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cardio.post-arrest.commotio-cordis.v1

Post-cardiac-arrest care — commotio cordis (R-on-T blunt chest impact)

cardiologyacuteadultpediatricacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.post-arrest.core.v1 — narrowed to commotio cordis cohort. Blunt non-penetrating chest impact during R-wave vulnerable period (5–30 ms before T-wave peak) → R-on-T → VF (most common) or asystole; structurally normal heart. Demographics: young athletes (mean age 15 yr), male predominance >95%, baseball / lacrosse / hockey / karate. Survival dominated by AED time-to-shock (within 3 min → 50%+ survival per Maron 2009 PMID 19741059). Post-ROSC dominated by structural disease exclusion (HCM, ARVC, anomalous coronary) + channelopathy screen (LQTS, Brugada, CPVT) + sports-return decision + chest-trauma supportive care. Long-term: ICD GENERALLY NOT INDICATED per AHA 2016 commotio cordis statement (PMID 27045128) — secondary prevention via NOCSAE ND200 chest protector (lacrosse) + venue AED programs + family CPR/AED training. Inherits manifest + design-brief pointer from parent. 5 setting playbooks (ed, icu, inpatient, transition, outpatient). 4 severity triggers: failed AED defibrillation, mechanical chest complication, ICD-eligibility evaluation post-unmasked substrate, sports-return clearance pending. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute Phase E wave 14.

Entry points (3)

  • symptom
    ROSC after commotio cordis cardiac arrest — young athlete with witnessed blunt precordial impact then immediate collapse
    rosc_after_commotio_cordis_arrest
  • history
    Witnessed precordial blunt impact (baseball, lacrosse, hockey puck, karate strike) immediately followed by collapse — classic commotio cordis trigger (Maron & Estes 2010 PMID 20335586)
    witnessed_chest_impact_during_sports_then_collapse
  • history
    Young athlete (typical age 8–25) with witnessed sports-related sudden arrest with no known underlying cardiac disease — commotio cordis high on differential
    young_athlete_sudden_arrest_no_underlying_disease_known

Required inputs (22)

