Commotio Cordis: What to Know and How to Communicate with Patients, with Jesse Morse, MD

Jesse Morse, MD

The United States was introduced to a medical diagnosis most had never heard of before January 2, 2023: commotio cordis.

After what appeared to be a routine tackle during a Monday Night Football game between the Cincinnati Bengals and the Buffalo Bills, Damar Hamlin, a defender for the Bills, collapsed onto the field and the audience was forced to watch as medical personnel responded to the apparent cardiac arrest, with many now speculating the cause of this arrest to be a phenomenon known as commotio cordis.

Occurring as the result of trauma to the chest wall during the upstroke of a T-wave, commotio cordis is regarded among sports medicine specialists as a rare, but dangerous occurrence. Due to the timing of the trauma, this causes the heart to enter ventricular fibrillation (VF) and, most often, requires subsequent defibrillation in order to restore normal rhythm. In 1998, NHL defenseman Chris Pronger experienced VF as a result of commotio cordis suffered following a shot to the chest during a game.

For most, the sight of a human superhero, somebody in peak physical condition in their prime athletic years, collapsed on the field was jarring. So jarring, discussions around commotio cordis, which is what many hypothesize occurred as a result of the trauma involved in the play preceding Damar Hamlin’s collapse, have taken centerstage in discussions on sports and mainstream television outlets alike. Although no diagnosis of commotio cordis has been confirmed by official sources, the fear that has come as a result of the unfortunate incident may prompt conversations, whether it be with young athletes or parents voicing interest, and offer a teachable moment for providers.

To learn more about approaching these conversations and what providers should know about commotio cordis, the editorial team of HCPLive reached out to Jesse Morse, MD, a sports medicine and regenerative medicine specialist with the Osteopathic Center in Miami, FL, for more insight. That conversation is the subject of the following Q&A.

Commotio Cordis: What to Know and How to Communicate with Patients, with Jesse Morse, MD

HCPLive: Can you provide our audience with a brief overview of commotio cordis?

Morse: So, commotio cordis is actually pretty rare. There's probably only been 10-15 cases documented over the past 20 years or so and it's really more of a diagnosis of exclusion.

It is a little tricky to confirm. It is a very unique situation where the cardiac cycle, predominantly at the upstroke of the T wave, gets impacted with, usually, a blunt force trauma to the chest or sternum are and it just happens to be at that exact moment. Now, instead of rolling off and continuing and then going back to the full normal cycle, it ends up turning into VF almost immediately.

When it happens, it's usually a weird combination of factors. Usually, it's a baseball or a lacrosse ball or something like that. It doesn't have to be fast, the most common seem to occur around 40 miles an hour. It's usually a round object and does not have to be penetrating. In Hamlin's case, if indeed that is the diagnosis, it was probably really the combination of the opposing player's elbow or landing on it. However, it was hard to see exactly what hit him.

The problem is, once you hit VF, you're stuck. You really struggle to get out of it because the heart has difficulty resetting itself without help. So, traditionally, when you see it, you really need to start CPR immediately. Ideally, you want to put an AED on immediately. The data shows the earlier you put it on, the better the results. We're talking one minute, two minutes, three minutes—very early.

This happens, but it's rare. That's likely what happened. If this happens, there are a lot of possibilities, but if you're able to get it out of that VF with an AED quickly then usually they do really well. The longer the anoxia, the more concerning it becomes.

HCPLive: As the most common form of arrhythmia, many patients may be familiar with atrial fibrillation (AF). How might you approach potential conversations about the differences in AF and VF?

Morse: So, AF is relatively common. It's by far the most common arrhythmia and most commonly impacts elderly, but not always. It is annoying and it causes some issues where you may have to be on blood thinner, but it's not going to probably kill you directly or at least not acutely. Most people with AF go in and out AF all the time.

VF is a different monster. A lot of ventricular arrhythmias are scary. They are immediate, they cause massive changes in the electrical conductivity of the heart, and most of them are fatal. You would much rather have AF than VF. And if you were to guess, when a cardiac arrhythmia is fatal, it was probably VF. You can see athletes with AF, and it's not super common, but it can happen. VF is, thankfully, very rare because the outcomes can be catastrophic and fatal.

HCPLive: What do you think might be important for a primary care provider or APP in family medicine to know about commotio cordis when preparing for potential conversations with patients?

Morse: I think the important thing is to understand what it is, its rarity, and, obviously, how to potentially treat it. They should know this is one of those things where if you see an athlete get struck by a ball or some type of moving object in the chest, and they're not moving, then you have to react quickly. If it happens, you would rather want to put the paddles on and say, "Oh, they're normal sinus rhythm", then not put them on and cause more issues.

At the same time, this is really low down the totem pole. I would also say, cardiac screenings in athletes are helpful, you would have to kind of go to someone like myself. American Medical Society for Sports is our organization, you can go onto the website, find a doc, there's a bunch of us around the country, and we do sports cardiology. So, we are comfortable with this. In general, I would just advise providers to just be cognizant of what it is and how you treat it if it were to happen to happen.

Editor's note: This transcript has been edited for length and clarity.