Commotio cordis?A report of three cases

Commotio Cordis: A Comprehensive Review

Commotio cordis is a rare, however, potentially fatal, cardiovascular phenomenon arising from direct chest wall trauma, causing sudden cardiac arrest and potentially death. It is primarily seen in young athletes who participate in contact and organized sports. Though debated, the cause of commotio cordis is believed to involve specific timing of chest impact during ventricular electrical activity leading to severe arrhythmic events. Due to sudden onset, the first step in management is immediate and effective basic life support with automated external defibrillation, followed by advanced cardiac life support. Future considerations should include secondary prevention measures such as protective padding in contact sports. It is paramount that clinicians are vigilant in recognizing potential cases of commotio cordis in the field and provide immediate care. This review consolidates the current understanding of commotio cordis, emphasizing the importance of awareness and early intervention. Future research is warranted, including retrospective and observational studies to identify high-risk patterns or trends associated with the condition.

Commotio Cordis in Non-Sport-Related Events: A Systematic Review

BACKGROUND

Commotio cordis is an increasingly recognized cause of sudden cardiac death. Although commonly linked with athletes, many events occur in non-sport-related settings.

OBJECTIVES

The goal of this study was to characterize and compare non-sport-related vs sport-related commotio cordis.

METHODS

PubMed and Embase were searched for all cases of commotio cordis from inception to January 5, 2022.

RESULTS

Of 334 commotio cordis cases identified, 121 (36%) occurred in non-sport-related contexts, which included assault (76%), motor vehicle accidents (7%), and daily activities (16%). Projectiles were implicated significantly less in non-sport-related events (5% vs 94%, respectively; P < 0.001). Nonprojectile etiologies in non-sport-related events mostly consisted of impacts with body parts (79%). Both categories affected similar younger aged demographic (P = 0.10). The proportion of female victims was significantly higher in non-sport-related events (13% vs 2%, respectively; P = 0.025). Mortality was significantly higher in non-sport-related events (88% vs 66%, respectively; P < 0.001). In non-sport-related events, rates of cardiopulmonary resuscitation (27% vs 97%, respectively; P < 0.001) and defibrillation (17% vs 81%, respectively; P < 0.001) were both lower and resuscitation was more commonly delayed beyond 3 min (80% vs 5%, respectively; P < 0.001).

CONCLUSIONS

Commotio cordis occurs across a spectrum of non-sport-related settings including assault, motor vehicle accidents, and daily activities. Both categories affected a younger and male-predominant demographic. Mortality is higher in non-sport-related commotio cordis, likely owing to lower rates of cardiopulmonary resuscitation, defibrillation, automated external defibrillator availability, and extended time to resuscitation. Increased awareness of non-sport-related commotio cordis is essential to develop a means of prevention and mortality reduction, with earlier recognition and prompt resuscitation measures.

Diagnostic Criteria for Commotio Cordis Caused by Violent Attack: Review of the Literature

The diagnosis of lethal commotio cordis (CC) is really complex. The forensic pathologist's task is even more relevant when he/she has to explain a CC diagnosis caused by an assault in a trial. The purpose of this study was to analyze the literature on lethal CC as a result of violent attacks and identify relevant parameters that may help in the diagnosis. A review of the relevant articles was performed. Fifty-two cases of CC caused by violent attacks were identified. The collected data allowed to confirm the following literature's criteria for CC diagnosis in case of assaults: witnessed occurrence of a blunt, nonpenetrating blow to the chest preceding cardiovascular collapse; absence of structural damage to the sternum, ribs, or heart itself; and absence of any underlying cardiovascular abnormalities (such as other causes of sudden death). Regarding the assessment of the third criterion, the authors suggest that the pathologist should always specify the scientific autopsy guidelines that he/she used to differentiate CC from the other causes of sudden death. In addition, the authors highlight the importance of a multidisciplinary approach for a correct interpretation of clinical, autopsy, and laboratory findings.

Blow/trauma to the chest and sudden cardiac death: Commotio cordis and contusio cordis are leading causes

Background

In forensic practice, a blow to the chest can lead to sudden cardiac death (SCD). Commotio cordis and contusio cordis are leading causes.

Methods

From a database of 4678 patients who suffered from SCD, we found three patients with commotio cordis and two patients with contusio cordis. All the patients were examined macroscopically and microscopically and had negative toxicology screen.

