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Hong Kong Journal of Emergency Medicine Cardiac arrest after blunt chest injury in a patient with undiagnosed idiopathic ventricular fibrillation OF Wong , SK Lam , YH Chan , PHK Tsang , LK Ng , CK Koo We report a case of cardiac arrest occurring in a patient after blunt chest injury with fist during an assault event. The patient survived with prompt cardiopulmonary resuscitation and defibrillation. Subsequent electrophysiology study revealed inducible ventricular fibrillation and automatic implantable cardioverter defibrillator was implanted. The cardiac complications from blunt chest trauma are discussed. (Hong Kong j.emerg.med. 2011;18:101-106) Keywords: Commotio cordis, heart arrest, sudden cardiac death, thoracic injury, ventricular fibrillation Introduction and other arrhythmogenic conditions (e.g. long QT syndrome and Brugada syndrome). 1,2 Most of Sudden cardiac deaths in young healthy adults were t h e s u d d e n c a rd i a c d e a t h i n c i d e n t s a m o n g commonly caused by structural heart diseases (e.g. Chinese population were reported to be associated hypertrophic cardiomyopathy), conduction-system with underlying coronar y ar ter y disease and abnormalities (e.g. Wolff-Parkinson-White syndrome) cardiomyopathy. 3 However, sudden death could also occur in individuals with no underlying cardiac problem after chest blows in the condition called Correspondence to: Wong Oi Fung, MRCSEd, FHKCEM, FHKAM(Emergency Medicine) commotio cordis (in Latin for agitation of the heart). Tuen Mun Hospital, Department of Anaesthesia and Intensive Traumatic cardiopulmonary arrests due to blunt injury Care, Tsing Chun Koon Road, Tuen Mun, N.T., Hong Kong are often associated with severe and catastrophic vital Email: firstname.lastname@example.org organ injury and it is recommended to withhold or Tsang Ho Kai, Patrick, MRCP, FHKCP, FHKAM(Medicine) terminate resuscitation efforts based on the out-of- Ng Lap Kwan, MBBS hospital primary assessment if apnoea, pulselessness and Koo Chi Kwan, FHKCA(IC), FJFICM, FHKAM(Anaesthesiology) absence of organised electrocardiogram (ECG) activity Tuen Mun Hospital, Department of Accident and Emergency are found at scene.4 Commotio cordis is an exceptional Medicine, Tsing Chun Koon Road, Tuen Mun, N.T., Hong Kong condition of traumatic cardiac arrest and the victim Lam Shing Kit, MBBS, MRCSEd with commotio cordis could be salvaged by prompt resuscitation and defibrillation. We report a patient Tuen Mun Hospital, Department of Medicine, Tsing Chun Koon Road, Tuen Mun, N.T., Hong Kong with cardiac arrest and ventricular fibrillation (VF) as Chan Yu Ho, MRCP, FHKCP, FHKAM(Medicine) the initially recorded rhythm by the automated external 102 Hong Kong j. emerg. med. Vol. 18(2) Mar 2011 defibrillator (AED) after a chest blow by other's fist. including his father and two brothers. However, he The patient had a clinical condition suggestive of had never been admitted into hospital for episode of commotio cordis but a thorough cardiac assessment syncope or documented cardiac arrhythmia. He revealed an undiagnosed idiopathic ventricular collapsed after being struck by others with fist on his fibrillation (IVF). An automatic implantable chest wall. No cardiopulmonary resuscitation (CPR) cardioverter defibrillator (AICD) was subsequently was initiated by the by-standers. The ambulance crews implanted. arrived at scene around 15 minutes after the incident to find that the patient was in cardiac arrest. Prehospital CPR was performed and an AED was applied to the Case report patient. The initial rhythm was VF and a shock was initiated. The time from collapse to activation of shock A 27-year-old man was brought to the emergency was about 20 minutes. After defibrillation, there was department in August 2010 for being found cardiac a short period of asystole followed by episodes of arrest in an assault event. He enjoyed good past health ventricular tachycardia (VT) but no further shock was but had family history of sudden cardiac death delivered (Figure 1). He returned to sinus rhythm and Figure 1. ECG recording from the AED. The AED identified the initial rhythm to be VF and advised to deliver the shock. After defibrillation, there was a short period of asystole and then repeated episodes of VT were recorded. No further shock was advised to deliver and the rhythm returned to sinus rhythm at the end of the recording. Fung et al./Blunt chest trauma 103 had restoration of spontaneous circulation around T wave in chest leads, ST depression in lateral chest 25 minutes after his collapse. On arrival to the leads (V4 to V6) and normal corrected QT interval accident and emergency depar tment, he had (Figure 2). Glasgow Coma Score (GCS) 3/15, blood pressure 87/46 mmHg, pulse rate 91 beats per minute and He was subsequently transferred to the intensive care temperature 34.6oC. He required assisted ventilation unit (ICU) for mechanical ventilatory and inotropic with bag-valve mask. support. He developed an episode of VT with unstable haemodynamic state and cardioversion was performed He was managed with standard advanced trauma life with response. Bedside echocardiogram showed no s u p p o r t . Pr i m a r y s u r v e y w i t h s i m u l t a n e o u s pericardial effusion, good left ventricular ejection resuscitation was performed and he was intubated fraction, normal right ventricle and no regional with cervical spine protection for apnoea. Physical wall abnormalities. The serum troponin I level was examination revealed only superficial abrasions over 0.016 ng/ml which was within normal ranges his left side chest and abdomen. The cervical spine (reference range <0.06 ng/ml). The creatine kinase X-ray revealed normal alignment and no fracture. The (CK) level increased to 14975 U/L (reference range chest X-ray showed no pneumothorax and normal 62-297 U/L) on day 3. The electrolytes were normal. mediastinum. Bedside ultrasonography showed absence The urine toxicology screening was negative. His of intraabdominal free fluid. Urgent computerised condition was stabilised and the conscious state tomography of brain, thorax and abdomen were all improved. He was extubated on day 3. His GCS was unremarkable. ECG showed sinus rhythm with 'tall' 14/15 (E4V4M6) on discharge from ICU. Figure 2. The ECG of patient taken upon arrival to the emergency department showing sinus rhythm. There were absence of features suggestive of arrhythmogenic cardiac diseases (e.g. prolonged QTc and Brugada patterns) and conduction system abnormalities (e.g. delta wave ). 