Commotio Cordis The
Single, Most Common Cause of Traumatic Death in Youth
Baseball
Thomas J. Abrunzo, MD \s=b\Two cases of blunt chest trauma caused a baseball are one death. At least one of these was in an consequence of cardiac concussion or commotio
by
reported, including
cordis,
entity not described in the pediatric literature. Concussion of the heart is a functional injury, in contrast to cardiac contusion or cardiac rupture, which pertains to structural injury. However, a cardiac concussion appears more likely
to have immediate, dire consequences than the structural in-
jury of cardiac contusion. Both of the cases presented occurred in the Little League baseball setting. Blunt chest
reported to cause two to three deaths in youth baseball each year. There appears to be an increased pediatric susceptibility to this type of injury. Unfortunately, these cases are quite resistant to resuscitative therapy. Devices trauma is
and techniques for primary and secondary prevention exist, but have yet to be systematically verified and implemented.
(AJDC. 1991;145:1279-1282)
chest trauma in children is usually a major force, such as an accident or fall from an extreme height.1-2 There has been little recognition that youth sports present yet an¬ other route for fatal blunt cardiac injury, and even less rec¬ occur in the absence of ognition that these fatalities can structural injury to the heart. The spectrum of blunt car¬ diac injury extends from a concussion ("a violent jar or shock")3 to gross, structural disruption.4-5 Unfortunately, a concussion can cause mortal injury as quickly as a rup¬ tured ventricle. Published data regarding commotio cordis (CC) reveal current resuscitation attempts as uniformly unsuccessful. Successful resuscitation may involve the use of the precordial thump, a technique not generally recom¬ mended for children. Difficulties in resuscitating patients with this problem dramatize the importance of primary and secondary prevention, that is, avoiding exposure and early treatment, respectively. Two illustrative cases are presented.
significant described the setting of Clinically automobile in
PATIENT REPORTS Patient 1.—The
patient,
a
healthy 10-year-old boy,
was a
right-handed batter in the Little League for 9- to 12-year-old chilAccepted for publication From Pediatric
Fla.
Reprint requests
Abrunzo).
March 28, 1991.
Emergency Services, St Joseph's Hospital, Tampa, to 2706 Fountain
Blvd, Tampa,
FL 33609 (Dr
dren. The pitcher was 9 years old and not remarkable for his pitch¬
un¬ ing velocity, according to bystanders. There was informal, substantiated consensus that he was throwing "about 30 mph."
pitch struck the batter in the left side of the chest and he was momentarily stunned. He fell to the ground and witnesses re¬ ported gasping respirations. A bystander found the carotid pulse to be present. However, the victim was almost immediately pale and cyanotic. Within about 30 seconds, the pulse was not felt and two-person cardiopulmonary resuscitation was begun by a nurse and paramedic bystander. Emergency medical services paramed¬ A
ics arrived at the
was
scene
within 8 minutes of the event. The victim
apneic, cyanotic, and the electrocardiogram was interpreted
fine ventricular fibrillation. His pupils were fixed and dilated. Serial defibrillations of 100 J, 100 J, and 200 J produced no change in rhythm. The boy's trachea was intubateci and 0.5 mg of epinephrine was administered endotracheally. The rhythm contin¬ ued in either fine ventricular fibrillation or asystole. The boy was transported by helicopter to our pediatrie emergency depart¬ ment, receiving assisted ventilations and external cardiac com¬ pressions. On arrival in the emergency department, endotracheal tube placement was confirmed by auscultation and chest roentgenography. Cardiac rhythm was noted to be asystole. On physical examination, an approximately 3- to 4-cm crescentic ecchymosis just inferior and lateral to the left nipple was detected. As the patient was being evaluated, weight-estimated doses of as
Department Editors.—William
B. Strong, MD, Augusta, Ca; CarlL. Stanitski, MD, Pittsburgh, Pa; Ronald E. Smith, PhD, Seattle, Wash; Jack H. Wilmore, PhD, Austin, Tex
section provides current information re¬ lated to the medical needs of young athletes, as pertinent to counseling young athletes and their parents regarding sports participation and practices contributing to the health maintenance of the athlete, as well as current concepts in the prevention, diagnosis, and treatment of sports-related illnesses and injuries. Editorial Comment.—Commotio cordis, a rarely described entity in the pediatrie literature, is a distinct entity of which the pediatrician should be aware. The trauma may be lethal, but fortunately is rare. Because of its rarity, there should be no community outcry for increasing pro¬ tective garb, eg, chest protectors, for youth baseball players. Life is a risk! We, unfortunately, do not live in a risk-free society. To attempt to make youth sports abso¬ lutely risk-free would be so expensive that no children or few children would benefit from the wonders of sports participation. —W.B.S.
Purpose.— This
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/09/2015
bicarbonate, epinephrine, atropine, and calcium were given; the
dosages were repeated 5 minutes later.
rine infusion
was
A continuous
epineph¬ slow, wide-complex rhythm
ordered. A Pulse and
was blood generated. pressure were absent. The pupils remained fixed and dilated. The patient was pronounced dead when no further cardiovascular or neurologic response to therapy was elicited. Autopsy revealed the heart to be free of gross or microscopic evidence of injury or congenital
abnormality.
