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Position Statement on Commotio Cordis

Sports Science and Safety

Commotio Cordis is a rare but potentially catastrophic phenomenon that can result in sudden cardiac arrest. Commotio Cordis can occur when a blunt, but often relatively mild blow to the area of the chest directly over the heart occurs during a precise moment of the heart’s cycle, leading to sudden cardiac arrest. Examples of the blunt object may include: baseball, lacrosse ball, hockey puck, fist, shoulder or knee.

The heart responds to the blow with an interruption of the electrical impulse, thus sending the heart into ventricular fibrillation. This causes insufficient blood flow, loss of oxygen to tissues and may result in death. The location of the blow (directly over the left ventricle of the heart) timing of the blow in the cardiac cycle (10 – 30 milliseconds prior to the peak of the T wave) and the force of the blow (most commonly at 35 – 40 mph) all contribute to a Commotio Cordis incident.

The National Commotio Cordis Registry located within the Minneapolis Heart Institute Foundation reports 188 deaths attributed to Commotio Cordis from 1996 through the spring of 2007. Approximately 48% of Commotio Cordis deaths occurred during organized sports, and 39% of these fatalities occurred despite the wearing of some form of chest protection. Of the 188 fatalities, the mean age was 14.7 years, the age range from 7 weeks to 50 years, and 96% were male. Data from the Registry also indicates that only 19% of the individuals who experienced Commotio Cordis survived the incident.

As of May 2007, of the 188 cases of Commotio Cordis logged into the Registry, 8 (5% of the total) were male lacrosse players. Six of these athletes passed away, and two survived. Their ages ranged from 13 years to 22 years, and three were goalkeepers. Five of these players competed on the high school/junior high school level, and the other three competed at the collegiate level. The Registry has no record of Commotio Cordis occurring in a female lacrosse player and, for reasons not completely understood, only a small fraction of the 188 cases in the Commotio Cordis Registry involved females.

Research conducted by Drs. Mark Link and Barry Maron reviewed 32 athletes who suffered Commotio Cordis wearing some form of chest protection. These athletes were playing the following sports: baseball (3 catchers), ice hockey (14, including 2 goalkeepers), men’s lacrosse (6, including 3 goalkeepers) and football (10). Twenty-eight of the athletes studied died and 4 survived. Other research conducted by Drs. Link and Maron indicates the effectiveness of timely CPR. Of 149 cases of Commotio Cordis reviewed in the study, 78 individuals were administered CPR in less than 3 minutes. Of these 78, 40 died, 16 survived for a short period of time in a coma and then died, and 22 survived. 56 of the 149 cases studied were given CPR after 3 minutes. Of these, one survived and the remaining 55 died. And of the 15 cases that did not receive CPR all passed away. This information clearly demonstrates the need for immediate assessment followed by CPR (3) if Commotio Cordis is suspected.

Studies completed by Dr. Link show that no current chest protection technology in any sport is effective in preventing Commotio Cordis (1). Dr. Barry Maron also reported that current chest protection is inadequate for this event at the American Heart Association annual meeting in 2006. (2)Clearly quick recognition of Commotio Cordis and responsive action are critical to survival.

Recognition of Commotio Cordis and appropriate action

Recognition of Commotio Cordis occurring right in front of someone is unlikely. The scenario presents as the athlete sustains a blow to the center of the chest, may collapse immediately or walk a couple steps and then collapse. The first key to survival is the recognition of that collapse and entry into an Emergency Action Plan. Observers must quickly take action by checking breathing and pulse, activating the EMS system (call 911), send for the AED and initiate CPR if necessary. As soon as the AED arrives, apply the electrodes to assist in monitoring the athlete. It will be unclear the actual cause of the Sudden Cardiac Arrest (SCA) until the athlete is evaluated by a cardiologist.

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 percent. Other facts are:

  • The average response time nationally for emergency medical personnel equipped with defibrillators is 10 minutes, making access to defibrillators on-site or in first-responder vehicles (police cars, fire trucks, etc.) extremely important.
  • Even in the hospital setting, traditional resuscitation procedures many times result in significant delays before an SCA victim receives defibrillation therapy; consequently, survival averages from in-hospital sudden cardiac arrests are only 15%.
  • resuscitation (CPR) works to temporarily circulate blood to vital organs; however, CPR cannot restore a patient's heart to a healthy rhythm. The AHA states that the definitive survival treatment for an SCA victim is a defibrillation shock.
  • Published studies have proven that early defibrillation, within the first few minutes of SCA, can save up to 74 percent of victims.

Recommendation

US Lacrosse recommends that, along with CPR and AED training for all team personnel, the following steps should be taken in order to best prepare for the rare but potentially catastrophic Commotio Cordis incident:

  1. Establish an emergency action plan, including the training of all coaches and team personnel in CPR with AED;
  2. Provide quick and easy access to an AED;
  3. Teach athletes to avoid being hit directly in the chest by a shot;
  4. Educate all team personnel to recognize the mechanisms of Commotio Cordis;
  5. Educate all team personnel in the need for IMMEDIATE CPR if Commotio Cordis is suspected. The longer the delay in beginning CPR and AED treatment, the greater the likelihood of loss of life;
  6. Understand that the current chest protection models, although useful in preventing traumatic injury, will not eliminate the threat of Commotio Cordis*;
  7. Require all protective athletic equipment to meet all appropriate safety standards, if they exist. NOCSAE, ASTM, HECC, PECC are such appropriate bodies;
  8. *US Lacrosse will maintain information on its web site (www.uslacrosse.org) should any appropriate chest protection become available.

    Sources:

    (1) Weinstock, Maron et al, "Failure of Commercially Available Chest Wall Protectors," Pediatrics 2006, 117:656-662.

    (2) Maron, Barry, November 13, 2006, AHA Meeting Remarks, Chicago.

    (3) Maron, Barry and Link, Mark, May 4, 2007, US Lacrosse Commotio Cordis Summit Remarks, Baltimore.

    (4) Link, MS, Maron, B, Wang, PJ et al, "Reduced Risk of Sudden Death fro Chest Wall Blows (C0mmotio Cordis) with Safety Baseballs", 2002, Pediatrics, 109:873-877.

    (5) Maron, Gohman, Kyle et al, "Clinical Profile and Spectrum of Commotio Cordis", JAMA 2002; 287:1142-1146

    Internet Resources:
    • Acompora Foundation: www.la12.org
    • Parent Heart Watch: www.parentheartwatch.org