• Defined as sudden cardiac death due to a blunt, nonpenetrating anterior precordial impact that results in ventricular fibrillation (VF).
• One of the most common causes of sudden death in young male athletes (mean age is 15, 95% are male), which is likely due to decreased chest wall thickness as well as increased likelihood in participation in activities that may involve trauma to the chest.
• Most commonly occurs in sports with spherical small hard projectiles such as baseball, but has been reported in hockey, lacrosse, softball, and fist fights.
• Almost never caused by pneumatic objects (i.e., soccer/tennis balls).

Diagnostic Criteria:

• History: witnessed immediate collapse after a blunt chest impact.
• ECG: VF after impact and normal ECG at baseline.
• Imaging (Echo/CT): no structural heart disease.
• Physical examination: possible delayed onset chest wall contusion overlying the heart.

Investigations:

• There is no role for radiology in the management of commotio cordis, but it can be used to rule out concomitant injury such as sternal fracture.
• Point of care ultrasound may be helpful in ruling out concomitant injuries such as pneumothorax or pericardial effusion/tamponade.

Diagnostic considerations:

• Commotio cordis is a result of having chest wall impact of a specific speed, at a very specific location, and precisely at the right timing in the cardiac cycle to induce VF. Structural damage is only to the chest wall itself. This is an important point in distinguishing sudden cardiac death from more severe trauma that may cause cardiac contusion or myocardial rupture.
• One should also consider other causes of traumatic arrest, such as tension pneumothorax, cardiac or coronary laceration or tamponade, traumatic valvular injury, pulmonary laceration, great vessel injury, hemorrhagic shock, etc., or extrathoracic injuries, depending on the mechanism of injury.

Management:

• Based on standard basic and advanced life support algorithms.
• Focus is on resuscitation from cardiac arrest due to ventricular fibrillation.
• Involves CPR and early defibrillation, with potential role for rescue ventilation or epinephrine should the arrest be prolonged.
• If an AED is not immediately available and the patient is completely unresponsive with no pulse, a precordial thump (impacting the bottom third of the sternum with the ulnar aspect of a clenched fist from ~20cm height), can be attempted, but should not delay defibrillation or CPR.

Prognosis

• In the past, the mortality associated with commotio cordis was reported to be low, with no survivors in the first reported 25 cases. However, more recent cases between 2006-2012 report a 58% survival likely due to earlier recognition, CPR, defibrillation, and activation of emergency medical services

Follow-up and return to activity

• Survivors of commotio cordis should have comprehensive cardiac assessment to exclude underlying heart disease (i.e. channelopathies, cardiomyopathies, catecholaminergic polymorphic ventricular tachycardia) – this includes 12-lead ECG, ambulatory ECG monitoring, echocardiogram, cardiac MRI, and exercise stress test.
• If this workup for cardiac pathology is unremarkable, the patient may return to training and competitions
• Of note, chest wall protectors have not shown to prevent commotio cordis

Figure 1: Taken from the American Heart Association (2012)

1. Walls, R.M., Hockberger, R.S., & Gausche-Hill, M. (2018). Rosen’s Emergency medicine: concepts and clinical practice (9th ed.). Elsevier.

   
   

2. Madias, C. (2021). Commotio Cordis. UpToDate. Retrieved on November 22, 2021 from https://www.uptodate.com/contents/commotio-cordis

   
   

3. Tainter, C. R., & Hughes, P. G. (2021). Commotio Cordis. In StatPearls. StatPearls Publishing.

   
   

4. Horeczko, T. & Inaba, A.S. (2018). Cardiac Disorders. In Rosen’s Emergency medicine: concepts and clinical practice (9th ed., pp. 2099-2125). Elsevier.