Patient 2. —An 11-year-old male baseball player was struck in the mid and upper sternum by a Little League regulation base¬ ball thrown by another player during practice. The ball was "pegged hard" according to the victim's later recollection. Two adult witnesses reported the victim's immediate collapse. The boy fell forward, landing prone on the grass. Within 15 seconds, witnesses turned the patient supine, noting that his eyes were rolled back and his mouth was clenched, and that he did not re¬ spond to verbal and tactile stimuli. Urinary incontinence was evident. Cyanosis was not noted. His pulse rate was not evalu¬ ated. Witnesses attempted unsuccessfully to open the boy's clenched mouth. About 30 to 60 seconds into the event, attempts at cardiopulmonary resuscitation by chest compression were begun. After an estimated 10 compressions, the boy roused and became verbally responsive. He was found alert and responsive by emergency medical services personnel who arrived at the scene within 10 minutes of onset of the event. The boy arrived at our facility with normal, stable vital signs and normal mental status. Physical examination showed no external signs of chest trauma. The patient pointed to the mid and upper sternum as the site of chest impact, but denied pain or tenderness. No swelling, erythema, or ecchymosis was noted. Results of a cardiac exam¬ ination, including inspection of the precordium, auscultatory evaluation of the first and second heart sounds, precordial and distal pulse palpation, jugular venous pulse, liver palpation, and examination for peripheral edema, were all negative. Electrocardiographic monitoring, venous access, and blood sampling for a complete blood cell count, electrolytes, and fractionated creatine kinase were ordered. The initial electrocardiogram showed minimal ST segment elevation, which was not present on an electrocardiogram done 24 hours later. The initial creatine kinase level was elevated to 396 U/L (normal range for age, 30 to 230 U/L). The initial creatine kinase-MB fraction level was 3.6 ng/mL, and at 24 hours after injury, 3.5 ng/mL (normal range, 0 to 7 ng/mL). An echocardiogram was reported as normal. The patient's medical history was significant for hospitalization at 5 years of age for episodes of "falling asleep in school." This eval¬ uation, including electroencephalogram and Holter monitoring, revealed no abnormalities and the episodes did not recur. There was no family history of congenital heart disease, seizures, or premature death. The patient played youth football, basketball, and baseball without ever experiencing exertional syncope or near-syncope. He was discharged after an uneventful 3 days of observation. He was to be reevaluated in 2 weeks.
COMMENT The US Consumer Product Safety Commission has gen¬ erated data implicating ball impact to the chest as the sin¬ gle, most common cause of traumatic death in youth base¬ ball.6-7 However, these data appear not to have affected the community's main child health advocates—pediatricians. Blunt cardiac injury in children has received little atten¬ tion in the pediatrie literature. Cardiac concussion is not even mentioned in standard texts in pediatrics,8-9 pediatrie
cardiology,10'1 pediatrie surgery,12 pediatrie trauma,1314 pediatrie intensive care,15 or pediatrie emergency medi¬ cine.16
The spectrum of blunt cardiac injury includes gross disruption of the anatomy, such as rupture of the ventri¬
cles, ventricular septum, chordae tendineae, or the car¬ diac valves; less severe damage causing contusion of my-
ocardium, often involving elevation of
serum cardiac enzymes and various electrocardiogram changes; and concussion or functional, nonstructural injury causing dysrhythmia.4-5 This latter injury, known as CC, probably exists in a transient, benign form. Such cases are proba¬ bly not generally recognized or subjected to medical analysis. Patient 2 appears to represent an incremental level of involvement, with objective, but self-limited signs and symptoms. Patient 1 represents an extreme manifes¬ tation of CC, a malignant, irreversible form resulting in death. The incidence of CC in the population is not known. The pediatrie patient is generally thought to be more sus¬ ceptible to thoracic parenchymal injury after nonpenetrating trauma than the adult. Thoracic organs can be damaged in the absence of obvious injury to the skin or ribs. This is generally attributed to a thinner layer of soft tissue in the chest wall, and increased compliance of the immature rib cage.17 These latter factors enhance direct transmission of force to the underlying parenchyma. In addition, neuromuscular immaturity with respect to injury avoidance makes the child more liable to injury in general.18 Seven recent case reports of fatal CC from sports pro¬ jectiles such as a baseball, softball, hockey puck, and la¬ crosse ball were found in the medical literature.,9"24 All the reports describe collapse within seconds, unsuccessful resuscitation, and postmortem findings negative for structural cardiac damage. They involve both children and young adults. The baseball and softball cases do not appear to involve great force. The resistance of dysrhythmias in CC to resuscitative efforts is puzzling. In many of the cases reported, resus¬ citation was unsuccessful even when begun immediately after the injury was sustained. Liedtke et al25 suggested temporary alterations in coronary blood flow as a possi¬ ble explanation for the cardiopathy of CC. Experimental cardiac trauma studies suggest that rela¬ tively low levels of blunt injury induced only dysrhyth¬ mias; intermediate energy levels produced varying de¬ grees of contusion associated with impairment of ventric¬ ular function; and the highest levels of energy were nearly always fatal, causing gross, structural cardiac disruption.26 It seems that dysrhythmia is a specific manifestation of CC, not the response of an abnormal host to trivial chest injury. Lindsey et al,27 drawing on the work of German and Russian investigators, compared the differential features of cardiac concussion and contusion (Table). Of particular interest in the Table is the characteristic immediate onset, loss of consciousness, hypotension, and immediate disturbance of rhythm and conduction that marks CC as distinct from, and more dangerous than, cardiac contusion. Therapy for the child who collapses after blunt chest trauma seems to be the same as for any other emergency: airway maintenance, assisted ventilations, chest com¬ pressions, and defibrillation, as indicated by electrocardiographic monitoring.28 The lack of efficacy in the cases reviewed is disturbing. One might speculate on the pos¬ sible use of the precordial thump. This maneuver is used for the adult victim of witnessed ventricular fibrillation.29 Indeed, if ventricular fibrillation is the mechanism of death in CC, it seems reasonable to employ the precordial thump; if unsuccessful, immediate cardiopulmonary re¬ suscitation should be instituted. In the past, the American Heart Association cautioned against the use of the pre-
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/09/2015
Differential Features of Cardiac Concussion and Contusion
Concussion
Feature
Contusion
Site of trauma Direction of force
Precordial only Sternum to vertebra
Chest, anywhere
Force
Sharp,
Generally violent
not
necessarily
Thoracic cage intact Onset Course Loss of consciousness Blood pressure Disturbances of rhythm and conduction Changes in ST segment and
Insignificant
violent Essential
Not essential
Immediate
Gradual
Transitory
Lasting
As
Not characteristic
apy, cate
high lethality, and prevalence in youth baseball indi¬ the aggressive implementation of prevention efforts.
