pediatric housecalls Robert R. Jarrett M.D. M.B.A. FAAP

Cardiac Arrest: Commotio Cordis – Treatment and Prevention

Ok, it’s been over a week and your 17-year-old Commotio Cordis patient who suffered a cardiac arrest on the baseball field is back for his follow-up and an answer to his question: “When can I go back to playing baseball?”

You knew he was coming and you’ve had a week to prepare what to tell him… so, go ahead, I’d like to hear this too…

14-year-old Commotio Cordis survivor and basket of ‘get well’ baseballs.[Awkward silence]… Hmm, I so much was hoping to pick up some new pointers from you because this is one of the tough ones.

Ok, I’ll help out. I usually begin with an ‘ice breaker’ of sorts.

Commotio Cordis: Childhood Cardiac Arrest
Not Always Fatal With Prompt Treatment

Good so see you again Astin, are you tired of being called the ‘miracle boy’ yet? (Referring to the local newspaper article) They made it sound like you’re the only boy athlete ever who had a heart attack; but, you’re not you know. [(aside) I need to check you over again so while you’re getting undressed I’ll tell you about the very first boy athlete ever recorded with a cardiac arrest.]

This may come as bit of a surprise to you but way back before they invented cell phones people still needed to communicate with each other. It was really tough to fight battles without radios so army commanders would have a whole collection of young long-distance runner boys to carry messages back and forth.

A very old manuscript recorded that one of those boys, Pheidippides, was assigned to run back to Athens (Greece) from the battle-front and report to the king that his army had just defeated the Persians.

We don’t know how long the distance was but it was probably pretty long. After he caught his breath he reported the message and then fell dead – it was 490 BC after all, before we had invented defibrillators.

The point of this follow-up physical exam isn’t supposed to be just a grin, slap on the back and sign the forms. It should be a good one, this boy just about died we need to show some respect. Some conditions and side-effects of heart failure take a while to show themselves; so, things could have changed with his body since the hospital… possibly a lot.

Astin’s body and strength and coordination all look good but he doesn’t seem as animated to you as he was even back when he was hospitalized – sort of ‘down.’

You begin calling out all the good things you’re noticing about his exam thinking perhaps it’s fear showing up on his face. Heart sounds, rate and rhythm are great; pulses in neck, arms and legs are strong and correlate well with the heart beat; you hear no ‘murmer-like’ sounds over the vessels in his neck, chest, abdomen or groin.

Your body doesn’t look like it even remembers having a heart problem, Astin, but your face looks like you can’t get a date for the dance. You worried about something?

His dad interjected that they had been researching the internet and now ‘they’ weren’t sure they even wanted to play baseball any more. Everything they see is about sudden cardiac arrest and that almost no child ever lives and nothing can be done about it and some even say CPR is futile and doesn’t work.

Wow! That’s a big burden. No wonder you’re not appreciating my jokes. [(aside) Astin, I need to check your heart after you’ve exercised a bit so why don’t you start doing some jumping jacks while I explain about the internet. If you get light-headed or feel funny let me know.]

Oh crap! Another internet problem. Look, the internet is a great thing, it’s revolutionized our lives, we now wouldn’t know what to do without it; BUT… IT’S FULL OF CRAP! I can even say with confidence “MOSTLY full of crap!” It’s been taken over by the un-informed and the deceitful wanting to make a buck; and those trying to ‘social engineer’ you into doing what they want.

I use the internet. But, I never, ever give full credence to what I find there. It does inform people about things they never would have known; and, it has been a great blessing for social change – yes, even basically good guys aren’t above using it to ‘manipulate’ legislation and funding for pet projects.

Such is the case with the Google topic: “sudden cardiac arrest in athletes or children.” That’s the rub. A lot of things can cause “sudden cardiac arrest (SCA)” or “sudden cardiac death (SCD)” in athletes. Commotio Cordis is only one of the things – but it’s a lot more associated with the SCA end of things than any of the other causes.

My guess is that you were ‘Google-ing’ for something like ‘cardiac arrest’ instead of ‘Commotio Cordis’ weren’t you? But even if you weren’t, Google thinks it knows more about what you ‘really’ want than you do yourself and will throw in all that other junk anyway.

First thing I want you to learn is to ‘never trust what you read on the internet’ (except my blog of course) [(aside) and you go on to explain the things about the internet I’ve mentioned above]. Second, ‘cardiac arrest’ in child athletes is so rare we can’t even get enough of them to do good studies – there are only about 60 a year counting every US school clear down to elementary and even those had to be hunted out of newspaper reports!

