Hey - another ER doc here and as usual, coming in after Fisk:
A blow to the chest can cause sudden, cardiac death. It’s called commotio cordis. Essentially, the trauma causes a brief electrical spike. If it happens during a particular point of the cardiac cycle, it can stop the heart immediately. It is much much more common in young children due to the increased compliance of the chest wall. Most cases that I’ve ever heard of occur with a strike to the sternum, usually a punch or a ball – like in baseball or lacrosse.
It’s extremely rare. Only about 10 to 20 cases a year are reported. I don’t think I’ve ever heard of a case in anyone over the age of 20 years of age. Every case I’ve heard of, or attended to, involved baseball. I would think shoulder pads would prevent the anterior chest from this type of injury. Modern pads cover the upper/mid sternum and anterior chest. Resuscitation was historically dismal, but that has improved with better recognition. There is some speculation that certain individuals are more predisposed given a possible underlying dysrhythmia. The variables that are necessary for this to occur include the shape of the projectile, the velocity and timing of the incident. Without going into the specifics of the cardiac electrical cycle and repolarization, the most common underlying dysrhythmias include long QT syndrome, and a condition called Brugada syndrome.
A blow to the chest does transmit electrical activity through the chest wall into the heart. If this occurs, it creates an electrical spike which (if timed to occur exactly) can cause a "R on T phenomena". The waves of the EKG are labelled PQRST (U). This causes ventricular fibrillation which must be immediately electrically corrected (defibrillation) or else the heart will stop. Whenever I’m at the bedside and a patient’s heart stops (rare, but it happens enough) the quickest way I have to get it restarted is a thump, essentially a punch into the chest of the patient. It is thought that a normal punch to the chest confers approximately 2-5 J of energy. A punch, hit, ball, etc is more like 20-40J. Enough to stop the heart if it happens at the precise wrong time. To be clear, this is an enormously rare event. Just an awful situation. Defibrillation will almost surely save him if that's the issue. I'm sure the med staff on the field know this stuff cold and the defibrillators are all right there.
Edit: Docsplaining, clarity
Excellent recap.
Just as a point of reference, the amount of joules used to “shock” a heart in fibrillation/arrest is 200-360J, so it’s actually (scarily) not a huge fraction to cause the rare arrhythmia (if commotio cordus is in fact the diagnosis, which I personally think is probably most likely - other causes of arrest after blunt chest trauma typically (a) require way more force (ie, aortic disruption) or (b) take a bit more time to cause arrest (tamponade, tension pneumothorax etc).
Aren't there meds or combinations of meds that in crease the interval, and increase the risk of this?
for long QTc syndrome (see below), yes. But not necessarily commotio cordis.
Is what was described before essentially a coma? Pulse, not breathing on own.
eh - “not breathing on your own” is always hard to get a read on, because as soon as one is intubated, they are sedated (and occasionally paralyzed, usually as part of the intubation but sometimes after) and “not breathing on their own”. Intubating patients used to be the first thing we did for arrest patients, but subsequently (and appropriately) it has become secondary to good chest compressions and defibrillation (if indicated). Intubation then becomes secondary and gets done either after return of spontaneous circulation (heart starts beating again) or, if tons of appropriately trained medical providers around, when it is convenient or during a lull in the action.
My guess is they suspend and resume tomorrow.
Upthread someone linked to a good story about the Muamba situation, that was also a long time in the ambulance. Basically one of the things is that you can do a lot of stuff in the ambulance, and don't want to be moving while you do it. Once you've done all the same things you'd be doing either way, you drive to the best hospital for the job.
Not sure what local EMS protocols are (and I am sure given the age/profile they would transport), but some EMS protocols (ie, NH) mandate staying on scene until ROSC (heart beats again). It’s really hard to do effective chest compressions (which are secondary in importance in terms of outcomes only to appropriate defibrillation) in the back of an ambulance, so I get the delay.
I’m not a doctor, and I didn’t stay at holiday inn express last night, but generally with a serious trauma the EMTs are in radio communication with the hospital regarding what to do. And at an NFL game, there’s already doctors there. So even if the prognosis was very bad, I doubt they would say, eh we’re just gonna call it here and not hurry. It’s more likely a decision was made with and by doctors that he could receive better care stationary in the ambulance than hauling ass to the hospital.
see above. EMS crews do use online (and offline) medical control, but they are well trained and likely would not need to use in this case, unless there was something really wonky where they needed to go outside of usual protocols.
There is speculation - but not objective evidence (the n of commotio is so, so low) that long QT syndrome and Brugada MAY be correlated with a higher incidence. Impossible to validate but it makes some physiologic sense.
I agree with the physiologic sense. Both of these have the longer appearing t wave upstroke on the EKGs, which seems like it would increase the (tiny) risk, marginally. Both of these conditions are associated with sudden cardiac death in young people (including athletes), but via different mechanisms that don’t require blunt chest trauma .
I'm not sure how rigorous the medical screening process is, but hopefully those would be seen on an EKG? I agree commotio cordis seems mostly likely, but the fact that they intubated even after ROSC makes me nervous
See above re: long QT and brugada. These will show up (to an extent HOCM, which is why Hank Gathers arrested) on an EKG, but commotio cordis can happen in people with normal EKGs, based purely on bad luck of timing and force and location of chest trauma.
As a possible (apocryphal) aside. My dad (also a doc) said that he was responsible for screening for Bruins players back in the day, and he said that Ray Borque had an abnormal EKG (left bundle branch block) which he should have not cleared, but he did. Again, no idea on the veracity of that claim, but I leave my dad his stories as he gets older.
For the doctors: I am guessing they need to verify cardiac function, and then they have to assess the impact of reduced oxygen to the brain for the period of time it was impacted right? That takes some time, I would guess, not being a doctor. Just to say, delay in an update is not surprising here.
Basically, yes. 9 minutes of CPR (“down time”, low flow to the brain), really isn’t that long though, and he had early effective CPR and early defibrillation. That really doesn’t seem bad to me. It can be hard to assess after when some one is I think aged and got a bunch of medications. I think the thing I would most want to know would be whether he had further arrhythmias or not, or if it was 10 minutes and done. I guess also whether there were any other blunt chest injuries.
