New EMT, don't understand a couple of calls.

[VirginiaEMT]

Dilated pupils can also be caused by loss of blood (hypovolemia).

This is my point, wouldn't this be a reason for the high flowo2. It would have been my guess that because of the blood loss, we should have given high flow o2 to prevent her from becoming shocky instead of waiting for her to get shocky.

 

[JPINFV]

As for the discussion of force.... bear in mind that force has little to do with commotio cordis. It happens most with young athletes, so the kid pitching or what not is probably not throwing that hard.

I agree with USAF too.... I'd rather take the very small risk of commotio cordis and get hit in the chest. Even if you did fall victim to it, it'd be a quick and painless way to go. Head injuries scare me much more than death.

Based off of pure observation (including playing Little League growing up), I'd say that LL'ers suffering any sort of long term damage from taking a pitch to the helmet is also extremely rare. I'd be interested in the incident rate of taking a line drive (in contrast to, say, a pop fly that would almost guarenteed to be deflected off of a glove) though. However, it seems that every few years a case of CC makes it to the news.

 

[VirginiaEMT]

Oh boy oh boy oh boy.... sudden cardiac death in young athletes is my favorite. I have written quite a few papers on it.... though usually focused on intrinsic causes.

Commotio cordis is extremely rare, and like Adam stated, one must be hit in a specific 10-30 millisecond long segment of the cardiac cycle, in the right spot as well. Postmortem exam usually reveals no internal trauma or hemorrhage... occasionally a little bruising but nothing that would normally be fatal or even problematic. It truly is an electrical phenomenon.

Research has been done on chest protectors commonly used in sports but they do little to nothing to guard against commotio cordis.

Resuscitation is futile, especially considering how most victims are healthy and young.

I am not familiar with commtio cordis. However, I do have a son who is a basketball nut and is also 16 and 6'8" tall. Could you explain?

 

[LucidResq]

I agree, especially with the bit on access to AEDs, however a recent study showed a 30% survival rate (to hospital discharge) of adolescents (12-19) who experienced out-of-hospital cardiac arrest in VT or VF.... of course commotio cordis is most common in adolescents, is out-of-hospital and is VF.

Hyperbolic... maybe. And you're right about the distinction between velocity and force. My bad.

Atkins, D. L., Everson-Stewart, S., Sears, G. K., Daya, M., Osmond, M. H., Warden, C. R., Berg, R. A., and the Resuscitation Outcomes Consortium Investigators 2009. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: The Resuscitation Outcomes Consortium epistry-cardiac arrest. Circulation 119:1484-1491.

 

[LucidResq]

I am not familiar with commtio cordis. However, I do have a son who is a basketball nut and is also 16 and 6'8" tall. Could you explain?

Essentially what happens in commotio cordis is a person is struck in the chest by some projectile at a very specific moment in the cardiac cycle, throwing the heart into ventricular fibrillation and cardiac arrest. The person does not die from something like blood loss or physical damage caused by the object hitting them, they die due to the interference with their heart's electrical cycle.

It is most common in sports like baseball and lacrosse, because as USAF quoted from a study:

Projectiles with a non-solid core tend to collapse on contact and absorb much of the impact energy. Only a single event has been attributed to chest impact with an air-filled soccer ball.

I wouldn't be worried about it with your son playing basketball. Even if he played something like baseball, commotio cordis is extremely rare.

 

[usafmedic45]

Even if he played something like baseball, commotio cordis is extremely rare.

The few I have heard about involved elbows or headbutts to the chest, but as you said, it is a very rare occurrence.

 

[VirginiaEMT]

Essentially what happens in commotio cordis is a person is struck in the chest by some projectile at a very specific moment in the cardiac cycle, throwing the heart into ventricular fibrillation and cardiac arrest. The person does not die from something like blood loss or physical damage caused by the object hitting them, they die due to the interference with their heart's electrical cycle.

It is most common in sports like baseball and lacrosse, because as USAF quoted from a study:


I wouldn't be worried about it with your son playing basketball. Even if he played something like baseball, commotio cordis is extremely rare.

