Commotio Cordis

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A Moment in History

William S. Halsted, MD
(1852 – 1922)

American anatomist, teacher, and surgeon, William Stewart Halsted was born in New York City, USA to a wealthy family of English origin. His father was involved in charitable work and Governor and trustee to a city hospital. Not a brilliant student initially, Halsted took an undergraduate in Liberal Arts in Yale, CT., after which he entered the Medical College of Physicians at the Columbia College, where he excelled.

As a second-year medical student Halsted applied and obtained a position in surgery at a local hospital. In here he learned about Lister’s antiseptic technique and became an adamant proponent of it to reduce infection. In 1877 Halsted obtained his MD. After a short time as House Physician at the New York Hospital, Halsted traveled to Europe to further his education studying for two years at the Universities of Vienna, Leipzig, and W?rzburg.

Besides being at the forefront of surgical and antiseptic techniques (introducing the use of rubber gloves in surgery), Halsted was extremely concerned with the way medical students were taught in the US. He pioneered bedside clinical round discussions with the medical students after two years of basic sciences studies. Halsted developed the idea of a patient chart; he also developed the residency program for medical students in use today.

Halsted is probably the most influential researcher and surgeon at the turn of the century. He dedicated time to the study of intestinal anastomoses and the use of silk as a suture material. His experimental work in 1887 proved that the inclusion of the submucosa layer in an anastomosis was mandatory, as well that a single layered anastomosis was enough to attain closure. Perhaps Halsted’s most important contribution was the application and use of the scientific method to surgical questions. Halsted’s principles, also known as "Halsted's Rules of Surgery", set the standards used today in surgical suturing and surgical stapling.

He also pioneered the development and surgical techniques for radical mastectomy as a treatment for breast cancer.

As a side effect of this studied in anesthesia and the use of cocaine for anesthesia, Halsted became addicted to this substance, a problem that followed him through the years. Without impairing his capacity as a researcher and a surgeon, Halsted eventually recovered. He died in Baltimore in 1922 as a complication to surgery.

Sources:
1. Dubay, A. D., & Franz, G. M. (2003). Acute Wound Healing: The Biology of Acute Wound Failure. Surg Clin NA, 83, 463-481.
2. Halsted, W. S. (1887). Circular Suture of the Intestine - An Experimental Study. Am J Med Sci, 436-461.
3. “William Stewart Halsted: his life and contributions to surgery” Osborne, P. Lancet Oncol 2007; 8: 256–65
4. “William Stewart Halsted: Surgical pioneer” Burress, P Endoc Today (2010), 8: (2) 22
5. “William Stewart Halsted (1852–1922) Neurological stamp” Haas, LF J Neurol Neurosurg Psych 2000;69:641
Original image courtesy of "Images from the History of Medicine" at www.nih.gov

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Details: Published: January 02, 2024

UPDATED: One year ago, on Monday January 2nd 2023, Damar Hamlin suffered a cardiac arrest as a consequence of a tackle that impacted his chest. The football player had suffered a Commotio Cordis, a rare but known athletic cardiac injury that was reversed by the medical support teams present at the Cincinnati Football Stadium.

One year later, the University of Cincinnati has published a press release entitled "The Damar Hamlin Effect: Revolutionizing CPR and AED Training Nationwide". Because of this accident, the awareness for training in CardioPulmonary Resuscitation (CPR) and the need and availability of Automated External Defibrillators (AEDs) has increased. His foundation has to-date raised over 9 million dollars!

Following is the original (and updated) post:

I have received several questions regarding this term and its meaning, because of the cardiac arrest suffered on the field by the Buffalo Bills defensive player Damar Hamlin while playing the Cincinnati Bengals on January 2nd, 2023.

01/02/2023 Bengals stadium

For those who were watching the game, close to the end of the first quarter Hamlin blocked another player in what looked like a normal and standard play. Immediately after, Damar Hamlin stood up and immediately collapsed. The video can be seen here. The player was treated on the field and later reports indicated that he had suffered a cardiac arrest and was treated with CPR (manual cardiopulmonary resuscitation), the use of an AED (Automated External Defibrillator) and oxygen. The player was intubated and was considered to be in critical, but stable condition.

The consensus is that Damar Hamlin suffered a ventricular arrhythmia, which allowed the heart to beat erratically, but not be able to pump blood, which is why he had to be defibrillated using the AED.

The cause for this is an uncommon (30 cases per year in the US) but known situation known as Commotio Cordis, a ventricular dysrhythmia caused by a sudden hit to the sternum in a particular location*. It has been seen in baseball and softball players where the pitcher is hit in the sternum by a fast ball coning from first base. Also seen in lacrosse players. In most cases this happens in younger individuals where the four sternabrae that form the body of the sternum have not yet completely ossified, making the sternum and lower costal cartilages quite flexible, being able to “bend in” when hit directly and compress the heart.

As some of you may know, I am a 7th Degree Black Belt in Goju-Ryu Karate. This type of punch to the sternum is one of the many techniques used in advanced Martial Arts. In most cases this punch will slow down an opponent, but it does not cause Commotio Cordis. It is a technique that should only be practiced under very close supervision. In fact, this technique was thought to be legend and was called “the touch of death” in China.

Commotio Cordis at a karate tournament

An example of Commotio Cordis caused by a Karate punch can be see in the following YouTube video. The image in this article shows the instant the chest strike happens at 6 seconds in the video. Look at the hand of the practitioner on the right and the devastating consequence that follows. Please note the similarity of the situation in this video and what happened to Damar Hamlin. There is a lapse of time between the Commotio Cordis cardiac arrest where the athlete gets up or walks followed fainting and unconsciousness. What is distressing is that the young martial artist who suffered this devastating injury died at the tournament. The judges were not aware of the situation, no one felt his pulse, or started life-saving CPR. Because of the content this video is age-restricted and you may have to sign in to view it.

The words are Latin. Commotio means “agitation or commotion”. Cordis means heart. The conditions to cause Commotio Cordis need to be exact, as the heart needs to be in ventricular repolarization, when the heart ventricles are starting to refill with blood. The "window" for a sternal hit to cause Commotio Cordis is very small.

Please, if you do not know how to provide CPR, take a full CPR course or at least attend a short 10 minute training like the one provided by University of Cincinnati Health in their "Take 10 Cincinnati" program.

For additional information please visit StatPearls at https://www.statpearls.com/ArticleLibrary/viewarticle/19761

Commotio Cordis

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