Emergent Care / Stabilization:
Airway, breathing, and circulation (ABCs). Establish intravenous (IV) access, place the patient on a cardiac monitor with continuous pulse oximetry, and have resuscitation equipment available.

The initial treatment of patients with commotio cordis should follow standard advanced cardiac life support (ACLS) algorithms, ideally with initiation of bystander cardiopulmonary resuscitation (CPR) and early defibrillation.

Diagnosis Overview:
Myocardial concussion or commotio cordis, which means "disturbance of the heart" in Latin, is an acute form of blunt cardiac trauma caused by a sharp, direct blow to the mid-anterior chest. It can stun the myocardium and lead to malignant dysrhythmias such as ventricular fibrillation and cardiac arrest.

Commotio cordis is the second-most common cause of death in young athletes, following hypertrophic obstructive cardiomyopathy. Susceptible patients are usually young, male, aged 5-15 years, and have no known predisposing cardiac conditions.

Commotio cordis is a common occurrence in sports that use small, hard projectiles, such as lacrosse, baseball, and hockey. It can also occur in other sports and even nonsport activities due to collision with body parts such as elbows, fists, and knees. The impact object's hardness, location, and velocity affect ventricular fibrillation risk. The impact is usually mild and not powerful enough to cause major harm to the sternum, heart, or ribs. This differs from cardiac contusion, which causes structural damage to the heart.

Commotio cordis commonly occurs during ventricular repolarization, a period of 20-40 minutes of the upslope of the T wave. During this time, a mechanical injury that is concentrated can stretch out the cardiac fibers. This can create an impulse that is not synchronized, known as a mechanical R-on-T phenomenon. This can then lead to ventricular fibrillation.

Cardiac arrhythmias documented soon after the collapse are generally ventricular fibrillation. Early reports showed poor survival, but more recently, survival from these events has increased to more than 50% due to quicker response times and access to external defibrillation. Autopsy results usually reveal a normal heart structure with no signs of damage.

Monitoring for dysrhythmias is essential. Blunt injury can lead to tachycardia, new bundle branch block (right or left), supraventricular tachycardia, atrial and ventricular fibrillation, and minor dysrhythmias such as occasional premature ventricular contractions.

Ongoing efforts to develop more effective chest protectors can decrease the risk of sudden cardiac death in vulnerable athletes. The American Heart Association and American College of Cardiology recommend using age-appropriate softballs to reduce the risk of commotio cordis, as well as the timely availability of automated external defibrillators (AEDs).

Related topic: ventricular fibrillation