Thanks.....

 

[usafmedic45]

I agree, especially with the bit on access to AEDs, however a recent study showed a 30% survival rate (to hospital discharge) of adolescents (12-19) who experienced out-of-hospital cardiac arrest in VT or VF.... of course commotio cordis is most common in adolescents, is out-of-hospital and is VF.

From the abstract of that article:

Survival for all pediatric OHCA was 6.4% (3.3% for infants, 9.1% for children, and 8.9% for adolescents)

From another part of the article:

Survival to hospital discharge for all nontraumatic pediatric OHCA was 6.4% compared with 4.5% survival for adult

Overall survival rate among pediatric patients who received EMS treatment was 7.8%, with 3.5% for infants, 10.4% for children, and 12.6% for adolescents.

Importantly, this study demonstrates that commonly reported overall survival figures are heavily influenced by very poor infant survival, whereas children and adolescents have substantially greater survival compared with adults.

Where are you getting a 30% survival rate from? The only mention I see of a statistic approaching that is an in-hospital study with 27%:

First, a study from the National Registry of Cardiopulmonary Resuscitation showed that the survival to hospital discharge after pulseless in-hospital cardiac arrest was higher among children (0 to 18 years) than adults (27% versus 18%), primarily because of better outcomes with a first documented rhythm of asystole/pulseless electric activity.

Also keep in mind the following:

The ROC Epistry–Cardiac Arrest is a large, diverse observational study conducted over a short time period. However, a large database with significant heterogeneity of event identification and potential variability in data abstraction may limit validity.13 Of note, the ROC Epistry–Cardiac Arrest database does not capture outcomes beyond hospital discharge, including neurological outcome.

BTW, here's a link to the full article in case anyone is interested: http://circ.ahajournals.org/cgi/content/full/119/11/1484

 

[LucidResq]

Table 4.

 

[lightsandsirens5]

The few I have heard about involved elbows or headbutts to the chest, but as you said, it is a very rare occurrence.

So why would defib not "fix" this? Isn't it just strait up VF caused by trauma?

 

[Lifeguards For Life]

Oh boy oh boy oh boy.... sudden cardiac death in young athletes is my favorite. I have written quite a few papers on it.... though usually focused on intrinsic causes.

Commotio cordis is extremely rare, and like Adam stated, one must be hit in a specific 10-30 millisecond long segment of the cardiac cycle, in the right spot as well. Postmortem exam usually reveals no internal trauma or hemorrhage... occasionally a little bruising but nothing that would normally be fatal or even problematic. It truly is an electrical phenomenon.

Research has been done on chest protectors commonly used in sports but they do little to nothing to guard against commotio cordis.

Resuscitation is futile, especially considering how most victims are healthy and young.

Statistics compiled by the US Consumer Product Safety Commission1 indicate that there were 88 baseball-related deaths to children in this age group between 1973 and 1995, an average of about 4 per year. This average has not changed since 1973. Of these, 43% were from direct-ball impact with the chest (commotio cordis); 24% were from direct-ball contact with the head; 15% were from impacts from bats; 10% were from direct contact with a ball impacting the neck, ears, or throat; and in 8%, the mechanism of injury was unknown

-http://aappolicy.aappublications.org/cgi/content/full/pediatrics;107/4/782

there are other studies with similar statistics

 

[Lifeguards For Life]

So why would defib not "fix" this? Isn't it just strait up VF caused by trauma?

The treatment of Commotio Cordis is no different from any other cardiopulmonary emergency associated with asystole.

The relatively low rate of survival from Commotio Cordis is most likely caused by the delay in instituting effective CPR measures because bystanders frequently fail to appreciate the severity of the event, lack knowledge of Commotio Cordis, or mistakenly believe that the trauma was insignificant. Many observers have commented that they" believed that the wind was knocked out of the person".

What do you guys think about the use of the precordial thump, in witnessed cases of Commotio Cordis, when a defibrillator is not available?