Results

The three patients who died due to commotio cordis were young males (16, 23 and 38 years old). The circumstances of death were: a blow to the chest by a football, by a friend during a party and during an assault. The hearts were completely normal at autopsy. The two patients who had contusio cordis were older males (42 and 63 years old). Both patients died during traffic accidents. At autopsy, one had significant contusion over the left ventricle, and the second had contusion over the right ventricle.

Conclusion

This study indicates that a blow to the chest is very important to document in the circumstances of death, and a detailed history is vital. It raises the left ventricular intra-cavitary pressure, leading to commotio cordis with immediate death with a normal heart. Blunt chest trauma can cause direct myocardial lesions, with acute changes leading to contusio cordis.

Homicidal commotio cordis caused by domestic violence: A report of two cases

Commotio cordis is a rare and fatal mechano-electric arrhythmogenic syndrome, occurring mainly during sports activities. The present study describes two cases of sudden death due to homicidal commotio cordis caused violence from an intimate partner. The two decedents were both young women. They suffered from physical abuse by their intimate partner and collapsed immediately after being punched in the precordium. Electrocardiograms were recorded at the hospital and showed ventricular fibrillation in one case. An autopsy was performed in each case, and no structural cardiac damage, evident lesions of other internal organs or underlying diseases were found. Combined with the negative toxicological analysis, it was concluded that the cause of death was commotio cordis due to a blunt force to the anterior chest. To the best of the authors' knowledge, there is no published report on commotio cordis caused by physical abuse from an intimate partner. The accurate diagnosis of the cause of death is emphasised, as it is important for judicial fairness.

A fatal case of commotio cordis caused by an accidental fall on the beach

Sudden cardiac death is a major health problem and a recurring issue in forensic medicine. Most cases are attributed to congenital heart disease, cardiomyopathy, myocarditis, pathology of the coronary arteries, long or short QT interval syndromes, Brugada syndrome or secondary toxic effects of cardioactive drugs. Sudden death caused by Commotio cordis after an accidental fall is very rare in women. Victims are essentially young people who die following a direct blow to the chest sustained during physical activity. In the following, we report a case of an adult with no significant past medical history, walking on the beach with friends, who died from commotio cordis following an accidental fall on the wet sand. This article deals with post-mortem diagnosis, and demonstrates the importance of a detailed understanding of the circumstances surrounding the death, as well as systematic histological examination of the heart, as the heart will generally appear normal under macroscopic examination. It is important to note that commotio cordis can also occur in adults.

Imprudent blow, catastrophic consequence: a case of commotio cordis associated with violence

Commotio cordis is a rare and catastrophic mechano-electric feedback syndrome, and it is especially apt to occur in male children, adolescents and youths during sports activities. The authors present a case of unexpected sudden death due to commotio cordis associated with violence. In a house of detention, a 19-year-old boy was punched and kicked in the face, neck and chest during a fight with another suspect in their ward. Unfortunately, his precordium was the major injured region. The victim turned pale, then lost the ability to resist and lost consciousness immediately. When the emergency medical personnel arrived, the victim was found in a condition of cardiac and respiratory arrest and he was pronounced dead at the scene without cardiopulmonary resuscitation. Both autopsy signs and forensic morphology were in accord with the criteria for commotio cordis diagnosis, showing no cardiac or other organic fatal lesions and no underlying cardiac diseases; moreover, the toxicological screening was negative for alcohol, drug and common toxicants. In the present case, the whole fight was seen by some witnesses in their ward, and it was recorded by the monitoring unit. Based on the statements of the witnesses and the monitoring videotape, combined with the forensic pathological and toxicological examinations, all the testimonies supported the conclusion that the cause of death was commotio cordis.

Cardiac pathology in death from electrocution

To better characterize the morphologic changes in electrocution, morphologic changes in the hearts of 21 subjects, who died instantaneously of electrocution, were compared to the hearts of decedents with different types of death. Sixteen myocardial samples per heart were processed for histological examination, and sections were prepared with a variety of specific stains. The frequency, location and extent of myocellular segmentation (stretching and/or rupture) of intercalated discs and associated changes of myocardial bundles and single myocells [myofibre break-up (MFB)] were recorded, quantitatively analysed and statistically evaluated. The frequency of MFB was maximal in cases of electrocution (90%). The findings show that MFB is an ante-mortem change and may be a distinct finding in electrocution.