school athletes die of SCD each year. Although the incidence of cardiac arrest among athletes is low, such an event demands an immediate response. The purpose of this report is to review the etiology of commotion cordis (CC) and to present possible KEY POINT prevention strategies. (ommotio cordis (C() is a rare but deadly Case reports of CC concussion of the heart, ( ( occurs as a have been documented result of a blunt force to the chest wall, over the past 130 years,' Reports were often cited CC is often associated with youth sports, .n such as baseball and hockey, m as SCD, with no structural damage, during Educated athletic trainers and therapists, performance of routine coaches, and players can help prevent CC. .r tnanual labor. Theories about the etiology of CC include alteration in coronary blood flow and mechano-electrical feedback,' Currently, the general consensus among experts is that CC is primarily an electrical event that results in instantaneous ventricular fibrillation (VF), SCD in athletes is most often attributable to a congenital or acquired cardiac disease (e,g,, hypertrophie cardiomyopathy) but may also result from a seemingly innocuous chest blow from body contact with an opponent or the impact of a projectile (i,e,, a baseball), A "cardiac concussion" can induce cardiac arrest in the absence of any premorbid cardiac disease or structural abnormality. Although CC appears to be a random event, there have been a number of cases that have had legal ramifications. In 1993, an Italian hockey player was charged with unintentional manslaughter when his opponent died suddenly after having been hit in the chest, The prevalence of CC in sport has not been clearly established, because many cases are not reported or are simply reported as accidental deaths,' A National Commotio Cordis Registry was established at the Minneapolis Heart Institute Foundation in 1995 to track cases of CC, with a focus on sport events,^

Clinical Presentation
The creation of the National Commotio Cordis Registry has provided a more accurate description of the circumstances of CC cases. Most cases have occurred during participation in competitive youth baseball (Figure 1 ), but participation in hockey, lacrosse, soccer, Softball, and karate has also been reported,* The events usually involve a blow to the chest from a projectile thrown at normal velocity, with most victims being adolescent males between 5 and 15 years of age who had no preexisting heart condition (Table 1),' Immediately after chest impact, collapse usually occurs, and resuscitation efforts are rarely successful. Cases have been reported, however, that involved the victim briefly continuing to perform an activity in a conscious state (e,g,, attempting to stand, speak, cry, walk, or throw a baseball) before subsequently collapsing in a state of cardiac
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Many c e cases occur during participation in competitive youth baseball.

TABLE 1. GENERAL PROFILE AND STATISTICS OF C C VICTIMS ''^

Athletes participating in organized, competitive sports 56-62 % Athletes participating in recreational sports 22% Victims engaging in everyday activities (e.g. accidental kick, remedy for hiccups, hit by a snowball, etc.) 22% Victims hit by projectile 58% Instances involving body contact with another person or a stationary object 42 % Athletes wearing chest protection 28% Race: White 80% Sex: male 95% Mean age 15 9 years old (27% younger than 10; 10% older than 25)

heart cycle (diastole), specifically during the 15 to 30 msec period preceding the T-wave peak."* Chest blows received outside this defined interval can produce a heart block that is generally not lethal. Thus, the incidence of CC "near-miss" cases may be great. The force of chest impact is a third factor that is directly related to the risk for cardiac arrest. An animal study of chest blows with baseballs demonstrated that the softest baseballs triggered VF in fewer impacts than those of intermediate hardness or the hardness of a standard baseball.' Moreover, the velocity at which baseballs are thrown in the 15-30 msec window can affect risk for cardiac arrest. Occurrence of VF in juvenile swine was greatest at 40 mph, and the occurrence was lower at velocities that were either less than or greater than 40 mph. The high-velocity impacts may have created structural damage that precluded the occurrence of VF" Thus, the risk of VF appears to be linked to a specific velocity of chest wall impact. The susceptibility of young athletes to CC may be attributable to the amount and rate of chest wall compression that results from the external blow. A more compliant chest wall transmits a greater amount of impact energy to the heart.'^ A defect in the function of sodium channels, or irregular activation of potassiumATP channels, may also play a role in sudden death that is attributable to C C

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Prevention and Immediate Care
The survival rate of individuals who experience VF is 15 96.^ Athletic trainers and therapists (ATs) must recognize and react to CC immediately. The recommendations of the National Athletic Trainers' Association for prevention of CC include training athletic personnel in the recognition of the signs and symptoms of CC and teaching athletes how to avoid being hit in the chest." Utilization of protective athletic equipment may seem to be an obvious method of prevention; however, while some experts have advocated the use of sportspecific chest protectors, it may not protect young athletes from deadly blows.^ Chest padding can shift during play, thereby allowing a ball to hit the unprotected chest wall, and protective gear has not been found to adequately dissipate the pressure generated by chest wall impact to prevent CC.'^ Further research is needed to establish the characteristics of protective gear that will provide optimum effectiveness. Age-appropriate safety balls should be used to decrease incidence of CC in youth baseball. The
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arrest.^ This suggests that VF may be tolerated for a brief period, before cardiac arrest occurs.^