The author acknowledges the assistance of Jerome Schulman, MD; Jean Mooney; the emergency department staff, and library staff of St Joseph's
script.
Hospital, Tampa, Fla,
in the
preparation of this
manu¬
References 1. Tellez DW, Hardin WD, Takahashi M, Miller J, Galvis AG, Mahour GH. Blunt cardiac injury in children. J Pediatr Surg.
1987;12:1123-1128. a
rule
Frequently drops
Normal; rarely up
Characteristic,
Absent
immediate
Generally absent
or
delayed
Always present
waves
cordial thump in children.30 This is because of the infrequency of ventricular fibrillation as a presenting arrhyth¬ mia, the possibility of iatrogenic trauma to the heart, and the propensity for converting a benign rhythm to a malignant one. A different approach to children is not addressed in the most recent publication of advanced cardiac life support standards.29 The precordial thump should be scientifically evaluated for its potential as emergency therapy for pediatrie CC. Trauma has long been recognized as the "Number 1 killer of children."31 Sports-related death from injury is much less commonly observed.32-33 While the pediatrie medical literature generally acknowledges the nontrau¬ ma tic cardiac causes of youth sports deaths,34"38 traumatic cardiac death has not generated much interest. This is notwithstanding information from the US Consumer Product Safety Commission stating that in the 10-year period from 1973 to 1983, 51 children from age 5 to 14 years died of baseball-related injury, 23 of whom died of ball impact to the chest.6 This would make ball impact to the chest the single, most common cause of traumatic death in youth baseball. Deaths are reported within and outside the formal Little League setting, suggesting that adult su¬ pervision is not always protective. If helmets and genital cups are a standard part of Little League equipment, the incidence and lethality of blunt chest trauma should also mandate consideration of protective equipment. Manu¬ facturers have already marketed a "reduced injury factor" ball of lower mass and momentum than the standard ball (Tampa Tribune. March 29, 1990:1-C). Protective vests are also currently marketed (Tampa Tribune. April 26, 1990:3B). The data available demand that more information be gathered and that protective devices be evaluated with the purpose of their implementation in youth baseball.39-40 SUMMARY Commotio cordis or concussion of the heart is a distinct entity from cardiac contusion. It has received little attention as a source of pediatrie mortality. It appears to be the sin¬ gle, most common cause of traumatic death in youth base¬ ball. Although infrequent, its apparent resistance to ther-
2. Langer JC, Winthrop AL, Wesson DE, et al. Diagnosis and incidence of cardiac injury in children with blunt thoracic trauma. J Pediatr Surg. 1989;24:1091-1094. 3. Anderson DM, Patwell JM, Plaut K, McCullough K, eds. Dorland's Illustrated Medical Dictionary. 27th ed. Philadelphia, Pa: WB Saunders Co; 1985:370. 4. Tenzer ML. The spectrum of myocardial contusion: a re-
view. J Trauma. 1985;5:620-627. 5. Cohn P, Braunwald E. Traumatic heart disease. In: Braunwald E, ed. Heart Disease. Philadelphia, Pa: WB Saunders Co; 1988:1535-1538. 6. Rutherford GWJr, Kennedy J, McGhee L. Hazard Analysis: Baseball and Softball Related Injuries to Children 5-14 Years of Age. US Consumer Product Safety Commission; 1984. 7. King Al, Viano DC. Baseball Related Chest Impact: Final Report to the Consumer Product Safety Commission. US Consumer Product Safety Commission; 1986. 8. Behrman RE, Vaughan VC, Nelson WE. Nelson Textbook of Pediatrics. Philadelphia, Pa: WB Saunders Co; 1987. 9. Rudolph AM, ed. Pediatrics. East Norwalk, Conn: Appleton & Lange; 1987. 10. Moss AJ, Adams FH, Emmanouilides GC, Riemenschneider TA, eds. Heart Disease in Infants, Children and Adolescents. Baltimore, Md: Williams & Wilkins; 1989. 11. Anderson RH. Pediatric Cardiology. New York, NY: Churchill Livingstone Inc; 1987. 12. Welch KJ, Randolph JG, Ravitch MM, O'Neill JA, Rowe Ml, eds. Pediatric Surgery. Chicago, Ill: Mosby\p=n-\Year Book; 1986. 13. Mayer TA. Emergency Management of Pediatric Trauma. Philadelphia, Pa: WB Saunders Co; 1985. 14. Eichelberger MR, Pratsch GL, eds. Pediatric Trauma Care. Rockville, Md: Aspen Systems Corp; 1988. 15. Rogers MC, ed. Textbook of Pediatric Intensive Care. Baltimore, Md: Williams & Wilkins; 1987. 16. Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. Baltimore, Md: Williams & Wilkins; 1988. 17. Shoemaker WC, Thompson WL, Holbrook PR. Textbook of Critical Care. Philadelphia, Pa: WB Saunders Co; 1984. 18. Zuckerman BS, Duby JC. Developmental approach to injury prevention. Pediatr Clin North Am. 1985;32:17-29. 19. Dickman GL, Hassan A, Luckstead EF. Ventricularfibrillation
following a baseball injury. Phys Sportsmed. 1978;6:85-86.
