Commotio cordis: a case of ventricular fibrillation caused by a cricket ball strike to the chest

A healthy 25-year-old man was attending cricket practice in March, 2012, when he was struck over the praecordium by a cricket ball while batting right-handed without a chest protector. He collapsed within 30 s of impact and was found unconscious by coaching staff trained in first aid.

Cardiopulmonary resuscitation (CPR) was started and emergency services were called. Paramedics attended the scene 9 min after the injury. They found the patient to be in ventricular fibrillation (appendix) and immediately delivered a 200 J biphasic shock, resulting in return of spontaneous circulation and sinus rhythm.

The patient regained consciousness and was taken to hospital. An ecchymosis was visible over the region of the apex beat (figure). Serum electrolytes, 12-lead electrocardiogram (ECG), echocardiogram, maximal exercise stress test, and cardiac MRI were normal. The patient made a full recovery and returned to work as an engineer 2 weeks later. He remained well on follow-up in January, 2014, and continues to play cricket with the use of a chest protector.

Ecchymosis at site of cricket ball impact, over the region of the apex beat was noted.

The condition of commotio cordis, in which sudden cardiac death or successfully resuscitated ventricular fibrillation occur after a blow to the chest, is well described.

Most cases arise in young athletes playing sports with small, hard projectiles such as ice hockey or lacrosse, although cases have been described in baseball, hockey, softball, and karate. Suspected cases have been seen in cricket, although the initial cardiac rhythm was generally asystole.
Cricket is known as a gentleman’s game and is rarely associated with serious injury; however, death while playing cricket has been reported, with the first known case being Frederick, Prince of Wales, who died in 1751 after being hit in the chest by a cricket ball.

Our patient was struck on the praecordium by a cricket ball delivered at a speed of 80—100 km/h during cricket practice, and had a cardiac arrest with ventricular fibrillation which was successfully defibrillated.
Previously reported survival rates of 25% have improved recently as a result of prompt initiation of CPR and defibrillation.

This case highlights the importance of bystander CPR and early access to external defibrillation. Induction of commotio cordis in anaesthetised pigs provides insight into the electrophysiological consequences of praecordial trauma. Investigators were able to initiate ventricular fibrillation only under precise conditions, in which the projectile impact occurred within the vulnerable phase of cardiac repolarisation, 15—30 ms before the T-wave peak

This phase represents only 1% of the cardiac cycle, thus explaining the rarity of commotio cordis.

Our patient’s age and body habitus (body-mass index 21 kg/m2) are consistent with reports that commotio cordis occurs more commonly in patients with a thin and compliant chest wall,1 which allows greater transmission of energy to the heart after impact. The speed of projectile impact is also important, with the highest rates of ventricular fibrillation induction shown at 64 km/h, and lesser rates at lower and higher speeds.

Although cricket is generally a safe pursuit, injuries and death can happen.
In this case a successful outcome was achieved because of early basic life support and defibrillation. Continuing efforts to train coaching staff and players in first aid and ensure timely access to defibrillation should reduce the mortality associated with this condition.

Dr G Mohan.