Preventing Commotio Cordis in Youth Baseball
Athletes of all skill levels often assume many risks of injury to themselves when they participate in their particular sports. Most injuries such as cuts, bruises, tears, sprains, strains, broken bones, and concussions while unfortunate have become common and are no longer as shocking as they used to be. This is not true however for Commotio Cordis which “is a rare, but deadly concussion of the heart” (Kim, 2010, p. 1). Commotio Cordis has been found to be most prevalent in youth baseball and much is being done to help prevent it.
Commotio Cordis Causes
As illustrated below in Figure 1; Commotio Cordis can be initiated by not only a baseball, but by other small hard projectiles such as a hockey puck, lacrosse ball, and even a fist or elbow.
(Pathophysiology of Commotio Cordis, 2010)
Figure 1 also demonstrates how the impact of the projectile must happen during a 20 millisecond window during the upstroke of a T-Wave in order for Commotio Cordis to occur. In addition to high velocity projectiles; the anatomy of young children plays a key role in causing the event to happen. Compared to adults; most young children have thinner, less developed rib cages and lack the protective musculature in the chest necessary to prevent injury (Maron, & Estes, 2010).
Since the occurrence of Commotio Cordis cannot be completely stopped many precautionary measures are being taken to ensure the safety of young athletes. Perhaps one of the most important steps of prevention against Commotio Cordis is educating the general public. Commotio Cordis is such a rare event that it is relatively unknown to most of the general public which can negatively affect rescue response time. Informing the public on how to recognize Commotio Cordis as well as how to care for the victim will increase the chance of survival by increasing rescue response time. The public should also be made aware that Commotio Cordis in youth (or adults) is not confined to the sports field and that even an unintentional, modest-seeming blow to the chest delivered without malice (e.g., in playful boxing) can trigger life-threatening ventricular tachyarrhythmias (Maron, 2010).
Young athletes should also be educated on how to protect themselves from being a victim of Commotio Cordis. Instructing young baseball players in personal safety and placing a priority on avoiding direct blows to the chest through the use of coaching techniques that emphasize a player to turn away from the ball in order to avoid errant pitches can also help to decrease the threat of Commotio Cordis (Maron, 2010).
In addition to public education; the modification of sport equipment has become another area of focus in Commotio Cordis prevention. Development of baseballs which are softer than standard baseballs called “safety balls” have been found to decrease the risk of ventricular fibrillation and the occurrence of sudden death caused by a direct blow to the chest (Link, Maron, Wang, Pandian, VanderBrink, & Estes, 2010). This is a practical approach to injury prevention because baseball chest impact is the most common cause of Commotio Cordis (Link, 2002) and players are more vulnerable in baseball than they are in sports that require more padding such as football.
Safety balls are primarily made up of rubber and lack the dense, hard core of cork and twine that is found in most standard baseballs (Maron, 2010). These safety balls are primarily intended for young athletes who are thirteen years old or younger. Unfortunately, even though scientific testing by researchers has given validity to the use of safety balls over standard baseballs through finding compelling evidence that showed decreased rates of Commotio Cordis with their use; (Classie, Distel, & Borchers, 2010) there is still opposition to their full implementation in the sport. Parents of athletes, coaches, and sports administrators have objected to the use of safety balls due to the unpredictable nature of the balls when they bounce in addition to the lack of velocity that is able to be produced from striking the ball with a bat (Link, 2002).
Another method of prevention regarding equipment being used is the inclusion of chest protectors and vest that are designed to absorb the impact of a projectile such as a baseball. Unfortunately further research on chest protectors has concluded that they alone do not offer the player enough protection from arrhythmia after a blow to the chest (Maron, 2010).
