|
|
| (10 intermediate revisions by 4 users not shown) |
| Line 1: |
Line 1: |
| [[Image:Heart-thorax-gray.gif|thumb|200px|right|Human adult thorax, showing the outline of the heart (in red). The sensitive zone for mechanical induction of heart rhythm disturbances lies between the 2nd and the 4th ribs, to the left of the sternum]]
| |
| {{SI}}
| |
| {{WikiDoc Cardiology Network Infobox}}
| |
| {{CMG}}
| |
| __NOTOC__ | | __NOTOC__ |
| '''Associate Editor-In-Chief:''' {{CZ}} | | {{Commotio cordis}} |
| | '''For patient information, click [[Commotio cordis (patient information)|here]]''' |
|
| |
|
| {{Editor Join}} | | {{CMG}}; {{AE}} {{MHP}} |
|
| |
|
| ==Overview==
| | {{SK}} Commotion of the heart |
| '''Commotio cordis''' (from Latin ''commotion of the heart'' - a functional effect of mechanical stimulation in the absence of structural damage, as opposed to '''myocardial contusion''' which involves tissue damage) is a sudden disturbance of heart rhythm observed nowadays mostly in young people during participation in sports. It occurs as the result of a blunt, non-penetrating impact to the [[precordium|precordial region]], often caused by impact of a ball, a bat or other projectile. The impact is transmitted to the heart muscle, and depending on the precise timing in relation to the [[cardiac cycle]], it may affect the heart's electrical activity, causing an [[arrhythmia]], such as an ectopic beat, [[ventricular tachycardia]] or [[ventricular fibrillation]].
| | == [[Commotio cordis overview|Overview]] == |
|
| |
|
| Pre-existing conditions, such as undetected electrical or structural abnormalities in the [[heart]] of these individuals, have been speculated to render individuals more vulnerable, but this view is not currently corroborated by hard evidence. The phenomenon was confirmed experimentally in the 1930s, with research in anaesthetized rabbits, cats and dogs <ref>Schlomka G. Commotio cordis und ihre Folgen. Die Einwirkung stumpfer Brustwandtraumen auf das Herz. Ergebnisse der inneren Medizin und Kinderheilkunde. 1934;47: 1-91.</ref> <ref>[http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2018736 An open access article on Commotio Cordis]</ref>
| | == [[Commotio cordis perspective|Historical Perspective]] == |
|
| |
|
| ==Incidence== | | == [[Commotio cordis pathophysiology|Pathophysiology]] == |
|
| |
|
| ''Commotio cordis'' is a very rare event, but nonetheless is often considered when an athlete presents with [[sudden cardiac death]]. Some of the sports which have a risk for this cause of trauma are baseball, soccer, ice hockey, polo, rugby, cricket, softball, pelota, fencing, lacrosse, boxing, karate, kung fu and other martial arts. Children are especially vulnerable due to their more fragile [[thorax|thoracic skeleton]]. The USA ''Commotio Cordis Registry'' had more than 130 cases recorded by September 2001, with most of the cases occurring in Little League baseball, lacrosse and softball. The real number of cases may be much larger. <ref>[http://www.la12.org/pdf/Ch29.pdf Sudden Death Caused by Chest Wall Trauma (Commotio Cordis)]</ref>
| | == [[Commotio cordis causes|Causes]] == |
|
| |
|
| ==Other situations== | | == [[Commotio cordis differential diagnosis|Differentiating Commotio cordis from other Diseases]] == |
|
| |
|
| ''Commotio cordis'' may occur also in other situations, such as in children who are punished with blows over the precordium, cases of torture, frontal collisions of motor vehicles (the impact of the steering wheel against the thorax, although this has decreased substantially with the use of safety belts and air bags).
