Contact Sports: A new concussion dilemma
By Prof Dr Steve Cornelius, Sports Law Centre, University of Pretoria, South Africa
The world of sport, and particularly contact sport, is still struggling to deal with the debilitating long-term health risks of repetitive head injuries and concussion. The National Football League (NFL) in the United States settled a $1 billion class action suit by former players who suffer from early onset dementia, whilst reports have indicated that former ice hockey and rugby union players, who also suffer from early onset dementia and other debilitating effects of head injuries, are also taking aim at national and international federations to claim compensation.
Now, it seems, a new kind of concussion has reared its head – one that is so nefarious that it does not wait to manifest itself in the future but requires immediate intervention to prevent permanent brain damage or death. This terrible new affliction is often called cardiac concussion. The medical community knows it better as commotio cordis. This kind of injury received headline news at the beginning of January when Buffalo Bills safety Damar Hamlin collapsed after a tackle during the NFL match between the Buffalo Bills and the Cincinnati Bengals. It was determined that Hamlin had suffered cardiac arrest following commotio cordis and had to be resuscitated by medical personnel on the field before he could be moved to hospital.
According to Oxford Reference (Cardiac concussion - Oxford Reference) Commotio cordis can result from a sharp localised non-penetrating blow to the chest, during a vulnerable phase of the cardiac cycle. The blow disrupts the heartbeat, resulting in an irregularity, such as ventricular fibrillation, which may lead to a potentially instantaneous and lethal cardiac arrest.
Some cardiologists regard it as a very rare freak accident, but others claim that it could represent one of the most common causes of sudden death in young athletes.
In cases of sudden death, it seldom leaves any pathologically significant signs of trauma and is not associated with any pre-existing structural, pathologic, or histologic condition that could reveal an increased risk of cardiac concussion. As a result, it is often overlooked in cases of the sudden death of an athlete.
However, some cases that have been positively identified involved a baseball player who collided with a catcher during a game (Cardiac Concussion: Definition, Differential Diagnosis, and... : The American Journal of Forensic Medicine and Pathology (lww.com), a batsman struck on the chest by a cricket ball (Commotio cordis: a case of ventricular fibrillation caused by a cricket ball strike to the chest - The Lancet) and Damar Hamlin making a tackle in the NFL.
A search of literature suggests that commotio cordis may not be that uncommon, with at least 23 cases of sudden death due to commotio cordis being reported in high school and college lacrosse in the United States (Commotio cordis and the epidemiology of sudden death in competitive lacrosse - PubMed (nih.gov)) as a result of players being hit on the chest by a ball. In cricket, at least 29 cases of commotio cordis have been identified after players were struck on the chest by a cricket ball ((PDF) 207 Cricket Related Commotio Cordis (researchgate.net)). At least 17 cases, involving football, cricket and rugby union have been identified in the United Kingdom (A Lethal Blow to the Chest as an Underdiagnosed Cause of Sudden Death in United Kingdom Sports (Football, Cricket, Rugby) - ScienceDirect).
As a result, the sports world will have to take notice of this risk. When dealing with safety issues in sport, federations would be well-advised also to consider ways to reduce the risk of commotio cordis. For instance, in rugby union, the rule which requires that tacklers must lead with their arms and may not charge first into an opponent, should reduce the risks involved. In sports, such as cricket, baseball and lacrosse, protective gear worn over the chest, should be considered.
Even more important that preventative measures, sports federations should ensure that medical staff are adequately trained to identify commotio cordis instantaneously and respond immediately with the correct procedures. It is the kind of injury where mere seconds make the difference between life and death. If cardiopulmonary resuscitation (CPR) is not administered within the first two minutes, the survival rate is less than 50%. If CPR is not administered within three minutes, the survival rate drops to 3% and the possibility of permanent brain damage increases by the minute, even if the injured player survives.
In this regard, credit must go to the NFL for the way in which the Damar Hamlin incident was handled. Hamlin got up after the tackle and almost immediately collapsed. Emergency medical personnel were on the field within seconds and almost immediately began CPR. It was obvious that they had immediately identified the signs of commotio cordis and responded appropriately without any hesitation. The result was that Hamlin, who could so easily have been another fatality, is now on his way to a full recovery. The good news for him is that players who do survive commotio cordis without brain injury, seldom have any recurring cardiovascular symptoms.
Other sports can do well to look at the NFL example and ensure that their medical staff are also trained to react appropriately. In addition, credit should also go to the NFL for the way in which the match situation was handled. Play was immediately suspended whilst the medical personnel attended to Hamlin. Then, despite the fact that the match was only halfway through the first quarter and also despite the fact that the match was significant in respect of the play-offs for both the Bills and the Bengals, the bold decision was taken to abandon the match altogether. This sent a clear message that the welfare of a player was paramount and that all other concerns were relegated to insignificance.
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