AED Machines & CPR
Education and the implementation of safer equipment can both help to reduce Commotio Cordis from occurring, but should the event still happen only cardiopulmonary resuscitation (CPR) and the use of an automated external defibrillator (AED) can save a life. Research has shown that the use of AEDs have been able to effectively terminate ventricular fibrillation caused by Commotio Cordis after a direct blow to the chest (Maron, 2010). In order to do this however the AED machine must be readily available at the sporting event due to the small window of opportunity to save the life of a Commotio Cordis victim. The window of opportunity is so small that “for every minute that passes without CPR and defibrillation, the chances of survival decrease by 7-10%” (“Facts every second counts,” 2009, p. 1).
Parents, coaches, officiating staff and any other personnel involved in youth baseball games should be knowledgeable and preferably certified in CPR and the use of AEDs. AEDs should always be present during practices and baseball games and visiting teams should familiarize themselves with the AED at the home team’s field since they could potentially have a machine that they are unfamiliar with. Although the use of AEDs can increase the rate of survival should Commotio Cordis occur there is still a chance that even if immediate care is given, an AED can still fail to restore the heart to normal rhythm after Commotio Cordis has occurred (Maron, 2010).
At the moment the top three most effective methods for combating Commotio Cordis include educating everyone involved in youth baseball events in order to increase early recognition, starting CPR or if readily available using an AED after early recognition, and finally implementing the use of safety balls. Unfortunately the use of chest protectors has been found to only offer a false sense of security and should not be not be thought of as a final solution.
While chest protectors are currently not a viable method of protection; on-going research is looking to improve upon this method of protection by studying how the exact site of impact plays a role in Commotio Cordis. One such study conducted by the American College of Cardiology used young pigs to determine if impacts that occurred “directly over the cardiac silhouette is necessary to produce ventricular fibrillation” (Link & Maron, 2001, p. 649). The young pigs were struck with safety balls of varying hardness at 40mph in different parts of the cardiac silhouette. After many trials the study concluded that “the precise location of chest wall impact is a critical determinant of Commotio Cordis” (Link, 2001, p. 654). While it may seem cruel to experiment on young pigs and induce ventricular fibrillation; this research will help in the development of better chest protectors in the hopes of saving more human lives.
In youth baseball Commotio Cordis is a shocking event that carries with it heartbreaking consequences. Fortunately through continued scientific research we will learn more about this injury and how we can better prepare ourselves for it. The continued research being done will help to improve upon old protection methods as well as develop new methods. While it may seem cruel to experiment on young pigs and induce ventricular fibrillation; this research will help in the development of better chest protectors in the hopes of saving more human lives and other studies like it will do the same.
Classie, J., Distel, L., & Borchers, J. (2010). Safety baseballs and chest protectors: A systematic review on the prevention of commotio cordis. The Physician And Sportsmedicine, 38(1), 83-90.
Facts every second counts. (2009). Rural and Community Access to Emergency Devices, http://www.americanheart.org/downloadable/heart/1267543040777TD%20edited%20FINAL%20Every%20Second%20Counts%20-%20AED%20fact%20sheet.pdf.
Kim, J. (2010). Commotio Cordis in the Athlete. Population-Specific Concerns, 15(4), 27-29.
Link, M., Maron, B., VanderBrink, B., Takeuchi, M., & Pandian, N., Wang, P., & Estes, N. (2001). Impact directly over the cardiac silhouette is necessary to produce ventricular fibrillation in an experimental model of commotio cordis. Journal of the American College of Cardiology, 37(2), 649-654.
Link, M., Maron, B., Wang, P., Pandian, N., VanderBrink, B., & Estes, N. (2002). Reduced risk of sudden death from chest wall blows (commotio cordis) with safety baseballs. Pediatrics, 109(5), 873-877.
Maron, B., & Estes, N. (2010). Commotio cordis. The New England Journal Of Medicine, 362(10), 917-927.
Pathophysiology of commotio cordis. (2010). Retrieved November 13, 2010, from: http://libproxy.cortland.edu:2078/img/embimages/rdk/NEJ/11MAR10/13F2.jpg?ephost1=dGJyMMvl7ESepq84zOX0OLCmr0iepq5Srqa4SK6WxWXS