| | == [[Commotio cordis epidemiology and demographics|Epidemiology and Demographics]] == |
|
| |
|
| Cases of ''commotio cordis'' have been recorded in people who were shot by firearms over the precordium and were using body armour <ref>Cannon L. Behind armour blunt trauma--an emerging problem. ''J R Army Med Corps.'' 2001 Feb;147(1):87-96. Review. PMID 11307682</ref>, thus stopping the bullet but causing a mechanical impact to the thorax (the so-called Behind Armour Blunt Trauma or BABT); or after being hit by less-lethal crowd control firearm shots using rubber bullets or plastic bullets <ref>Hiss J, Hellman FN, Kahana T. Rubber and plastic ammunition lethal injuries: the Israeli experience. ''Med Sci Law.'' 1997 Apr;37(2):139-44. PMID 9149508</ref>
| | == [[Commotio cordis risk factors|Risk Factors]] == |
|
| |
|
| In contrast, the [[precordial thump]] (hard blows given over the precordium with a closed fist in order to revert [[cardiac arrest]]) is a sanctioned procedure for emergency resuscitation by trained health professionals witnessing a ''monitored'' arrest when no equipment is at hand, endorsed by the latest guidelines of the [http://www.erc.edu/index.php/ilcor/en/ International Liaison Committee on Resuscitation]. It has been discussed controversially, as - in particular in severe hypoxia - it may cause the opposite effect (i.e., a worsening of rhythm - ''commotio cordis''). In a normal adult, the energy range involved in the [[precordial thump]] is 5-10 times below that associated with commotio cordis <ref>Kohl P, Sachs F & Franz M (eds): ''Cardiac Mechano-Electric Feedback and Arrhythmias: from Pipette to Patient''. Elsevier (Saunders), Philadelphia 2005 ISBN 9781416000341 </ref>
| | == [[Commotio cordis natural history, complications and prognosis|Natural History, Complications and Prognosis]] == |
|
| |
|
| ==Mechanism of injury== | | ==Diagnosis== |
| [[image:CCLEKGPig.jpg|thumb|300px|center|Six lead electrocardiogram and intraventricular pressure measurement from an 11 kg swine undergoing a 48 km/h (30 mph) chest wall impact with an object the shape and weight of a standard baseball<ref>Madias C., Maron J.M., Alsheikh-Ali A.A., Estes N.A.M., Link M.S. Commotio Cordis, Indian Pacing and Electrophysiology Journal 7 (4): 235-245 (2007) PMID 17957272</ref>]]
| |
| [[Image:Commotio-cordis-ecg.jpg|center|thumb|300px|Electrocardiogram schematic tracing, showing the period of vulnerability to stretch-induced ventricular fibrillation which occurs in commotio cordis]]
| |
| The following factors increase the chance of ''commotio cordis''<ref>Geddes LA, Roeder RA. Evolution of our knowledge of sudden death due to commotio cordis. ''Am J Emerg Med.'' 2005 Jan;23(1):67-75. Review. PMID 15672341</ref> <ref>Kohl P, Nesbitt AD, Cooper PJ, Lei M. Sudden cardiac death by Commotio cordis: role of mechano-electric feedback. ''Cardiovasc Res.'' 2001 May;50(2):280-9. Review. PMID 11334832</ref>:
| |
|
| |
|
| * Direction of impact over the precordium (precise area, angle of impact)
| | [[Commotio cordis history and symptoms|History and Symptoms]] | [[Commotio cordis physical examination|Physical Examination]] | [[Commotio cordis laboratory findings|Laboratory Findings]] | [[Commotio cordis electrocardiogram|Electrocardiogram]] | [[Commotio cordis echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Commotio cordis other imaging findings|Other Imaging Findings]] | [[Commotio cordis other diagnostic studies|Other Diagnostic Studies]] |
| * Total applied energy (area of impact versus energy, i.e., speed of the projectile multiplied by its mass)
| |
| * Impact occurring within a specific 10-30 millisecond portion of the cardiac cycle. This period occurs in the ascending phase of the T wave, when the ventricular myocardium is repolarizing, moving from [[systole]] to [[diastole]] (relaxation).
| |
|
| |
|
| The small window of vulnerability explains why it is a rare event. Considering that the total cardiac cycle has a duration of 1000 milliseconds (for a base cardiac frequency of 60 beats per minute), the probability of a mechanical trauma within the window of vulnerability is 1 to 3% only. That explains also why the heart becomes ''more'' vulnerable when it is physically strained by sports activities:
| | ==Treatment== |
| # The increase in heart frequency (exercise [[tachycardia]]) may double the probability above (e.g., with 120 beats per minute the cardiac cycle shortens to 500 milliseconds without fundamentally altering the windows of vulnerability size);
| | [[Commotio cordis medical therapy|Medical Therapy]] | [[Commotio cordis primary prevention|Primary Prevention]] | [[Commotio cordis secondary prevention|Secondary Prevention]] | [[Commotio cordis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Commotio cordis future or investigational therapies|Future or Investigational Therapies]] |
| # Relative exercise-induced [[Hypoxia (medical)|hypoxia]] and acceleration of the excito-conductive system of the heart make it more susceptible to stretch-induced ventricular fibrillation.