20. Green ED, Simson LR, Kellerman HH, Horowitz RN, Sturner WQ. Cardiac concussion following softball blow to the chest. Ann Emerg Med. 1980;9:155-157. 21. Froede RC, Lindsey D, Steinbronn K. Sudden unexpected death from cardiac concussion (commotio cordis) with unusual legal complications. J Forensic Sci. 1979;24:752-756. 22. Frazier M, Mirchandani H. Commotio cordis, revisited. Am J Forensic Med Pathol. 1984;5:249-251. 23. Karofsky PS. Death of a high school hockey player. Phys
Sportsmed. 1990;18:99-103. 24. Edlich RF, Mayer NE, Fariss BL, et al. Commotio cordis in a lacrosse goalie. J Emerg Med. 1987;5:181-184.
25. Liedtke AJ, Allen RP, Nellis SH. Effects of blunt cardiac coronary vasomotion, perfusion, myocardial mechanics, and metabolism. J Trauma. 1980;20:777-785. 26. Lau VK, Viano DC, Doty DB. Experimental cardiac trauma: ballistics of a captive bolt pistol. J Trauma. 1982;21:39. trauma on
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/09/2015
27. Lindsey D, Navin T, Finley PR. Transient elevation of secreatine phosphokinase MB isoenzyme activity in drivers involved in auto accidents. Chest. 1978;74:15-18. 28. Chameides L, ed. Textbook of Pediatric Advanced Life Support. Dallas, Tex: American Heart Association; 1988. 29. Albarran-Sotelo R, Atkins JM, Bloom RS, et al. Textbook of Advanced Cardiac Life Support. Dallas, Tex: American Heart Association; 1987. 30. McIntyre KM, Lewis AJ, eds. Textbook of Advanced Cardiac Life Support. Dallas, Tex: American Heart Association; 1981. 31. Haller JA. Pediatric trauma: the number 1 killer of rum
children. JAMA. 1983;245:47. 32. Goldberg B. Injury patterns in
youth sports. Phys Sportsmed. 1989;17:175-186. 33. Mueller F, Blyth C. Epidemiology of sports injury in children. Clin Sports Med. 1982;1:343-352.
Epstein SE, Roberts WC. Causes of sudden competitive athletes. J Am Coll Cardiol. 1986;7:204\x=req-\
34. Maron BJ,
death in
214. 35. Maron BJ, Roberts WC, McAllister HA, Rosing DR, Epstein SE. Sudden death in young athletes. Circulation.
1980;62:218-229. 36. Topaz O, Edwards JE. Pathologic features of sudden death in children, adolescents and young adults. Chest. 1985;
87:476-482. 37. Neuspiel DR, Kuller LH. Sudden and unexpected natural death in childhood and adolescents. JAMA. 1985;254:1321-1325. 38. Denfield SW, Carson A Jr. Sudden death in children and young adults. Pediatr Clin North Am. 1990;37:215-231. 39. Hale CJ. Protective equipment for baseball. Phys
Sportsmed. 1979;7:59-63.
40. Ferstle J. Baseball deaths:
Sportsmed. 1978;6:21-22.
