Post on 16-Jul-2015
JOURNAL REVIEW
COMMOTIO CORDIS
Review article
NJEM Vol 362:917-927 March 11,2010
INTRODUCTION
• Ventricular fibrillation & sudden death from a blunt,non penetrating blow to the chest.
• No damage to ribs,sternum,heart
• No underlying cardiovascular disease
• “Commotio cordis” latin for agitation of heart
• First described in 19th century
• Occurs in children,adolescents,young adults
• Often in the setting of recreational,competitive sports
• This review focuses on clinical profile,proposed mechanisms, prevention and treatment of commotio cordis
INCIDENCE
• Unknown
• Third most frequent cause of sudden death in young athletes after hypertrophic cardiomyopathy and congenital coronary artery anomalies
EPIDEMIOLOGY
• From episodic case studies and the Minneapolis registry- 224 documented cases over 15 yrs
• Children & adolescents: mean age 15+_ 9 years
• 26% < 10 yrs
• 9% > 25yrs
• 20% of victims remain physically active seconds after the blow
EPIDEMIOLOGY
According to National commotio cordis Registry in Minneapolis-
Rarely in blacks or females
• Competitive sports
• Recreational sports
• Others- (25% of cases) horse kicks,playgroundswings
OUTCOME
• Usually but not invariably fatal
• 25% of cases did CPR or defibrillation result in survival
• Survival rates have increased over time.
35% in last 10yrs,compared with 15% in preceding 10yrs
Between 2006-2009 no of successful resuscitations>no of deaths by 20%
• This improvement is due to increased public awareness,increased availability of AEDS,earlyactivation of chain of survival(911,CPR,Defibrillation,)
• Some commotio cordis events abort spontaneously
MECHANISM
• Mechanical energy of the blow alters electrical activity of heart resulting in ventricular fibrillation
• Theoretical explanations such as excessive vagal reflex, coronary arterial vasospasm have since been abandoned
DETERMINANTS & TRIGGERS
• 1.location of blow- directly over heart , at centre of cardiac silhouette
• 2.Timing of blow- 10-20ms on upstroke of T wave
• 3.Velocity of projectile- impact velocity of 64km/hr
• 4. Object characteristics- hard,small sphere shaped objects
5. Thorax- thin,undeveloped ribcage
CELLULAR MECHANISMS
• Mechanical force causes Left ventricular pressure to rise to 250-450mmHg
• Cell membranes stretch ,activating ion channels(ATP sensitive potassium channels), increased transmembrane current flow.
PREVENTION
• Public education-
• Improved coaching techniques
• Improved sports equipment- soft balls, air filled balls rarely implicated .
• Chest protectors & vests
SECONDARY PREVENTION
• AEDs(Automated External Defibrillators)-
Has been effective in terminating life threatening ventricular tachyarrthmias and restoring sinus rhythm
May also fail to restore normal rhythm even under optimal conditions
• Precordial thumps not Shown to be effective
SUMMARY
• Increasing public awareness of commotio cordisas a cause of sudden death
• Commotio cordis occurs in otherwise healthy active young people during recreational and competitive sports
• Fatal cardiac events can occur secondary to even innocent precordial blows delivered at a particular moment in cardiac cycle
• Further efforts are needed in increased education, better athletic equipment, more AEDs at athletic events
Differentials of exercise related sudden death
• 1.Hypertrophic cardiomyopathyDominant cause of ESDGreater prevalence in blacksAbnormal hypertrophy of LV walls,spatial disarray
of fibres at molecular level
• 2.Congenital coronary artery anomalies-Left main artery from sinus of valsava-intramural course of coronary artery(“malignant “
myocardial bridge)
• 3.Arrythmogenic Right ventricular cardiomyopathy
Leading cause in Italy,Europe
ECG- QRS widening with epsilon wave
4.Myocarditis- asymptomatic or sublesymptoms- exercise intolerance,restingtachycardia,palpitations
• 5.Wolff-Parkinson-white
• 6.Primitive electric heart diseases (Channelopathies)
-Long , Short QT syndrome
-Brugada syndrome
-Polymorphic catecholamine ventricular tachycardia
• 7.Pharmacologic treatment & doping
-sympathomimetics-ephedrine,epinephrine,cocaine
-Erythropoietin
Anabolic steroids
THANK YOU IMMENSELY