And third, even though your heart did technically ‘stop,’ like in a ‘heart attack,’ it doesn’t seem to be because there was a problem with IT. It was more like it was a problem with the elbow that hit you in the chest!

[(aside) Son, you look a bit flushed. Stop jumping a minute and let me listen… take a big breath and hold it… good, breathe… hold again… good. Just sit here for a minute and let’s see how long it takes for your heartrate to go back to normal.]

You see, when Google throws in all the stuff about SCD, it’s about major athletes (obviously who died) and not about kids – who aren’t famous enough to make the national news. It gives you marathoner Jim Fix (1984), Olympian Flo Hyman (1986), basketball stars Pete Maravich (1988) Hank Gathers (1990), and Reggie Lewis (1993) and figure skater Sergei Grinkov (1995); all who died of cardiac causes. Totally not what you were looking for.

What you really have to dig to find out (besides the obvious thing that none of these were kids) is that Fix was 52 and died from an infarct; Hyman 31 from aortic dissection due to Marfan’s syndrome; Maravich, 40 and congenitally absent left coronary artery; Gathers, 23, hypertrophic cardiomyopathy (HTCM), arrhythmias and stopping his meds; Lewis, 27 and either cocaine use, HTCM or an adenovirus; and, Grinkov (28, a newly identified cardiac gene disorder). But still not what you were looking for.

Statistics are terrible for SCD in athletes (not just children) but the internet gives it between 1 in 735,000 for US Air Force Recruits; 1 in 200,000 for Minnesota high schools; and, 1 per 280,000 in Rhode Island under-30-year-olds. Nearly all statistics can tell you how many died but nothing about “out of how many” or “of what diagnosis” the things you need to know to make sense of the data. Again, only marginally relevant.

Between 2000 and 2006 Seattle researchers found 486 cases of SCA in school-aged children elementary to college; only one in 10 of them lived. It’s harder to resuscitate a child in SCA than an adult – less of them survive. True, but still not specific to Commotio Cordis.

Of the 69 cases each year, the overall survival rate of 11% actually ranged from 4% to 21% with better survival in the more recent years. We think it might be from increased automated external defibrillator (AED) use, but we’re not sure yet.

Ok, buddy, your heart seems to be working very well and I don’t find anything serious wrong with it; but, you are a little out of shape – well, who wouldn’t be with 3 days lying in bed being pampered by nurses who all had a crush on you and 2 weeks moping around the house. [(Aside) You give them a summary of the overall SCA statistics while you are checking Astin’s pulses]

The only thing I hear in your heart is a very soft murmur that I didn’t hear back in the noisy hospital. It sounds like what we call an “innocent childhood murmur” which usually “goes away” in adulthood; but I’d like to listen to it one more time when you’re back in shape.

Look, let’s do this. This has been a tough couple of weeks for you and you need to “UN-learn” some inaccurate things and worries you’ve seen on the internet. Truly, there is no pressure for you to play baseball if you don’t enjoy it. I can tell you: you will NOT wither up and fade away or be crushed psychologically if you can’t do one fun thing that you love doing.

Think of this: you don’t really know yet what things you are best at, or even what you like the most; because… you haven’t tried them all yet! How about scuba diving off a reef, or sky-diving or climbing Mount Denali? All of them might be safer than playing pro football and less risk of being hit in the chest with an elbow or puck.

For the next 2 weeks, here is your homework. Use the internet and a library with ‘real’ books to look up “Commotio Cordis” – don’t worry about any other topic. Write down some stuff and we’ll talk about it when I get to see you again. In fact don’t worry about anything, you’re doing great and were going to fix this so you will be happy.

Until then your heart and body seem like they’re ready to get outside into some air. No active school gym or sports yet but each day, after school, when your dad gets home from work, you two go for an hour walk and talk. You must stay by him, so he’s got somebody to call 911 in case he passes out, and when either of you get too winded to talk comfortably, you slow down or rest. And it must be for a full hour together even if the most he can do is stroll.

I’m counting that he’ll slow you down a bit at first but you can gradually speed up and even jog for distances by the time you see me next. If he hasn’t sped up by a week you can zig-zag faster in front or around him as long as you stay in talking distance. In two weeks you should both be in better shape, and I’m guessing happier.

Well, that wasn’t hard was it? Kind of enjoyable if I tell the truth and I’m already looking forward to seeing him get back in shape and finding out what he decides. It also gives us more time to look up if there is anything new on the subject since the last time we read about it.

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4 Posts in This Series