In Other AMA
unrecorded, preventable. Phys
Journals
ARCHIVES OF SURGERY
During Pregnancy: A Review of 79 Cases Thomas J. Esposito, MD, MPH; David R. Gens, MD; Lynn Gerber Smith, RN, MS; Ronald Scorpio, MD; Timothy Buchman, MD (Arch Surg. 1991;126:1073-1078) Trauma
Trauma in Pregnancy: Predicting Pregnancy Outcome David P. Kissinger, MD; Grace S. Rozycki, MD; John A Morris, Jr, MD; M. Margaret Knudson, MD; Wayne S. Copes, PhD; Sue M. Bass, ScM; H. Kendle Yates; Howard R. Champion, FRCS(Edin)
(Arch Surg. 1991;126:1079-1086)
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Single, Most Common Cause of Traumatic Death in Youth
Baseball
Thomas J. Abrunzo, MD \s=b\Two cases of blunt chest trauma caused a baseball are one death. At least one of these was in an consequence of cardiac concussion or commotio
by
reported, including
cordis,
entity not described in the pediatric literature. Concussion of the heart is a functional injury, in contrast to cardiac contusion or cardiac rupture, which pertains to structural injury. However, a cardiac concussion appears more likely
to have immediate, dire consequences than the structural in-
jury of cardiac contusion. Both of the cases presented occurred in the Little League baseball setting. Blunt chest
reported to cause two to three deaths in youth baseball each year. There appears to be an increased pediatric susceptibility to this type of injury. Unfortunately, these cases are quite resistant to resuscitative therapy. Devices trauma is
and techniques for primary and secondary prevention exist, but have yet to be systematically verified and implemented.
(AJDC. 1991;145:1279-1282)
chest trauma in children is usually a major force, such as an accident or fall from an extreme height.1-2 There has been little recognition that youth sports present yet an¬ other route for fatal blunt cardiac injury, and even less rec¬ occur in the absence of ognition that these fatalities can structural injury to the heart. The spectrum of blunt car¬ diac injury extends from a concussion ("a violent jar or shock")3 to gross, structural disruption.4-5 Unfortunately, a concussion can cause mortal injury as quickly as a rup¬ tured ventricle. Published data regarding commotio cordis (CC) reveal current resuscitation attempts as uniformly unsuccessful. Successful resuscitation may involve the use of the precordial thump, a technique not generally recom¬ mended for children. Difficulties in resuscitating patients with this problem dramatize the importance of primary and secondary prevention, that is, avoiding exposure and early treatment, respectively. Two illustrative cases are presented.
significant described the setting of Clinically automobile in
PATIENT REPORTS Patient 1.—The
patient,
a
healthy 10-year-old boy,
was a
right-handed batter in the Little League for 9- to 12-year-old chilAccepted for publication From Pediatric
Fla.
Reprint requests
Abrunzo).
March 28, 1991.
Emergency Services, St Joseph's Hospital, Tampa, to 2706 Fountain
Blvd, Tampa,
FL 33609 (Dr
dren. The pitcher was 9 years old and not remarkable for his pitch¬
un¬ ing velocity, according to bystanders. There was informal, substantiated consensus that he was throwing "about 30 mph."
pitch struck the batter in the left side of the chest and he was momentarily stunned. He fell to the ground and witnesses re¬ ported gasping respirations. A bystander found the carotid pulse to be present. However, the victim was almost immediately pale and cyanotic. Within about 30 seconds, the pulse was not felt and two-person cardiopulmonary resuscitation was begun by a nurse and paramedic bystander. Emergency medical services paramed¬ A
ics arrived at the
was
scene
within 8 minutes of the event. The victim
apneic, cyanotic, and the electrocardiogram was interpreted
fine ventricular fibrillation. His pupils were fixed and dilated. Serial defibrillations of 100 J, 100 J, and 200 J produced no change in rhythm. The boy's trachea was intubateci and 0.5 mg of epinephrine was administered endotracheally. The rhythm contin¬ ued in either fine ventricular fibrillation or asystole. The boy was transported by helicopter to our pediatrie emergency depart¬ ment, receiving assisted ventilations and external cardiac com¬ pressions. On arrival in the emergency department, endotracheal tube placement was confirmed by auscultation and chest roentgenography. Cardiac rhythm was noted to be asystole. On physical examination, an approximately 3- to 4-cm crescentic ecchymosis just inferior and lateral to the left nipple was detected. As the patient was being evaluated, weight-estimated doses of as
Department Editors.—William
B. Strong, MD, Augusta, Ca; CarlL. Stanitski, MD, Pittsburgh, Pa; Ronald E. Smith, PhD, Seattle, Wash; Jack H. Wilmore, PhD, Austin, Tex
section provides current information re¬ lated to the medical needs of young athletes, as pertinent to counseling young athletes and their parents regarding sports participation and practices contributing to the health maintenance of the athlete, as well as current concepts in the prevention, diagnosis, and treatment of sports-related illnesses and injuries. Editorial Comment.—Commotio cordis, a rarely described entity in the pediatrie literature, is a distinct entity of which the pediatrician should be aware. The trauma may be lethal, but fortunately is rare. Because of its rarity, there should be no community outcry for increasing pro¬ tective garb, eg, chest protectors, for youth baseball players. Life is a risk! We, unfortunately, do not live in a risk-free society. To attempt to make youth sports abso¬ lutely risk-free would be so expensive that no children or few children would benefit from the wonders of sports participation. —W.B.S.
Purpose.— This
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/09/2015
bicarbonate, epinephrine, atropine, and calcium were given; the
dosages were repeated 5 minutes later.
rine infusion
was
A continuous
epineph¬ slow, wide-complex rhythm
ordered. A Pulse and
was blood generated. pressure were absent. The pupils remained fixed and dilated. The patient was pronounced dead when no further cardiovascular or neurologic response to therapy was elicited. Autopsy revealed the heart to be free of gross or microscopic evidence of injury or congenital
abnormality.