104 Hong Kong j. emerg. med. Vol. 18(2) Mar 2011 Follow-up echocardiogram by cardiologist revealed Commotio cordis is a rare condition associated with neither structural abnormalities nor functional chest wall blows. It occurs in situations which involve impairment of his heart. Coronary angiogram was a direct, nonpenetrating, low energy impact to the chest normal. Flecainide and adrenaline infusion tests were leading to a life-threatening dysrhythmia, i.e. VF, in normal which ruled out underlying Brugada and long the absence of damage to the ribs, sternum, or heart. QT syndromes. In view of his strong family history of Most of the reported cases occurred in young athletes sudden cardiac death and the current episode of cardiac involving in various competitive sports, e.g. baseball, arrest, electrophysiology (EP) study was performed for ice hockey or lacrosse. It was also reported in other risk stratification and VF was induced. However, there circumstances including fighting. 9 There is a sudden was no demonstrable pre-excitation or accessory cardiac rhythm disturbance in commotio cordis and pathway with 1:1 conduction. An AICD was demonstrable evidence of significant mechanical or implanted. The patient was eventually discharged structural injury to the heart is typically absent. In a without neurological sequelae after a total of 25-day swine model of commotio cordis, VF occurred hospitalisation and was able to resume his previous consistently with low-energy impact to the chest wall daily activities. during a narrow window of cardiac cycle (30 to 15 milliseconds before the peak of the T wave). 10 In addition, VF occurred most frequently with blows Discussion directly over the centre of the cardiac silhouette. 11 Experimental model in swine showed that Blunt chest trauma induces cardiac injury by several pathophysiologic mechanism of commotio cordis mechanisms including direct energy transfer during the involved the activation of inactive potassium channel impact on the thorax, rapid deceleration of the heart by the precordial impact during the at-risk phases of and compression of the heart between the sternum and cardiac cycle, i.e. period of repolarisation.12 The critical the spine. 5 Although the incidence of clinically determinants for the triggering of commotio cordis are significant complications from cardiac contusion is the location and the timing of the blow. The initiation low, 6 severe complications, including malignant of cardiac arrhythmia involves the activation of arrhythmias and structural injuries of the heart, such ion channels which, to some extent, has common as valvular injuries, ventricular and atrial septal defects, mechanisms to certain primary arrhythmogenic coronary arteries lesions and pericardial injury with conditions associated with ion channelopathies. haemopericardium, could be resulted from high energy However, it is unknown whether the susceptibility to impact.5 Severe cardiac contusion could also result in commotio cordis varies in patient with arrhythmogenic significant impairment of cardiac function and even heart diseases. 9 Furthermore, commotio cordis is in cardiogenic shock.7 Electrocardiographic abnormalities general referred to a condition in the absence of are common presenting features of cardiac contusion underlying cardiovascular abnormalities.13 There is no and the frequent abnormalities reported include sinus evidence that patients who survive from commotio tachycardia, extrasystoles, right bundle branch block cordis are at increased risk of subsequent arrhythmia and changes in ST segment and T waves.5,8 The absence and thus, prophylactic implantation of AICD is of global impairment of cardiac contractility and generally not indicated.9 the subsequent normal ECG finding precluded a significant cardiac contusion in our patient. The In contrast, IVF, a condition with cardiac arrest due elevated CK level could be related to the defibrillation to spontaneous VF in the absence of structural heart and cardioversion. Moreover, the normal radiological problems and other identifiable causes, carries risk of results also ruled out other fatal intra-thoracic injuries, recurrence.14 Although the EP finding could be non- e.g. tension pneumothorax, massive haemothorax and specific, our patients had AICD implanted because he traumatic aortic disruption, contributing to his cardiac was a survivor of aborted cardiac arrest with inducible arrest. VF during EP study and had a strong family history Fung et al./Blunt chest trauma 105 of sudden cardiac death. A history of sudden cardiac cardiac arrest in our patient after the assault could not death in first degree relatives without apparent be confirmed as commotio cordis, the event had led a structural heart disease is associated with an elevated detailed cardiac assessment for the implementation of risk for primary sudden cardiac arrest. The reported AICD for his underlying cardiac disease. adjusted relative risk ranged from 1.57 to 1.8. 15,16 It was also not sure whether the event was primarily contributed by the blunt chest trauma independent to References his underlying cardiac problem, or the arrhythmia occurred independently to the trauma. 1. Liberthson RR. Sudden death from cardiac causes in children and young adults. N Engl J Med 1996;334 (16):1039-44. The prognosis of out-of-hospital cardiac arrest depends 2. Westrol MS, Kapitanyan R, Marques-Baptista A, Merlin on the length of collapse time, immediate availability MA. 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