  • agerequired
    demographic • used at CONTEXT
    Mean age ~15 yr in U.S. registry; pediatric resuscitation modifications below age 8; sports + protective-equipment counseling differs by age
  • sexrequired
    demographic • used at CONTEXT
    >95% male predominance in registry — relevant for athlete-cohort epidemiology + counseling, not for treatment differences
  • sport_and_implement_typerequired
    history • used at CONTEXT
    Baseball / lacrosse / hockey puck / karate — defines venue + chest-protector equipment + secondary-prevention strategy; informs accessibility of AED programs
  • witnessed_arrest_with_impact_timingrequired
    history • used at CONTEXT
    Witnessed impact-to-collapse <5 sec is highly specific for commotio cordis (R-on-T mechanism); witnessed → bystander CPR + AED accessibility drives outcome
  • time_to_cpr_minrequired
    history • used at CONTEXT
    CPR within 1 min dramatically improves outcome; CAHP/OHCA score input
  • time_to_aed_defibrillation_minrequired
    history • used at CONTEXT
    AED within 3 min → 50%+ survival per Maron 2009 PMID 19741059; >3 min → survival drops sharply; venue AED program presence is the dominant prognostic factor
  • initial_rhythmrequired
    history • used at CONTEXT
    VF most common (~80%); asystole less common (~20%); informs prognosis + R-on-T mechanism confirmation
  • family_history_sudden_death_or_channelopathyrequired
    history • used at CONTEXT
    Critical to differentiate commotio cordis from unmasked LQTS / Brugada / CPVT / HCM presenting at the time of impact; positive family history mandates genetic + advanced imaging workup
  • prior_cardiac_history_or_symptomsrequired
    history • used at CONTEXT
    Prior syncope, exertional symptoms, palpitations, or known cardiac disease points to underlying substrate rather than pure commotio cordis
  • sbprequired
    vital • used at TREATMENT
    MAP ≥65 target post-ROSC; vasoplegia less common than ischemic-arrest cohorts because heart structurally normal; SCAI staging if shock
  • core_temprequired
    vital • used at TREATMENT
    TTM target 33–37.5 °C × 24h (TTM2 PMID 34133859); follows AHA 2020 standard for comatose post-ROSC patients
  • spo2required
    vital • used at TREATMENT
    Avoid hyperoxia: SpO2 92–98% (AHA 2020 Class IIa)
  • ecg_12_lead_serialrequired
    imaging • used at INITIAL_WORKUP
    Often normal post-resolution; serial ECGs over 24–48h to detect unmasked LQTS (QTc), Brugada (V1–V3 type 1 pattern), CPVT (exertional polymorphic VT triggers), epsilon waves of ARVC; baseline for sports-return decision
  • tte_high_resolutionrequired
    imaging • used at INITIAL_WORKUP
    Rule out HCM (septal hypertrophy ≥15 mm), ARVC, anomalous coronary origin, valvular disease — the underlying substrates most commonly missed in young athlete arrest
  • cardiac_mri_at_4_to_6_wk
    imaging • used at FOLLOWUP
    Cardiac MRI at 4–6 wk post-arrest if echo equivocal or channelopathy suspected — rule out ARVC, infiltrative disease, scar, anomalous coronary; allows post-arrest stunning to resolve before assessment
  • coronary_anomaly_imaging
    imaging • used at FOLLOWUP
    CT or MR coronary angiography if anomalous origin suspected (sudden death cause in athletes); especially considered in young athletes <35
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Often modestly elevated from chest-wall trauma + post-arrest stunning; rise pattern helps differentiate from ACS-mediated arrest (rare in this cohort)
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Tissue hypoperfusion + post-arrest perfusion debt; clearance trajectory drives prognosis (SCAI 2022 PMID 35718438)
  • creatininerequired
    lab • used at CONTEXT
    Baseline + serial; AKI from post-arrest hypoperfusion; KDIGO 2012 staging
  • genetic_testing_if_family_history_or_sentinel_features
    lab • used at FOLLOWUP
    Targeted gene panel if family history or sentinel ECG / clinical features — rules in / out LQTS, Brugada, CPVT, ARVC, HCM as substrate; informs family-screening cascade
  • cxr_post_cprrequired
    imaging • used at INITIAL_WORKUP
    Rib fractures from CPR + sternal injury from impact; aspiration; pneumothorax
  • ct_chest_if_significant_trauma
    imaging • used at INITIAL_WORKUP
    High-energy projectile impact → consider chest CT if significant tenderness, deformity, hypoxia, or persistent troponin rise — rule out cardiac contusion, sternal fracture, pulmonary contusion, hemothorax

12-phase flow (12)