Patient 2. —An 11-year-old male baseball player was struck in the mid and upper sternum by a Little League regulation base¬ ball thrown by another player during practice. The ball was "pegged hard" according to the victim's later recollection. Two adult witnesses reported the victim's immediate collapse. The boy fell forward, landing prone on the grass. Within 15 seconds, witnesses turned the patient supine, noting that his eyes were rolled back and his mouth was clenched, and that he did not re¬ spond to verbal and tactile stimuli. Urinary incontinence was evident. Cyanosis was not noted. His pulse rate was not evalu¬ ated. Witnesses attempted unsuccessfully to open the boy's clenched mouth. About 30 to 60 seconds into the event, attempts at cardiopulmonary resuscitation by chest compression were begun. After an estimated 10 compressions, the boy roused and became verbally responsive. He was found alert and responsive by emergency medical services personnel who arrived at the scene within 10 minutes of onset of the event. The boy arrived at our facility with normal, stable vital signs and normal mental status. Physical examination showed no external signs of chest trauma. The patient pointed to the mid and upper sternum as the site of chest impact, but denied pain or tenderness. No swelling, erythema, or ecchymosis was noted. Results of a cardiac exam¬ ination, including inspection of the precordium, auscultatory evaluation of the first and second heart sounds, precordial and distal pulse palpation, jugular venous pulse, liver palpation, and examination for peripheral edema, were all negative. Electrocardiographic monitoring, venous access, and blood sampling for a complete blood cell count, electrolytes, and fractionated creatine kinase were ordered. The initial electrocardiogram showed minimal ST segment elevation, which was not present on an electrocardiogram done 24 hours later. The initial creatine kinase level was elevated to 396 U/L (normal range for age, 30 to 230 U/L). The initial creatine kinase-MB fraction level was 3.6 ng/mL, and at 24 hours after injury, 3.5 ng/mL (normal range, 0 to 7 ng/mL). An echocardiogram was reported as normal. The patient's medical history was significant for hospitalization at 5 years of age for episodes of "falling asleep in school." This eval¬ uation, including electroencephalogram and Holter monitoring, revealed no abnormalities and the episodes did not recur. There was no family history of congenital heart disease, seizures, or premature death. The patient played youth football, basketball, and baseball without ever experiencing exertional syncope or near-syncope. He was discharged after an uneventful 3 days of observation. He was to be reevaluated in 2 weeks.
COMMENT The US Consumer Product Safety Commission has gen¬ erated data implicating ball impact to the chest as the sin¬ gle, most common cause of traumatic death in youth base¬ ball.6-7 However, these data appear not to have affected the community's main child health advocates—pediatricians. Blunt cardiac injury in children has received little atten¬ tion in the pediatrie literature. Cardiac concussion is not even mentioned in standard texts in pediatrics,8-9 pediatrie
cardiology,10'1 pediatrie surgery,12 pediatrie trauma,1314 pediatrie intensive care,15 or pediatrie emergency medi¬ cine.16
The spectrum of blunt cardiac injury includes gross disruption of the anatomy, such as rupture of the ventri¬
cles, ventricular septum, chordae tendineae, or the car¬ diac valves; less severe damage causing contusion of my-
ocardium, often involving elevation of
serum cardiac enzymes and various electrocardiogram changes; and concussion or functional, nonstructural injury causing dysrhythmia.4-5 This latter injury, known as CC, probably exists in a transient, benign form. Such cases are proba¬ bly not generally recognized or subjected to medical analysis. Patient 2 appears to represent an incremental level of involvement, with objective, but self-limited signs and symptoms. Patient 1 represents an extreme manifes¬ tation of CC, a malignant, irreversible form resulting in death. The incidence of CC in the population is not known. The pediatrie patient is generally thought to be more sus¬ ceptible to thoracic parenchymal injury after nonpenetrating trauma than the adult. Thoracic organs can be damaged in the absence of obvious injury to the skin or ribs. This is generally attributed to a thinner layer of soft tissue in the chest wall, and increased compliance of the immature rib cage.17 These latter factors enhance direct transmission of force to the underlying parenchyma. In addition, neuromuscular immaturity with respect to injury avoidance makes the child more liable to injury in general.18 Seven recent case reports of fatal CC from sports pro¬ jectiles such as a baseball, softball, hockey puck, and la¬ crosse ball were found in the medical literature.,9"24 All the reports describe collapse within seconds, unsuccessful resuscitation, and postmortem findings negative for structural cardiac damage. They involve both children and young adults. The baseball and softball cases do not appear to involve great force. The resistance of dysrhythmias in CC to resuscitative efforts is puzzling. In many of the cases reported, resus¬ citation was unsuccessful even when begun immediately after the injury was sustained. Liedtke et al25 suggested temporary alterations in coronary blood flow as a possi¬ ble explanation for the cardiopathy of CC. Experimental cardiac trauma studies suggest that rela¬ tively low levels of blunt injury induced only dysrhyth¬ mias; intermediate energy levels produced varying de¬ grees of contusion associated with impairment of ventric¬ ular function; and the highest levels of energy were nearly always fatal, causing gross, structural cardiac disruption.26 It seems that dysrhythmia is a specific manifestation of CC, not the response of an abnormal host to trivial chest injury. Lindsey et al,27 drawing on the work of German and Russian investigators, compared the differential features of cardiac concussion and contusion (Table). Of particular interest in the Table is the characteristic immediate onset, loss of consciousness, hypotension, and immediate disturbance of rhythm and conduction that marks CC as distinct from, and more dangerous than, cardiac contusion. Therapy for the child who collapses after blunt chest trauma seems to be the same as for any other emergency: airway maintenance, assisted ventilations, chest com¬ pressions, and defibrillation, as indicated by electrocardiographic monitoring.28 The lack of efficacy in the cases reviewed is disturbing. One might speculate on the pos¬ sible use of the precordial thump. This maneuver is used for the adult victim of witnessed ventricular fibrillation.29 Indeed, if ventricular fibrillation is the mechanism of death in CC, it seems reasonable to employ the precordial thump; if unsuccessful, immediate cardiopulmonary re¬ suscitation should be instituted. In the past, the American Heart Association cautioned against the use of the pre-
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/09/2015
Differential Features of Cardiac Concussion and Contusion
Concussion
Feature
Contusion
Site of trauma Direction of force
Precordial only Sternum to vertebra
Chest, anywhere
Force
Sharp,
Generally violent
not
necessarily
Thoracic cage intact Onset Course Loss of consciousness Blood pressure Disturbances of rhythm and conduction Changes in ST segment and
Insignificant
violent Essential
Not essential
Immediate
Gradual
Transitory
Lasting
As
Not characteristic
apy, cate
high lethality, and prevalence in youth baseball indi¬ the aggressive implementation of prevention efforts.