Pathophysioloqy
The three major determinants of CC occurrence appear to be body location, timing, and force of impact.'^ Cardiac arrest that is attributable to CC is precipitated by impact directly over the heart. Although lesions are evident in only a minority of cases, there may be bruising on the left side of the sternum at the level of the nipples." Maron et al." found that VF only occurs when an athlete is hit during the repolarization phase of the
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adoption of safety balls in organized youth baseball is controversial, because some people feel that they alter fundamental aspects of the game. Contrary to this belief. Link et al.'have suggested that safety balls of intermediate hardness are indistinguishable from the standard baseball and should be used by older age groups. Training athletic personnel to recognize the mechanism of CC and to react immediately may increase the chances for survival of athletes who experience a low-impact blow to the chest. Immediate care for CC is the same as other cardiac emergencies: airway maintenance, chest compressions, and ventilation.'" Coaches and ATs, and perhaps even spectators, should be trained in cardiopulmonary resuscitation (CPR), and automated external defibrillators (AEDs) should be readily accessible. According to the American Heart Association, each minute of delay in delivering a defibrillation shock to a cardiac arrest victim reduces the chances of survival by 10%.'^ Thus, rapid response is essential. Because the most common cause of death in the 12 hours following a successful resuscitation is dysrhythmia, continuous ECG monitoring is essential.'*" Common misconceptions about prevention and immediate care include the ability to identify those at risk for CC through a preparticipation examination and the appropriateness of delivering precordial "thumps" for resuscitation. Because CC can occur in healthy athletes, a preparticipation exam has limited value for prevention of cardiac arrest. The use of the precordial thumps is controversial, particularly in children, because they can cause a regular heart rhythm to convert to VF'^ Arrhythmia following CPR or automated external defibrillation may be controlled with medication or through management of risk factors. Athletes who survive CC should avoid substances that contribute to an irregular heartbeat, which include caffeine, tobacco, alcohol, and appetite suppressants. Because arrhythmia following CPR or automated external defibrillation increases the risk of heart attack, cardiac arrest, and stroke, careful management of blood pressure, cholesterol level, body weight, and physical activity is important.'^

its recognition and initiation of a prompt response is essential. If resuscitation is successful, a good longterm prognosis is possible. I

References
1. Rasdorff EJ, Prodinger RJ. Sudden cardiac death in the athlete. Emerg Med Clinic N Am. \ 998; 16(2);281 -293. 2. Maron BJ, Epstein SE, Roberts WC. Causes of sudden death in competitive athletes.y/im CoUCardiol. 1986;7(1), 204-214, 3. Lateef F Commotio cordis; an underappreciated cause of sudden death in athletes. Sports Med. 2000;30(4). 301-308. 4. Curfman GD. Fatal impact; concussion of the heart. N Englf Med. 1998;338(25);184M843. 5. Maron BJ, DoererJJ, HaasTS, Link MS, Estes NAM III. C/iest Gear Ma;' not Protect Young Athletes From Deadly Blows. Available at; hltp.llwviw. americanheart.org/presenterjhtml7identifier = 3043387. Accessed January 21, 2010. 6. Maron BJ, Gohman TE, Kyle SB, Estes NAM 111. Clinical profile and spectrum of commotio cordis. J Am MedAssoc. 2002,287(9): 1142-1146. 7. Maron BJ, Poliac LC, Kaplan JA, Mueller FO. Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. N EnglJ Med. 1995;JJ3(6): 337-342. 8. Link MS, Wang PJ, Pandian NG, Bharati S, UdelsonJE, Lee MY. Vecchiotti MA, VanderBrink BA, Mirra G, Maron BJ, Estes NAM. 111. An experimental model of sudden death due to low energy chest wall impact (commotio cordis). N Englf Med. 1998;J38(25); 1805-1811. 9. Maron BJ. Link MS, Wang PJ, Estes NAM 111. Clinical profile of commotio cordis; an underappreciated cause of sudden death in the young during sports and other activities. J Cardiovas ElectrophysioL
1999;;O(I):II4-I2O.

10, Link MS, Maron BJ, Wang PJ, Pandian NG, VanderBrink BA, Estes NAM III. Reduced risk of sudden death from chest wall blows (commotio cordis) with safety baseballs, Pediatri. 2002; /09(l): 873-877, 11, Link MS, Maron BJ, Wang PJ, VanderBrink BA, Zhu W, Estes NAM 111, Upper and lower limits of vulnerability to sudden arrhythmic death with chest-wall impact (commotio cordis), J Am Coll Cardiol. 2003;4/(l);99-104, 12, Madias C, Maron BJ, Alsheikh-Ali AA, Estes NAM, Link MS, Commotio cordis, Indian Pac ElectrophysiolJ. 2007;7(4);235-245. 13, National Athletic Trainers' Association, NATA official statement on commotio cordis. Available at; http;//www,nata,org/statements/ofcial/ ASTFstmtCommotioCordisRevised091107(2).pdf, Accessed January 18, 2010, 14, Yabek SM, Commotio cordis. Available at: http;//emedicine,medscape. com/article/902504-overview. Accessed January 20, 2010, 15, U.S. Lacrosse Sports Science & Safety Committee, Position statement on commotio cordis. Available at: http://www,uslacrosse.org/safety/ commotio_cordis_position.phtml. Accessed January 18, 2010, 16, Crown LA, Hawkins W, Commotio cordis: clinical implications of blunt cardiac trauma. Am Fam Physician. 1997;55(7):2467-2470, 17, Yabek SM. Commotio cordis: treatment & medication. Avaiiabie at; http;//emedicine.medscape,com/article/902504-overview. Accessed May 3, 2009. 18, American Heart Association, Living with arrhythmias. Available at; http;//www,americanheart.org/presenter.Jhtml?identier = 35. Accessed January 21, 2010,

Summary
Cases of CC should be reported to the Minneapolis Heart Institute Foundation: www.suddendeathathletes. org. Although CC is uncommon, proper training for
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Jane Kim is a graduate student at California State University, Long Beach. She is currently working toward a Master's degree in KinesiologySports Medicine and Injury.

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