Commotio cordis is not a disease. It is a fatal arrhythmia that occurs accidentally in a person with no known heart abnormality.
The term comes from Latin and means “agitation of the heart,” an image that accurately reflects the sudden disruption of the heart’s electrical system. After a precisely located blow to the chest, the electrical activity becomes chaotic and the heart can no longer pump bloodBlood is composed of red blood cells, white blood cells, platelets, and plasma. Red blood cells are responsible for transporting oxygen and carbon dioxide. White blood cells make up our immune defense system. Platelets contribute to blood effectively. Instead, it quivers like shaken gelatin.
This rhythm disturbance — ventricular fibrillation — is immediately fatal without prompt treatment.
A long-recognized phenomenon
Commotio cordis has been described in medical literature for more than 120 years.
Today, fewer than 20 cases are reported each year in the United States.
The condition occurs almost exclusively in adolescents, with an average age of about 15, most often during organized sports such as Little League Baseball. Cases are less common in contact sports or martial arts, even though chest impacts also occur in these settings.
Necessary conditions
Several very specific elements must occur simultaneously for commotio cordis to develop:
- a direct blow to the front of the chest;
- an impact strong enough to disrupt the heart’s function but not strong enough to fracture ribs or the sternum;
- a strike delivered at a very precise moment in the heart’s electrical cycle: just after a heartbeat, at the beginning of ventricular repolarization.
A sudden loss of consciousness after a chest impact suggests commotio cordis, but other cardiac causes — such as an underlying condition leading to exertional syncope — must always be ruled out before confirming the diagnosis.
Why are some young people more vulnerable?
Several factors appear to increase susceptibility:
- the greater flexibility of the chest wall in younger individuals;
- a possible genetic predisposition;
- an apparent male predominance, which may reflect the historical underrepresentation of girls in the sports most commonly associated with commotio cordis.
Sudden Death
The clinical presentation is abrupt. Within seconds after the chest impact, the person collapses.
The blow does not simply cause pain; it suddenly disrupts the heart’s electrical activity. Instead of an organized electrical impulse traveling through the heart muscle — allowing coordinated and effective ventricular contraction — the electrical activity becomes chaotic. The ventricles no longer contract in a structured manner.
See also: The Electrical System
Without organized ventricular contraction, no bloodBlood is composed of red blood cells, white blood cells, platelets, and plasma. Red blood cells are responsible for transporting oxygen and carbon dioxide. White blood cells make up our immune defense system. Platelets contribute to blood pressure can be generated. BloodBlood is composed of red blood cells, white blood cells, platelets, and plasma. Red blood cells are responsible for transporting oxygen and carbon dioxide. White blood cells make up our immune defense system. Platelets contribute to blood flow to the brain stops. Loss of consciousness occurs almost immediately: this is syncope. Without rapid intervention, death follows within minutes.
Breathing becomes irregular or noisy, sometimes accompanied by brief body rigidity, and then stops completely.
This situation represents sudden cardiac death and requires immediate cardiopulmonary resuscitation (CPR) and the rapid use of an automated external defibrillator (AED).
A complex mechanism
The sequence that leads to ventricular fibrillation after a precisely located chest impact is complex.
In simple terms, the blow triggers a sudden imbalance in the electrical charges of heart cells at a critical point in the cardiac cycle.
A life-saving discovery
For many years, ventricular fibrillation represented one of the greatest fears in cardiology and cardiac surgery. In the face of this lethal arrhythmia, no effective treatment existed.
Everything changed with the development of a device capable of delivering an electric shock to reset the heart’s electrical system: the defibrillator.
This controlled impulse restores synchronization of the heart’s electrical activity and allows the muscle to regain an effective contraction. The heart pump resumes its normal role of circulating bloodBlood is composed of red blood cells, white blood cells, platelets, and plasma. Red blood cells are responsible for transporting oxygen and carbon dioxide. White blood cells make up our immune defense system. Platelets contribute to blood throughout the body.
See also: An Electrifying Breakthrough
A defibrillator is essential
The defibrillator is the crucial treatment for commotio cordis.
It must be used as quickly as possible to prevent irreversible neurological damage caused by cerebral anoxia, meaning a lack of oxygen to the brain.
See also: Automated External Defibrillator (AED)
Impact on survival
Survival rates have doubled thanks to two key factors:
- rapid initiation of cardiopulmonary resuscitation (CPR);
- widespread availability of automated external defibrillators (AEDs) in public places.
These devices are now extremely common, and their use is remarkably simple—simple enough that even a 10-year-old can operate them successfully.
For this reason, AED locations should always be clearly indicated, much like emergency exits.
Torsades de pointes: a different presentation
Some reported cases resemble “aborted” commotio cordis, where consciousness returns spontaneously. In such situations, the arrhythmia seems to be polymorphic ventricular tachycardia—also called torsades de pointes—rather than ventricular fibrillation.
Torsades de pointes produces a rapid and unstable rhythm that temporarily compromises bloodBlood is composed of red blood cells, white blood cells, platelets, and plasma. Red blood cells are responsible for transporting oxygen and carbon dioxide. White blood cells make up our immune defense system. Platelets contribute to blood pressure. Unlike ventricular fibrillation, however, this rhythm can sometimes stop suddenly, allowing a normal heartbeat to resume.
Supportive treatment
Management begins with CPR and the restoration of a normal heart rhythm, the essential steps previously described.
What follows depends largely on the person’s level of consciousness after defibrillation.
See also: Anyone Can Be a Hero – CPR
When no awakening occurs, mechanical ventilation is initiated to stabilize vital functions.
In this context, the main concern is brain injury resulting from the lack of oxygen during the cardiac arrest. To protect the brain and encourage recovery, medications are often used to place it in complete temporary rest.
This state is known as medically induced coma, intended to minimize potential neurological damage.
Cardiac evaluation
The cardiology workup aims to confirm that the heart is completely normal. This evaluation generally includes:
- an echocardiogram,
- coronary arteryThe two coronary arteries, the right and the left, form the blood network that supplies the heart with oxygen and nutrients. They are located directly on the surface of the heart and branch into smaller vessels that imaging,
- cardiac magnetic resonance imaging (MRI),
- and a study of the heart’s electrical activity.
Prognosis
Prognosis depends mainly on the extent of brain injury.
When no neurological damage is present, the outcome is generally excellent.
Conversely, the absence of brain activity after a medically induced coma indicates, unfortunately, that survival is no longer possible.
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