The author acknowledges the assistance of Jerome Schulman, MD; Jean Mooney; the emergency department staff, and library staff of St Joseph's
script.
Hospital, Tampa, Fla,
in the
preparation of this
manu¬
References 1. Tellez DW, Hardin WD, Takahashi M, Miller J, Galvis AG, Mahour GH. Blunt cardiac injury in children. J Pediatr Surg.
1987;12:1123-1128. a
rule
Frequently drops
Normal; rarely up
Characteristic,
Absent
immediate
Generally absent
or
delayed
Always present
waves
cordial thump in children.30 This is because of the infrequency of ventricular fibrillation as a presenting arrhyth¬ mia, the possibility of iatrogenic trauma to the heart, and the propensity for converting a benign rhythm to a malignant one. A different approach to children is not addressed in the most recent publication of advanced cardiac life support standards.29 The precordial thump should be scientifically evaluated for its potential as emergency therapy for pediatrie CC. Trauma has long been recognized as the "Number 1 killer of children."31 Sports-related death from injury is much less commonly observed.32-33 While the pediatrie medical literature generally acknowledges the nontrau¬ ma tic cardiac causes of youth sports deaths,34"38 traumatic cardiac death has not generated much interest. This is notwithstanding information from the US Consumer Product Safety Commission stating that in the 10-year period from 1973 to 1983, 51 children from age 5 to 14 years died of baseball-related injury, 23 of whom died of ball impact to the chest.6 This would make ball impact to the chest the single, most common cause of traumatic death in youth baseball. Deaths are reported within and outside the formal Little League setting, suggesting that adult su¬ pervision is not always protective. If helmets and genital cups are a standard part of Little League equipment, the incidence and lethality of blunt chest trauma should also mandate consideration of protective equipment. Manu¬ facturers have already marketed a "reduced injury factor" ball of lower mass and momentum than the standard ball (Tampa Tribune. March 29, 1990:1-C). Protective vests are also currently marketed (Tampa Tribune. April 26, 1990:3B). The data available demand that more information be gathered and that protective devices be evaluated with the purpose of their implementation in youth baseball.39-40 SUMMARY Commotio cordis or concussion of the heart is a distinct entity from cardiac contusion. It has received little attention as a source of pediatrie mortality. It appears to be the sin¬ gle, most common cause of traumatic death in youth base¬ ball. Although infrequent, its apparent resistance to ther-
2. Langer JC, Winthrop AL, Wesson DE, et al. Diagnosis and incidence of cardiac injury in children with blunt thoracic trauma. J Pediatr Surg. 1989;24:1091-1094. 3. Anderson DM, Patwell JM, Plaut K, McCullough K, eds. Dorland's Illustrated Medical Dictionary. 27th ed. Philadelphia, Pa: WB Saunders Co; 1985:370. 4. Tenzer ML. The spectrum of myocardial contusion: a re-
view. J Trauma. 1985;5:620-627. 5. Cohn P, Braunwald E. Traumatic heart disease. In: Braunwald E, ed. Heart Disease. Philadelphia, Pa: WB Saunders Co; 1988:1535-1538. 6. Rutherford GWJr, Kennedy J, McGhee L. Hazard Analysis: Baseball and Softball Related Injuries to Children 5-14 Years of Age. US Consumer Product Safety Commission; 1984. 7. King Al, Viano DC. Baseball Related Chest Impact: Final Report to the Consumer Product Safety Commission. US Consumer Product Safety Commission; 1986. 8. Behrman RE, Vaughan VC, Nelson WE. Nelson Textbook of Pediatrics. Philadelphia, Pa: WB Saunders Co; 1987. 9. Rudolph AM, ed. Pediatrics. East Norwalk, Conn: Appleton & Lange; 1987. 10. Moss AJ, Adams FH, Emmanouilides GC, Riemenschneider TA, eds. Heart Disease in Infants, Children and Adolescents. Baltimore, Md: Williams & Wilkins; 1989. 11. Anderson RH. Pediatric Cardiology. New York, NY: Churchill Livingstone Inc; 1987. 12. Welch KJ, Randolph JG, Ravitch MM, O'Neill JA, Rowe Ml, eds. Pediatric Surgery. Chicago, Ill: Mosby\p=n-\Year Book; 1986. 13. Mayer TA. Emergency Management of Pediatric Trauma. Philadelphia, Pa: WB Saunders Co; 1985. 14. Eichelberger MR, Pratsch GL, eds. Pediatric Trauma Care. Rockville, Md: Aspen Systems Corp; 1988. 15. Rogers MC, ed. Textbook of Pediatric Intensive Care. Baltimore, Md: Williams & Wilkins; 1987. 16. Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. Baltimore, Md: Williams & Wilkins; 1988. 17. Shoemaker WC, Thompson WL, Holbrook PR. Textbook of Critical Care. Philadelphia, Pa: WB Saunders Co; 1984. 18. Zuckerman BS, Duby JC. Developmental approach to injury prevention. Pediatr Clin North Am. 1985;32:17-29. 19. Dickman GL, Hassan A, Luckstead EF. Ventricularfibrillation
following a baseball injury. Phys Sportsmed. 1978;6:85-86.