 

[usafmedic45]

In one subset (pts w/ VF), that does not imply that the overall survival rate is 30%. Don't cherry pick data.

of course commotio cordis is most common in adolescents, is out-of-hospital and is VF.

Actually by the time EMS gets to them (which is what we are working from in the Atkins article), a significant are in asystole.

From the Madias et al article I cited earlier:

Analysis revealed 33 cases of VF, 3 with ventricular tachycardia, 3 with bradyarrhythmias, 2 with idioventricular rhythm, and 1 with complete heart block. Forty of the cases documented asystole, which was unlikely to be the initial rhythm after impact, and is more likely a result of prolonged time from event to rhythm documentation.

That would be:
Total of 82 cases
VF/VT- ~44%
Bradydysrhythmias- ~3.6%
Idioventricular- ~2.4%
Complete heart block- ~1.2%
Asystole- ~49%

Don't cherry pick data. This is a major problem in resuscitation research: you can't compare one group to another unless they are controlled for the variability. In this case, you have to include the overall cohort (all rhythms for comparison) rather than operating off the idea that all commotio cordis cases we see (or even the majority of them) are going to be in VF, mostly due to delays in access to care. If we were to achieve 100% access to AEDs in the first moments after a commotio cordis case occurs, chances are good that the survival rate would be very similar to what you are trying to compare it to, but unfortunately you are talking about two distinct groups. One is very homogeneous (all VF/VT) and the other is very heterogeneous (any rhythm).

Isn't it just strait up VF caused by trauma?

The main problem is delay in access to defib. It's not "trauma" technically (in the sense of tissue damage). It's more akin to the idea behind a precordial thump.

From the Madias article:

Similar outcomes were seen in our model of CC in which defibrillation with an automated external defibrillator (AED) within 1 or 2 minutes of VF resulted in successful resuscitation in 100% and 92% of animals, respectively [21]. Only 46% of shocks were successful after 4 minutes, and after 6 minutes survival decreased further to 25% (p<0.0001).

This average has not changed since 1973. Of these, 43% were from direct-ball impact with the chest (commotio cordis); 24% were from direct-ball contact with the head; 15% were from impacts from bats; 10% were from direct contact with a ball impacting the neck, ears, or throat; and in 8%, the mechanism of injury was unknown

Can I point out the potential issue with looking at that data to decide which is a bigger threat? The lethality of commotio cordis is much higher so the number is going to be much larger. One would really need to look at injury morbidity, not mortality statistics to see which poses a greater risk.

What do you guys think about the use of the precordial thump, in witnessed cases of Commotio Cordis, when a defibrillator is not available?

Can't hurt, but probably won't help. I recall an article that showed that it was actually more effective in asystole for some reason than in VF/VT.

 

[Lifeguards For Life]

Can't hurt, but probably won't help. I recall an article that showed that it was actually more effective in asystole for some reason than in VF/VT.

Originally Posted by Guardian
I've heard of the precordial thump causing commotio cordis, but not proper cpr...anyone hear different?

http://emtlife.com/showthread.php?t=3677&highlight=commotio+cordis

has anyone heard of this?

 

[LucidResq]

Interesting, I kind of assumed that head injury would be more prevalent.

It's V Fib, not asystole. Initially anyways.

Precordial thumps have caused commotio cordis... but as far as treating it... of course there are few really good clinical studies but there is little (I can't find any) evidence to support use of the precordial thump especially for V Fib....

Despite generating high LV pressures, precordial thumps were not effective in terminating VF. Based on these data, precordial thump for VF in cardiac arrest victims cannot be recommended but for asystolic victims might be beneficial.

Madias, C., Maron, B. J., Alsheikh-Ali, A. A., Rajab, M., Estes, M. A., and Link, M. S. 2009. Precordial thump for cardiac arrest is effective for asystole but not for ventricular fibrillation. Heart Rhythm 6:1495-1500.

The efficacy of precordial thump for termination of induced non-tolerated ventricular tachyarrhythmias is very low even with application early after the onset of arrhythmia. Our study provides new evidence about this safe but generally non-productive manoeuvre, which may inform future revisions of cardiopulmonary resuscitation guidelines.