| |
|
| |
|
| The [[cell (biology)|cellular]] mechanisms of ''commotio cordis'' are still poorly understood, but probably related to the activation of mechano-sensitive proteins, [[ion channels]].
| | ==Case Studies== |
| | [[Commotio cordis case study one|Case #1]] |
|
| |
|
| It is estimated that impact energies of at least 50 joules are required to cause cardiac arrest, when applied in the right time and spot of the precordium of an adult. Impacts of up to 130 joules have already been measured with hockey pucks and lacrosse balls, 450 joules in karate punches and an incredible 1028 joules in boxer Rocky Marciano's punch <ref>[http://www.science.ca/askascientist/viewquestion.php?qID=821 Amount of force in foot pounds behind the average human's punch]</ref>.
| |
|
| |
|
| The 50 joules threshold, however, can be considerably lowered when the victim's heart is under [[ischemia|ischemic]] conditions, such as in [[coronary artery]] insufficiency <ref>Kohl P, Sachs F & Franz M (eds): ''Cardiac Mechano-Electric Feedback and Arrhythmias: from Pipette to Patient''. Elsevier (Saunders), Philadelphia 2005 ISBN 9781416000341 </ref>
| | {{Injuries, other than fractures, dislocations, sprains and strains}} |
|
| |
|
| There is also an upper limit of impact energy applied to the heart; too much energy will create structural damage to the heart muscle as well as causing electrical upset. This condition is referred to as ''contusio cordis'' (from Latin for ''bruising of the heart''). On isolated guinea pig hearts, as little as 5 mJ was needed to induce release of [[creatine kinase]], a marker for [[muscle cell]] damage.<ref>Cooper PJ, Epstein A, Macleod IA, Schaaf ST, Sheldon J, Boulin C, Kohl P. Soft tissue impact characterisation kit (STICK) for ex situ investigation of heart rhythm responses to acute mechanical stimulation. ''Prog Biophys Mol Biol.'' 2006 Jan-Apr;90(1-3):444-68. Review. PMID 16125216</ref> Obviously one should take into account that this figure does not include the dissipation of energy through the chest wall, and is not scaled up for humans, but it is indicative that relatively small amounts of energy are required to reach the heart before physical damage is done.
| |
|
| |
|
| ==Outcome and treatment==
| |
|
| |
| [[Fulminant]] death is the most common outcome, because [[cardiopulmonary resuscitation]] requires quick action by a specialized medical team, using a [[defibrillator]] and cardioactive drugs, and these are rarely on hand in sports arenas. Due to the significant danger to children (death by ''commotio cordis'' is the first cause of fatalities in youth baseball in the US, with 2 to 3 deaths per year <ref>Abrunzo TJ. Commotio cordis. The single, most common cause of traumatic death in youth baseball. ''Am J Dis Child.'' 1991 Nov;145(11):1279-82. Review. PMID 1951221</ref>, it has been recommended that "communities and school districts reexamine the need for accessible automatic defibrillators and cardiopulmonary resuscitation-trained coaches at organized sporting events for children." <ref>Salib EA, Cyran SE, Cilley RE, Maron BJ, Thomas NJ. Efficacy of bystander cardiopulmonary resuscitation and out-of-hospital automated external defibrillation as life-saving therapy in commotio cordis. ''J Pediatr.'' 2005 Dec;147(6):863-6. Review. PMID 16356450</ref>
| |
|
| |
| ==Prevention==
| |
|
| |
| [[Image:Sports-dress-codes.jpg|thumb|center|300px|Equipment and dress used in several sports. clearly demonstrating the lack of protection against chest concussion. From left to right, top to bottom: boxing, field hockey, baseball, karate, cricket, lacrosse and soccer.]]
