When we (WHF and JSA) were medical students over 55 years ago in Boston, cardiopulmonary resuscitative techniques were just being introduced in hospitals. Primitive defibrillators and pacemakers became available for inpatient clinical use, and coronary care units were being established to better monitor patients with cardiac arrhythmias. For the first time, coronary care unit nurses were given permission to shock patients with ventricular tachycardia or ventricular fibrillation.
Cardiac resuscitation approaches were not routinely utilized in outpatient settings. I (WHF) worked as a first aid attendant during the 1960s in the old Boston Garden, which hosted multiple sporting events (hockey, basketball, wrestling, roller derby, and track), with no resuscitative equipment available except for oxygen. Anyone who had a suspected cardiac disorder at the Garden was transferred by ambulance to the nearby Massachusetts General Hospital. The available ambulances had no specialized equipment other than a stretcher. There were no emergency medical technicians or paramedics. Patients with community cardiac arrest were brought to the hospital and were most often dead on arrival. There were no specialized emergency medicine physicians.
The recent episode of a cardiac arrest in a football player, Damar Hamlin, on a Cincinnati playing field, was witnessed by millions of viewers, and highlighted resuscitation by trained personnel with modern defibrillators. Hamlin's cardiac arrest was almost certainly precipitated by the electrophysiologic phenomenon known as commotio cardis, where a sudden blunt impact to the chest leads to a rhythm change and cardiac arrest.
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It is an extremely rare condition most often caused by small hard objects such as a baseball, hockey puck, or a lacrosse ball striking the chest during the vulnerable period in the cardiac electrical cycle.2
Rarely is it caused by a collision of 2 athletes. Commotio cordis differs from a myocardial contusion related to more widespread blunt chest traumas as seen in auto accident victims (contusio cordis).The details of Hamlin's cardiac arrest are as follows. On January 2, 2023 during a Monday night football game in Cincinnati, Damar Hamlin, a 24-year-old playing at the defensive safety position for the Buffalo Bills, was hit in the chest during a collision with another player. Just after the collision he stood up, took 2 steps, and collapsed backward with loss of consciousness. Surrounded by his teammates who were praying and crying, he received immediate medical attention with cardiac resuscitation, including defibrillation, and within minutes was transported to the University of Cincinnati Hospital, where he was defibrillated a second time. His vital signs recovered quickly, and ultimately, he awoke and 2 weeks later was home watching his team play on TV.
What was the definitive cause for the sudden near-death of Damar Hamlin on the field? Most likely an episode of ventricular tachyarrhythmia related to blunt trauma, commotio cordis.
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Other possibilities for such a presentation in an otherwise healthy individual could be hypertrophic cardiomyopathy, which was the cause of death of a college basketball player, Hank Gathers, who died after collapsing at a nationally televised game. A more common cause of sudden death related to arrhythmia is ischemic heart disease, which would be very unlikely secondary to acute trauma and given the clinical presentation and young age of Damar Hamlin.Commotio cordis was first described during the 18th century in workers exposed to chest injury, but did not become well recognized until the 1990s, when episodes were observed in adolescent males who were struck in the chest by small speeding hard objects, for example, a baseball.
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Protective chest muscles may not yet be fully developed in younger athletes.2
Damar Hamlin appeared to be healthy prior to his cardiac arrest episode, and if no other underlying cardiac condition is identified, he should be able to return to competitive sports. Remarkably, with the tens of thousands of competitive sports competitions being played each year, commotio cordis is quite rare. Animal experiments suggest that the timing, location, velocity, and shape/hardness of the object striking the chest is the cause of the arrhythmia of commotio cordis.
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Damar Hamlin is now alive and well. The heroes of this episode are the health care workers who were trained to respond to Hamlin's cardiovascular collapse. We were also impressed with the response of universal prayer and good wishes from the entire country. Those of us who work each day in health care should be proud of the clinicians and resuscitation scientists who helped develop the current resuscitation devices and procedures that, in this case, led to triumph over tragedy.
Competitive sports are relatively safe, but there should continue to be precautionary moves made available with chest protectors, and the universal presence of defibrillators with trained individuals present. After 50 years, modern resuscitative procedures have indeed become a worldwide resource of great benefit.
References
- Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities.N Engl J Med. 1995; 333: 337-342
- Global epidemiology and demographics of commotio cordis.Heart Rhythm. 2011; 8: 1969-1971
- Commotio cordis: sudden cardiac death with chest wall impact.J Cardiovasc Electophysiol. 2007; 18: 115-122
- Rediscovering commotio cordis.Lancet. 2001; 357: 1195-1197
- Commotio cordis and the epidemiology of sudden death in competitive lacrosse.Pediatrics. 2009; 124: 966-971
- Marked variability in susceptibility to ventricular fibrillation in an experimental commotio cordis model.Circulation. 2010; 122: 2499-2504
- Reduced diameter spheres increases the risk of chest blow-induced ventricular fibrillation (commotio cordis).Heart Rhythm. 2011; 8: 1578-1581
Article info
Publication history
Published online: January 30, 2023
Accepted:
January 24,
2023
Received:
January 24,
2023
Footnotes
Funding: None.
Conflicts of Interest: There are no conflicts of interest for either of the authors.
Authorship: Both authors participated fully in the preparation of the manuscript.
Identification
Copyright
© 2023 Published by Elsevier Inc.