Haman, L., Parizek, P., and Vojacek, J. 2009. Precordial thump efficacy in termination of induced ventricular arrhythmias. Resuscitation 80:14-16.

 

[usafmedic45]

Interesting, I kind of assumed that head injury would be more prevalent

It is actually. It's just that the scope of that study is too narrow to show it. There's a very broad continuum of "head injury" (high frequency, low mortality) where as commotio cordis has a very high mortality despite a much lower frequency.

It's V Fib, not asystole. Initially anyways.

You can get asystole from blunt chest impact, although not commonly, but that is beside the point. You're missing what I am trying to get across. You can not accurately compare a group that on presentation to medical professionals are in a multitude of rhythms (especially mostly non-VF/VT) with a group that on presentation to medical professionals are in soley VF/VT and expect to get results that have validity. I don't know how much more clear I can make it without being unnecessarily (from a professional perspective since I think you're normally pretty sharp and personal standpoint since I consider you a friend) degrading. In other words, the two studies (or rather the Madias study and the VF/VT subset of the study you cited) are not looking at the same thing, even though they are both looking at "cardiac arrest outcomes". Does that make any sense?

Madias, C., Maron, B. J., Alsheikh-Ali, A. A., Rajab, M., Estes, M. A., and Link, M. S. 2009. Precordial thump for cardiac arrest is effective for asystole but not for ventricular fibrillation. Heart Rhythm 6:1495-1500.

That's the one I was referring to....just never got around to looking for it. Thank you!

 

[LucidResq]

Case study of precordial thump causing commotio cordis...

Precordial thump was performed due to complete AV block.

A precordial thump was performed to restart cardiac activation. Unfortunately, the precordial thump occurred during repolarization of the first ventricular escape rhythm, resulting in ventricular fibrillation, which required external cardioversion.

Cayla, G., Macia, J. C., and Pasquie, J. L. 2007. Precordial thump in the catheterization laboratory experimental evidence for commotio cordis. Circulation 115:e332+.

 

[LucidResq]

Oh USAF I wasn't arguing with you, I was referring to this:

The treatment of Commotio Cordis is no different from any other cardiopulmonary emergency associated with asystole.

I understand your point about cherry-picking data and such and know that one cannot truly compare the two studies, I just wanted to show that I wasn't completely coming out of left field when I said resus. is futile. In retrospect, probably not the best choice of words, but the survival rate is still low - just as it is with any out-of-hospital cardiac arrest. Of course early defib and CPR would save many of these kid's lives, but in the current situation this often isn't the case.

 

[Lifeguards For Life]

Case study of precordial thump causing commotio cordis...

Precordial thump was performed due to complete AV block.



Cayla, G., Macia, J. C., and Pasquie, J. L. 2007. Precordial thump in the catheterization laboratory experimental evidence for commotio cordis. Circulation 115:e332+.

Third-degree AVB is not v-fib or asystole. I'll have to look for the studies, but I believe the risks of a precordial thump are relatively low in a non pulse producing rhythm.

I generally hate anecdotal evidence, but I have seen one patient convert from V-fib following a precordial thump.

I'll try to locate a few studies on the use of precordial thump in witnessed v-fib/ non pulse producing rhythms.

 

[usafmedic45]

Oh USAF I wasn't arguing with you

Ah...that explains it. I couldn't figure out why you were not picking up what I was saying.

I just wanted to show that I wasn't completely coming out of left field when I said resus. is futile.

I don't think a 1 in 5 survival rate is all that bad, especially when with improved interventions we could easily raise it. Your definition of futile is a pretty loose.

In retrospect, probably not the best choice of words, but the survival rate is still low - just as it is with any out-of-hospital cardiac arrest.

Understood...see my comments below.

Of course early defib and CPR would save many of these kid's lives, but in the current situation this often isn't the case.

Which is why we must choose our words carefully and fully understand what they mean. Poor choices of words can discourage someone (perhaps one of the members on this list) from taking actions that might have significant impact on the outcomes of cases like this.