Commotio cordis is a condition whereby sudden death in the absence of cardiac damage occurs due to sudden blunt impact to the chest. To be more specific, the impact typically occurs in the low to mid left chest area.
This condition is most well-known to occur in athletes. Although many initially think of baseball, it has been found to occur in other sports also – hockey, lacrosse and even martial arts (sharp hand/fist, elbow or heel strikes to the chest). In fact, some of the earliest documentation of this phenomenon was found in texts written by Chinese martial artists describing carefully placed blows to the chest that were fatal and referred to as “strike of death” or “touch of death.”
As a result of the most recent event that shocked the pro-sports world and made “Commotio cordis” a familiar phrase, greater awareness of this injury was brought to the forefront with a 1995 article published in the New England Journal of Medicine. In that article, the most affected population was described as generally younger individuals with the mean age being around 15 years old.
Commotio cordis occurs when there is a strike to the left chest wall directly over the left ventricle of the heart causing ventricular fibrillation. The electrical impulses generated in the atria travel down through the atrioventricular septum, then split in the lower apex below the ventricles and travel up each side of the outer cardiac wall. In normal human anatomy, the positioning of the heart in the chest cavity exposes a portion of the cardiac wall around the left and right ventricles. When the strike occurs, the cardiac wall is distorted, causing a disruption in the electrical pathway and impulse.
Although there are documented cases of this occurring, the actual incidence is very small in relation to the overall number of chest wall strikes reported. Through multiple studies where this phenomenon was induced, it two things were found present: (1) the initial strike has to occur at a specific area of the chest wall; and (2) the strike has to occur at precisely the “right” moment in the heart’s electrical cycle, specifically the upslope of the T wave. Other factors also contribute to this, such as the velocity, shape, and hardness of the striking object; pliability of the ribs (typically in younger teens and children).
The strike at precisely the right moment in the electrical conduction results in a pathway disruption causing non-sustained polymorphic ventricular tachycardia which then converts to ventricular fibrillation. Initial treatment is immediate defibrillation and monitoring.
While chest wall strikes resulting in commotio cordis is not common, chest wall strikes can result in other injuries such as cardiac contusion (contusion cordis), fractured ribs and heart block.
There is no specific ICD-10-CM code for commotio cordis. Therefore, at a minimum the condition would be reflected using the induced arrhythmia (typically ventricular fibrillation) along with an external cause code for the mechanism of injury such as W21.- and activity (Y93.-). This is in concordance with the chapter specific notes that these codes can be used with codes from any chapter to better define the external cause. Additionally, other chest wall/thoracic injuries resulting from the blow would also be coded (e.g., contusion, fracture).
Robyn McCoart, Managing Auditor