20. Green ED, Simson LR, Kellerman HH, Horowitz RN, Sturner WQ. Cardiac concussion following softball blow to the chest. Ann Emerg Med. 1980;9:155-157. 21. Froede RC, Lindsey D, Steinbronn K. Sudden unexpected death from cardiac concussion (commotio cordis) with unusual legal complications. J Forensic Sci. 1979;24:752-756. 22. Frazier M, Mirchandani H. Commotio cordis, revisited. Am J Forensic Med Pathol. 1984;5:249-251. 23. Karofsky PS. Death of a high school hockey player. Phys
Sportsmed. 1990;18:99-103. 24. Edlich RF, Mayer NE, Fariss BL, et al. Commotio cordis in a lacrosse goalie. J Emerg Med. 1987;5:181-184.
25. Liedtke AJ, Allen RP, Nellis SH. Effects of blunt cardiac coronary vasomotion, perfusion, myocardial mechanics, and metabolism. J Trauma. 1980;20:777-785. 26. Lau VK, Viano DC, Doty DB. Experimental cardiac trauma: ballistics of a captive bolt pistol. J Trauma. 1982;21:39. trauma on
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27. Lindsey D, Navin T, Finley PR. Transient elevation of secreatine phosphokinase MB isoenzyme activity in drivers involved in auto accidents. Chest. 1978;74:15-18. 28. Chameides L, ed. Textbook of Pediatric Advanced Life Support. Dallas, Tex: American Heart Association; 1988. 29. Albarran-Sotelo R, Atkins JM, Bloom RS, et al. Textbook of Advanced Cardiac Life Support. Dallas, Tex: American Heart Association; 1987. 30. McIntyre KM, Lewis AJ, eds. Textbook of Advanced Cardiac Life Support. Dallas, Tex: American Heart Association; 1981. 31. Haller JA. Pediatric trauma: the number 1 killer of rum
children. JAMA. 1983;245:47. 32. Goldberg B. Injury patterns in
youth sports. Phys Sportsmed. 1989;17:175-186. 33. Mueller F, Blyth C. Epidemiology of sports injury in children. Clin Sports Med. 1982;1:343-352.
Epstein SE, Roberts WC. Causes of sudden competitive athletes. J Am Coll Cardiol. 1986;7:204\x=req-\
34. Maron BJ,
death in
214. 35. Maron BJ, Roberts WC, McAllister HA, Rosing DR, Epstein SE. Sudden death in young athletes. Circulation.
1980;62:218-229. 36. Topaz O, Edwards JE. Pathologic features of sudden death in children, adolescents and young adults. Chest. 1985;
87:476-482. 37. Neuspiel DR, Kuller LH. Sudden and unexpected natural death in childhood and adolescents. JAMA. 1985;254:1321-1325. 38. Denfield SW, Carson A Jr. Sudden death in children and young adults. Pediatr Clin North Am. 1990;37:215-231. 39. Hale CJ. Protective equipment for baseball. Phys
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40. Ferstle J. Baseball deaths:
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In Other AMA
unrecorded, preventable. Phys
Journals
ARCHIVES OF SURGERY
During Pregnancy: A Review of 79 Cases Thomas J. Esposito, MD, MPH; David R. Gens, MD; Lynn Gerber Smith, RN, MS; Ronald Scorpio, MD; Timothy Buchman, MD (Arch Surg. 1991;126:1073-1078) Trauma
Trauma in Pregnancy: Predicting Pregnancy Outcome David P. Kissinger, MD; Grace S. Rozycki, MD; John A Morris, Jr, MD; M. Margaret Knudson, MD; Wayne S. Copes, PhD; Sue M. Bass, ScM; H. Kendle Yates; Howard R. Champion, FRCS(Edin)
(Arch Surg. 1991;126:1079-1086)
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