Commotio Cordis: The Modern “Touch of Death”

Introduction:
In January 2023, Buffalo Bills player Damar Hamlin stood up after a tackle and immediately collapsed
(1). Chinese martial artists call it dim mak, or the “touch of death” (2). Previously being 10%, its survival
rate has now thankfully increased to 58% in recent years (3). However, it is important for awareness to be
spread, as it is the 3rd most common cause of sudden death in U.S. competitive athletes (4).

Definition:
Commotio cordis is a cardiac arrest (usually ventricular fibrillation or ventricular tachycardia) as the
result of a blunt impact to the precordium, without any underlying evidence of structural cardiovascular
disease or traumatic injury (5).

Risk factors of commotio cordis include:
● Male sex
● Impact over the cardiac silhouette
● Blows that occur during a narrow time
segment of the T-wave upstroke (6)
● Impacts at ~40 mph (7)
● Organized competitive sports
● Hard objects/balls (baseball, hockey
puck, lacrosse ball)
● Broader surface contact blows (football
helmet during a tackle, heel of a hockey
stick, karate kick, opponent’s shoulder in
a hockey check) (8)
● Mean age reported in the registry is 15 years
(9)
● Not wearing protective padding (10)

Pathophysiology:
It is not very well understood why it happens. However, it is believed that when a force like a chest blow
comes at a speed of 40–50 mph during a specific 10–30 millisecond window of myocardial repolarization,
there is an abrupt increase in left ventricular pressure that causes abnormalities within ion channels,
triggering a premature ventricular depolarization (12).

Figure 1 – Commotio Cordis Illustration (20)

Clinical Presentation:
● History: hit to the anterior chest (usually baseball)
● Rhythm strip/AED: usually ventricular fibrillation
● Exam: contusion overlying the heart, no pulse, unconsciousness due to inadequate organ
perfusion (9)
Investigations
● ECG: may reveal myocardial injury
● Radiography and point-of-care ultrasound: rule out other injuries (sternal fracture, pneumothorax,
pericardial effusion/tamponade)
● Troponin and echocardiogram: assess for myocardial contusion/structural abnormalities
● Stress testing/cardiac catheterization/pharmacological testing: rule out coronary artery disease,
Brugada syndrome, long-QT syndrome (9)
Differential Diagnosis (non-traumatic causes usually need echo/MRI to confirm)(13):
● Hypertrophic cardiomyopathy (HCM): LV hypertrophy
● Congenital coronary anomalies: abnormal slit-like ostium, compression between pulmonary
artery and ascending aorta
● Arrhythmogenic right ventricular dysplasia (ARVD): fibrofatty RV changes
● Dilated cardiomyopathy: disproportionately enlarged LV cavity
● Aortic rupture (Marfan): dissection and rupture
● Myocarditis: viral prodrome, fever, fatigue, troponin rise, LV dysfunction
● Valvular disease (aortic stenosis, MVP): valvular dysfunction on echo
● Electrical disorders (WPW, long QT, Brugada): ECG abnormalities
● Coronary artery disease (CAD): ischemic changes on ECG/troponins

Management: (14)
Stabilization of cardiac activity via resuscitation from ventricular fibrillation:
● Early defibrillation
● Chest compressions
● Epinephrine / amiodarone / lidocaine
● Post–cardiac arrest measures
Measures to ensure successful resuscitation of commotio cordis
victims include:
● Training of coaches, staff, and others for prompt recognition,
EMS activation, CPR, and defibrillation (Class I; Level of
Evidence B)
● Comprehensive evaluation for underlying cardiac pathology
and arrhythmia susceptibility in survivors (Class I; Level of
Evidence B)
● If no underlying abnormality is identified, individuals can
safely resume training/competition after resuscitation (Class
IIa; Level of Evidence C) (15)

Discussion:
Some articles demonstrate, for the first time, that individual susceptibility to commotio cordis exists, with
implications for decisions on return to sports after an event (16).
Preventive strategies:
● Rule changes (e.g., eliminating chest blocking of shots by defenders in lacrosse) (17)
● Coaching changes (e.g., teaching techniques to shield the chest) (17)
● Safety baseballs: reduced risk (softest safety baseballs triggered VF in only 11% of impacts, vs.
69% with standard baseballs) (18)
● Chest wall protectors: limited effectiveness (about 40% of sudden deaths in young athletes
occurred despite equipment generally perceived as protective) (19)

Stephanie Girgis Year 5 (2025/9/23 PR – ND, AF)

References:
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from: https://www.aclsmedicaltraining.com/adult-cardiac-arrest-vtach-and-vfib/
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20. https://www.ahajournals.org/doi/full/10.1161/CIRCEP.111.962712