Surviving Commotio Cordis

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The collapse and cardiac arrest of Buffalo Bills player Damar Hamlin on January 2nd?during a game against the Cincinnati Bengals was a shocking event that resonated beyond fans of both teams.?The seemingly healthy 24-year-old professional athlete stood up after what seemed like a routine tackle, and then fell backwards, unresponsive.?The medical team rushed to his side and rapidly administered CPR and defibrillation to the pulseless player, reviving him.?Following this, he was hospitalized on life support.?Many fans have never heard the medical term commotio cordis, now it is all over social media and the airwaves.

?What is commotio cordis anyway?

?According to UpToDate.com,?"Commotio cordis, which translates from Latin origin as "agitation of the heart," is defined as sudden cardiac death secondary to a blunt, nonpenetrating anterior precordial impact."

?Is commotio cordis a new thing?

Reports of sudden cardiac death following chest trauma have appeared in the medical literature since the 1700s. The exact number of times this has occurred is unknown due to lack of reporting to a central database.

?Because of this, in the mid-1990s, the National Commotio Cordis Registry was established in the United States.

Per UpToDate.com, since the establishment of the Registry, data on over 200 confirmed cases of commotio cordis have been published since it was started.

●Young people are most commonly affected (average age of registry cases was 15 years old); only 9 percent of reported cases occurred in those older than 25 years of age.

●95 percent of reported cases have been in males.

●75 percent of cases have occurred during athletics (50 percent during competitive sports, 25 percent during recreational sports).

●Most cases have been reported in sports with blunt projectiles (eg, baseball, lacrosse, hockey) and/or more physical body contact (eg, football).

How does commotio cordis cause cardiac arrest?

The sudden death that this causes is NOT due to injury to the heart structures, it is due to an electrical problem within the heart.

Although the injury is stimulated by a physical trauma, it is an ELECTRICAL event.?Upon impact, the normal heart rhythm, called sinus rhythm, is interrupted and causes a disorganized electric rhythm called ventricular fibrillation (V-fib for short).?When the heart is in V fib, the heart cannot beat in an organized way, therefore it cannot pump blood effectively, and the patient collapses and loses their pulse, which is cardiac arrest.

Wait...the heart has electricity and plumbing?

Yes!?The way the heart pumps blood is a beautiful combination of electrical and plumbing!

The plumbing is the blood flow through the chambers (heart) and pipes (blood vessels).?Deoxygenated blood (blood low in oxygen, 'blue' blood from your veins) returns from the body to the right side of the heart.?The muscles in the right side of the heart squeeze and push the blood forward to the blood vessels in the lungs, where the red blood cells fill with life-giving oxygen.?Then the blood flows from the lungs to the left side of the heart, which uses its strong muscles to squeeze the blood to your arteries and to all of the organs and cells of your body to deliver the oxygen.?Then the veins return the now deoxygenated blood to the right side of the heart and round and round the cycle goes!

The electricity is what helps drive and organize the coordinated squeezing of the heart muscles so blood is pumped and the relaxing of the heart muscles so the heart can refill with blood for the next squeeze.?When the electricity is working, all of the cells in the heart muscles get the signal to squeeze in sequence.?When the electricity gets disorganized, the muscles cells don't act together and the heart stops squeezing and pumping.

Why don't more chest wall injuries cause commotio?

Commotio occurs with a 'perfect storm' of factors.??

• The right spot - on the left chest wall over the heart
• The right timing - the hit occurs during the heart beat cycle when the heart ventricles transition from contracting to relaxing (approxmately a 20-40 milisecond window of time)
• The shape and hardness of the impacting object - solid, round, and hard objects are the most likely to cause commotio.?The smaller the object, the more the force is concentrated on a small specific impact area
• The speed of the impact - speeds of up to 40 mph can cause commotio.?Speeds higher than 40 mph are more like to cause structural damage (broken ribs, bruising or tearing of heart muscles) that lead to different causes of problems and death

If the injury doesn't have the right spot, timing, shape, hardness, and speed, it is much likely to cause commotio cordis.

Prevention of commotio

Wow, that sounds really scary!?Should you go out and buy chest guards?

Per UpToDate.com, "Surprisingly, commercially available chest wall protectors have not been shown to effectively prevent commotio cordis, both in the clinical arena and in laboratory animal studies. Many of the commotio cordis victims reported to the National Commotio Cordis Registry were wearing protective equipment at the time of their event."

But don't be discouraged! There are some preventative measures that can be taken

• Wear protective equipment that is designed for the sport you are playing
• Ensure equipment is properly fitted and in good working order (no thinning areas, holes, loose straps, etc)
• Avoid 'the line of fire' in projectile and contact sports whenever possible
• Take a CPR class so you are prepared if an arrest happens near you

What if you think someone has commotio right in front of you?

Don't worry about making the diagnosis of commotio! The diagnosis is determined by a combination of:

• A clinical scenario of collapse and cardiac arrest after blunt trauma to the chest AND
• EKG findings of ventricular fibrillation or full cardiac arrest (flat line) AND
• Images of the heart (echo ultrasound, CT scan, MRI, etc) show no structural abnormalities in the heart

It is VERY unlikely that you will have an EKG machine and advanced imaging available where you are at.?The good news is, you don't need to have an exact diagnosis to act!

Here is what you can do if someone collapses and is unresponsive:

• Designate someone to call 911 (better to choose a specific person than yell to a crowd and hope someone decides to do it)
• Check for a pulse?
• If there is no pulse, begin chest compressions immediately
• NO need to give mouth-to-mouth, just give chest compressions
• When possible, take turns doing compressions every 2 minutes.?It is a lot of physical work and tired people give less effective chest compression
• If there is an AED (defibrillator) on scene, open it, place the pads on the patient and follow the instructions

Not every sporting event you play in or attend will have multiple medical professionals, like the one's whose quick actions saved Damar Hamlin's life.?But you don't have to be a medical professional to save a life!?Chest compressions done by bystanders (like YOU!) can make a huge difference!?

Chest compressions done by a bystander can nearly DOUBLE the person's chance of survival!!

Hopefully, Damar Hamlin continues to make a full recovery.?And millions of people can learn from his injury and future lives can be saved!