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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: oifungwong@yahoo.com.hk
                                                                 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
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