  1. 1FRAME
    Commotio cordis = structurally normal heart + R-on-T VF from blunt precordial impact during 5–30 ms window pre-T-wave peak; survival dominated by AED time-to-shock; post-ROSC dominated by structural disease exclusion + channelopathy screen + sports-return decision (AED-NOT-ICD secondary prevention pattern); route to parent cardio.post-arrest.core.v1 for TTM + neuroprog
    inputs: witnessed_arrest_with_impact_timing, sport_and_implement_type
    advance: commotio cordis mechanism + AED timing documented
  2. 2ENTRY
    Standard ACLS for index arrest; immediate scene CPR + AED deployment; transport to nearest PCI-capable facility for post-ROSC care
    inputs: age, witnessed_arrest_with_impact_timing, time_to_cpr_min, time_to_aed_defibrillation_min
    advance: ACLS + AED + transport initiated
  3. 3CONTEXT
    Sport, implement, witnessed status, impact-to-collapse interval, time-to-CPR, time-to-AED, initial rhythm, family history of sudden death or channelopathy, prior cardiac symptoms
    inputs: sex, initial_rhythm, family_history_sudden_death_or_channelopathy, prior_cardiac_history_or_symptoms, sbp, core_temp, spo2, creatinine
    advance: context complete + GOC + family + sports-program incident reporting documented
  4. 4RED_FLAGS
    Failed AED defibrillation despite multiple shocks → ECPR consideration per ARREST PMID 33308475; concomitant traumatic injuries from impact (sternal fracture, cardiac contusion, hemothorax); refractory shock
    inputs: sbp, ecg_12_lead_serial
    actions: cardiogenic_shock
    advance: red flags screened + escalations triggered
  5. 5INITIAL_WORKUP
    ECG + serial troponin + BMP + lactate + ABG + CBC + CXR + bedside echo + CT chest if significant trauma + secondary survey for impact-related injuries
    inputs: ecg_12_lead_serial, troponin, lactate, tte_high_resolution, cxr_post_cpr
    actions: post_arrest_care, panel.cardiac, panel.renal
    advance: workup complete + structural disease screen initiated
  6. 6BRANCHING_WORKUP
    STEMI on post-ROSC ECG (rare in this cohort but considered) → cath; recurrent VT/VF or sentinel ECG for channelopathy → EP / channelopathy workup; ARDS post-trauma → ARDSnet vent; significant chest trauma → trauma surgery / CT surgery consult
    actions: acs_pathway, wide_complex_tach
    advance: cardiac vs trauma vs channelopathy branching decided
  7. 7DIFFERENTIAL
    Pure commotio cordis (structurally normal) vs unmasked underlying disease (LQTS, Brugada, CPVT, HCM, ARVC, anomalous coronary) vs cardiac contusion vs concomitant traumatic injuries — this differential drives the entire long-term plan (sports return + ICD vs no ICD)
    inputs: family_history_sudden_death_or_channelopathy, prior_cardiac_history_or_symptoms
    advance: commotio cordis confirmed vs alternative substrate identified
  8. 8RISK_STRATIFICATION
    CAHP/OHCA scores apply (witnessed + bystander CPR + low-flow time + initial rhythm); SCAI shock stage if hemodynamic instability; HEART score not directly applicable; structural-disease workup completion drives sports-return + ICD decision
    inputs: initial_rhythm, time_to_cpr_min, time_to_aed_defibrillation_min, sbp, lactate
    actions: calc.map, calc.heart, calc.ckd_epi_2021, calc.cha2ds2vasc
    advance: risk class + structural workup status documented
  9. 9TREATMENT
    Standard post-ROSC bundle (vasopressor → MAP ≥65, lung-protective vent, sedation, TTM 33–37.5 °C × 24h); chest-trauma supportive care (analgesia, pulmonary toilet); NO routine ICD (structurally normal heart); cardiology + EP consult for structural workup + sports-return planning; family meeting for incident reconstruction + AED program advocacy
    inputs: sbp, core_temp, spo2, creatinine
    actions: protocol.cardiogenic_shock
    advance: post-ROSC bundle + structural workup + family planning delivered
  10. 10DISPOSITION
    CICU vs MICU per predominant problem (cardiac surveillance dominant → CICU; significant trauma → trauma ICU); cardiology + EP own structural workup + sports-return decision
    advance: unit + service-line ownership assigned
  11. 11MONITORING
    Continuous telemetry × 24–48h for unmasked arrhythmia substrate; multimodal neuroprog ≥72h post-rewarm (Sandroni 2021 PMID 33745427); serial ECG q6h × 24h for QTc / Brugada / channelopathy emergence; BMP q6h
    inputs: ecg_12_lead_serial
    actions: panel.cardiac
    advance: monitoring + neuroprog + structural-screen timeline documented
  12. 12FOLLOWUP
    Cardiology + EP follow-up at 2–4 weeks for echo + ECG + Holter; cardiac MRI at 4–6 wk if structural workup equivocal; genetic testing if family history positive; sports-return clearance shared decision (typically permitted after complete evaluation if no substrate); family CPR + AED training; advocacy for venue AED programs (LifeVest 4hold AED + USA Lacrosse / NOCSAE chest protector ND200 advocacy); mental health (PTSD common in athlete + family); school + team incident debrief
    inputs: cardiac_mri_at_4_to_6_wk, coronary_anomaly_imaging, genetic_testing_if_family_history_or_sentinel_features
    advance: cardiology + EP + sports-return decision + family + AED advocacy + mental health follow-up booked