The following is an edited version of a feature story that appears in the April 2012 edition of Lacrosse Magazine. Visit the membership page to join US Lacrosse and start your subscription to Lacrosse Magazine.
By Paul Krome
The Feb. 7 passing of 12-year-old Tyler Kopp of Rochester, N.Y., following an injury he sustained while playing lacrosse, saddened the national lacrosse community.
Reviewing the circumstances around his passing yields a likely cause — a rare phenomenon called commotio cordis. US Lacrosse has been aware of commotio cordis for more than a decade and continues to educate the lacrosse community on its symptoms and treatments.
Commotio cordis is typically caused by a focal impact to an area of the chest directly over the heart during a very narrow window of the heart cycle, which causes ventricular fibrillation. Ventricular fibrillation is an abnormal heart rhythm that is fatal if not immediately corrected.
"Statistically, one is probably more likely to be struck by lightning than suffer commotio cordis," said Dr. Jeff Mandak, a cardiologist at Pinnacle Health Hospital’s Cardiovascular Institute in Pennsylvania and a member of the US Lacrosse Sports Science and Safety Committee.
Published literature on commotio cordis reveals why: victims must be struck directly over the heart during a particular 10- to 20-millisecond window of the heart cycle, more specifically, the upstroke of the T wave. That time period accounts for just 1 percent of the cardiac cycle, according to research by Dr. Barry Maron of the Minneapolis Heart Institute Foundation.
By comparison, a blink of the eye takes 300 to 400 milliseconds.
Though extremely rare, commotio cordis incidents often prove fatal. From 1996 through March 2010, Dr. Maron listed 224 fatal cases of commotio cordis in a registry, including 11 in lacrosse. Baseball/softball had the most at 63, followed by 18 in hockey and 14 in football.
Commotio cordis victims typically collapse within seconds of the chest impact and suffer sudden cardiac arrest (SCA).
At this time, there is no prevention for commotio cordis. Dr. Maron’s registry counts 125 commotio cordis fatalities in competitive sports, and of those, 40 were athletes wearing a chest protector.
Dr. Maron has cited earlier research that indicates the chances of a projectile the size of a baseball inducing ventricular fibrillation increases progressively up to an impact of 40 miles per hour. Above that speed, chances of structural damage to the chest or heart, rather than commotio cordis, increase.
"None of the currently available chest protectors offers a statistically significant decrease in the risk of commotio cordis," Dr. Mandak said. "One of the problems with a chest protector is that if it decreases the force of impact of a 70-mile-per-hour shot down to the force of a 40-mile-per-hour shot, it might theoretically increase the risk of commotio cordis."
US Lacrosse and the Acompora Foundation, created by John and Karen Acompora following the 2000 commotio cordis-induced death of their son, Louis, on the lacrosse field at Northport (N.Y.) High School, have contributed funding to the research and development of a mechanical model that could enable the National Operating Committee on Standards for Athletic Equipment (NOCSAE) to establish a manufacturing standard for chest protectors. That standard could aid the development of a chest protector to prevent commotio cordis.
While commotio cordis cannot be prevented, education and preparation can make the difference between life and death when it does occur.
"US Lacrosse has been awesome. It’s the only organization that has taken a proactive approach on a national level among governing bodies," Karen Acompora said. "No other sport has done that. I cannot understand why, as it’s not just a lacrosse issue."
"We started with a two-pronged approach," Dr. Mandak said. "One, to increase awareness of commotio cordis as a potentially catastrophic injury on the lacrosse field. Secondly, we had to make people aware of the life-saving value of AEDs and promote their availability both at the scholastic and club levels."
Dr. Mandak spoke of immediate recognition of commotio cordis, and for good reason. Once a victim loses consciousness due to ventricular fibrillation, every minute that passes decreases the chances of survival by 10 percent. Accordingly, the immediate deployment of an AED offers the victim the best opportunity for recovery.
"We strongly encourage lacrosse organizations, events and facilities around the country to purchase AEDs as a critical step toward ensuring the safest possible environment for lacrosse players, coaches, officials and spectators," Steve Stenersen, president and CEO of US Lacrosse, said.
To facilitate that increased distribution, US Lacrosse announced in August 2006 an alliance with Cardiac Science, a leading manufacturer of AEDs and provider of AED training. The alliance allows US Lacrosse members to purchase an AED for $1,395, a $600 savings compared to the regular price. In 2010, the organizations expanded the alliance to allow for the creation of the US Lacrosse AED Grant Program. The program, fueled in part by resources generated by US Lacrosse members and donors, provides an AED and comprehensive AED/CPR training to grant recipients.
"US Lacrosse has been very forward-thinking in terms of addressing the risk of sudden cardiac arrest on the lacrosse field," said Eddie Martin, senior marketing manager for defibrillation at Cardiac Science. "This alliance has worked very well. We’ve been able to increase the awareness of SCA and AEDs, and gotten a lot of teams and coaches interested in deploying AEDs."
AED training is available, but the units are easy to use by the public. Voice prompts walk users through the needed steps, and a metronome provides timing guidance for the delivery of CPR chest compressions. AEDs will administer a shock only if the victim needs it. The Cardiac Arrest Survival Act, signed by President Clinton in 2000, provides liability immunity to AED users and acquirers, and it supersedes state laws that are less protective.
US Lacrosse has awarded AEDs to 24 lacrosse programs in 17 states since the start of the grant program, and Martin estimated that several hundred AEDs had been delivered to US Lacrosse members since 2006.