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Spring 2021: Emergency Action Planning for Commotio Cordis

Commotio cordis is a disruption of heart rhythm that occurs as a result of a blow to the area directly over the heart. This occurs at a critical time during the cycle of a heart beat which produces an R-on-T phenomenon that leads to the onset of commotio cordis. Commotio Cordis is an uncommon, but often lethal, condition almost exclusively seen in athletics. Commotio Cordis occurs more frequently in males than females; and baseball seems to be the highest risk sport, but it has also been observed in other sports like hockey, lacrosse, and martial arts.

According to the American Heart Association, resuscitation efforts are successful in only 35% of cases, but this is similar to other types of cardiac events (1). Immediate initiation of CPR and defibrillation is vital in resuscitation efforts (2). In this issue, we discuss some very simple, but effective, educational tips for improving commotio cordis outcomes.

As is the case in all emergency response scenarios, accounting for the fundamental elements of an emergency action plan prior to an incident is vital to improving outcomes. Best practice emergency action plans provide education for all medical staff, coaches, and other event staff. The location and use of AEDs* as well as activation of EMS are of particular importance.

*AEDs should be within a 3 minute walking distance from any high risk venue.

Educating parents, coaches, and athletes about the causes of commotio cordis is vital.(3) The signs and symptoms of commotio cordis may seem obvious, but if you don’t witness the injury or you’re unaware of how commotio cordis presents, it can easily go unrecognized, resulting in a lethal delay in defibrillation. Here are some important characteristics of Commotio Cordis to keep in mind, and use to educate others:

  • Commotio cordis results from a direct blow to the chest during a vulnerable point in the heart’s rhythm. The blow can be caused by an object like a baseball or hockey puck, or by a blow from an elbow or fist;

  • There will be no signs of trauma;

  • The athlete may stumble forward for a few steps before collapsing and becoming unresponsive (2);

  • The need for immediate defibrillation may be overlooked because the athlete may appear to be breathing, but this is referred to as agonal breathing, a common presentation during cardiac arrest. Assume any collapsed athlete is in cardiac arrest until a carotid pulse is confirmed.

Eliminating the risk of commotio cordis entirely may not be possible, but there are measures that can be taken in order to reduce the risk. Using age appropriate equipment in sports like T-ball can help reduce the risk in youth sports. Wearing properly fitted protective equipment can protect players in certain positions, like catchers or lacrosse goalies. (2, 1) Making sure that coaches, parents, officials, and athletes are aware of the proper type and fit of protective equipment is an important role for the athletic trainer (3). Coaches can be a great asset in ensuring that protective equipment is maintained and properly fitted throughout the season. Chest protectors are the most common piece of equipment used in high risk sports. In an effort to better protect athletes, NOCSAE has provided performance standards for chest protection in lacrosse and baseball since 2018 (4).

In conclusion, a best practice emergency action plan is essential in appropriate management of commotio cordis. An emergency action plan that includes education regarding recognition and prevention strategies will have the greatest impact on outcomes related to commotio cordis.

  1. Link, M., Mark S. Link From the Cardiac Arrhythmia Service, & Link, C. (2012, April 01). Commotio Cordis. Retrieved January 27, 2021, from

  2. Belval, L. (2015, March 04). Commotio Cordis. Retrieved January 27, 2021, from

  3. NATA Official Statement on Commotio Cordis [PDF]. (2007, October). Carrollton: National Athletic Trainers’ Association.

  4. NOCSAE Chest Protector Standard for Commotio Cordis [PDF]. (2018, June). National Operating Committee on Standards for Athletic Equipment.

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