| |
|
| |
| The mandatory use of heavily padded special vests in front of the thorax is generally sufficient to prevent high energy impacts to the precordium. The problem with many sports such as soccer, baseball and karate is that, despite the danger posed by a multitude of punches, kicks, pads, mallets, bats, pucks and balls moving at high speeds, etc., their dress codes represent an obstacle to the use of mechanical protection to the precordium for all players, or at least for goalkeepers, batters, ball catchers, etc.
| |
|
| |
| For example, boxing traditionally requires a naked chest, cricket gear protects the legs but not the chest, and soccer has practically no protection gear at all; although the ball weights 450 grams, may reach speeds of 30 meters per second <ref>[http://physicsweb.org/articles/world/11/6/8 The physics of football]</ref>, and barrier defenses actually encourage the reception of the ball against the chest.
| |
|
| |
| Parents of children active in these sports are advised to adopt simple protective measures, particularly in informal "backyard" games, which are often much more dangerous than formal ones, which require some protection.
| |
|
| |
| ==Legal issues==
| |
|
| |
| Several people have been convicted of involuntary manslaughter in cases involving insufficient and slow medical help to athletes who underwent ''commotio cordis'' during sports events <ref>Maron BJ, Mitten MJ, Greene Burnett C. Criminal consequences of commotio cordis. ''Am J Cardiol.'' 2002 Jan 15;89(2):210-3. Review. PMID 11792344</ref>, as well as in cases of intentional delivery of contusive blows. In one such case, a man was sentenced to 18 years of prison for killing his own son with a blow to the chest.
| |
|
| |
| ==References==
| |
| {{Reflist|2}}
| |
|
| |
| ==External links==
| |
| *[http://www.heart.co.il/01_education/support_Files/NEJM_2003_349_1064-Maron.pdf Sudden Death in Young Athletes]
| |
| * [http://www.jhu.edu/trayanova/research/lab/projects/each/weihui_CommotioCordis/2320.avi Induction of Ventricular Arrhythmias Following A Mechanical Impact: A Simulation Study in 3D].
| |
| * [http://www.emedicine.com/ped/topic3019.htm Commotio cordis]
| |
| * [http://theacc.collegesports.com/sports/m-lacros/spec-rel/030105aaa.html Sports Sciences Feature: Commotio Cordis; Sudden death following chest wall trauma]
| |
| * [http://www.escardio.org/knowledge/OnlineLearning/slides/ESC_Congress_2005/Kohl-FP1296/ Mechanical effects on heart rhythm: from commotio cordis to pre-cordial thump]
| |
| * [http://www.erc.edu/index.php/ilcor/en/ International Liaison Committee on Resuscitation (ILCOR)]
| |
| * [http://circ.ahajournals.org/content/vol112/24_suppl/ American Heart Association guidelines on resuscitation]
| |
| * [http://www.resus.org.uk/pages/mediMain.htm Resuscitation Council (UK) guidelines on resuscitation]
| |
| * [http://www.hmc.org.qa/hmc/heartviews/commotio_cordis.htm Six-lead ECG showing electrophysiologic and hemodynamic consequences of an impact to the chest wall by a wooden object at 30 miles/hour]
| |
| * [http://www.heart.co.il/01_education/support_Files/NEJM_1995_333_337-Maron.pdf Blunt impact to the chest leading to sudden death from cardiac arrest during sport activities]
| |
| * [http://www.physoc.org/publications/proceedings/archive/article.asp?ID=J%20Physiol%20557PPC12 Histological validation of mechanically induced tissue damage in Guinea pig isolated heart]
| |
|
| |
| {{Injuries, other than fractures, dislocations, sprains and strains}}
| |
| {{chest trauma}}
| |
| {{SIB}}
| |
|
| |
| [[Category:Chest trauma]]
| |
| [[Category:Cardiology]] | | [[Category:Cardiology]] |
| | [[Category:Emergency medicine]] |
| [[Category:Sports medicine]] | | [[Category:Sports medicine]] |
| | | [[Category:Death]] |
| | [[Category:Chest trauma]] |
| [[de:Herzverletzung]] | | [[de:Herzverletzung]] |
|
| |
|
| {{WikiDoc Help Menu}} | | {{WikiDoc Help Menu}} |
| {{WikiDoc Sources}} | | {{WikiDoc Sources}} |