Looking to provide athletes the best heart protection possible
Commotio cordis is a sudden cardiac arrhythmia caused by a direct blow to the chest. It typically results from a low-velocity impact to the chest from a thrown or batted ball, puck or other object typically traveling between 20 and 50 mph. The risk increases the closer the impact is to the center of the heart.Death results when an abnormal rhythm, ventricular fibrillation, develops. However, blood circulation to the heart may also be affected.
For commotio cordis to occur, the impact has to be precisely timed to strike the heart during a 15 to 30-millisecond phase of the electrical cycle. It can cause sudden death in young baseball, softball and hockey players, as well as other athletes.
Commotio Cordis by the Numbers
- The sport with the highest incidence of commotio cordis is baseball, followed by softball, hockey, football, soccer and lacrosse.
- An overwhelming 95 percent of cases affect males.
- The most frequently affected age group is 10 to 18 years.
- Since 1995, the U.S. Commotio Cordis Registry received reports of over 225 cases. Many more unreported cases are suspected of having occurred.
- The Registry reports a survival rate of 24 percent.
Survival Outcome
While instances of commotio cordis are rare, sadly, the death rate is 90 percent. Unfortunately, the lack of response to CPR efforts by healthy young athletes is unexplained.
History shows that responding with CPR efforts within three to five minutes is critical. Studies indicate 
that the chances of surviving an incident of commotio cordis are enhanced if a shock from an automated external defibrillator (AED) can be delivered promptly. Most ballparks don’t have AEDs, and those that do must have well-practiced procedures in place for the rapid use of the device. Otherwise, all is for naught.
Also, the high-profile lawsuit in New Jersey of a pitcher being struck by a batted ball that came off of an alleged “hot bat” involved commotio cordis resulting in a permanent disability to the pitcher. The metal bat manufacturer and others were sued. What is interesting to note is that commotio cordis usually occurs only when a projectile travels at a relatively slow speed, usually between 20 and 50 mph. In this case, the basis for the lawsuit was that the ball speed was too fast as a result of the alleged “hot bat.”
Protecting Against Commotio Cordis
Researchers have been looking for solutions, typically in the form of chest protectors. But statistics show that somewhere between 20 and 30 percent of commotio cordis victims collapsed while wearing chest protection of some sort. Obviously, this means that the protection athletes were given wasn’t good enough.
Educating coaches, players and parents about the importance of preventing precordial blows is critical. For example, baseball and softball players should be taught to step aside or to turn and deflect balls using the shoulder, not the chest wall.
Commotio cordis is not related to an underlying heart condition. Therefore, susceptibility cannot be predetermined by a medical screening.
Spectators, players, and staff need to be able to recognize the signs of commotio cordis and take immediate action if a player is struck in the chest and collapses.
New NOCSAE Standards in Protection
In July 2018, the National Operating Committee on Standards for Athletic Equipment (NOCSAE) set the world’s first performance standard for chest protection from commotio cordis. NOCSAE developed separate versions for baseball and lacrosse. Governing bodies of the various sports will decide whether or not they include compliance with these NOCSAE standards in their rules of play and when that goes into effect.
The Science Behind the New Standards
Together with the Louis J. Acompora Memorial Foundation, NOCSAE funded more than $1.1 million in 
research that pinpointed the cause of commotio cordis, including the critical moment of occurrence. To test impacts to the chest and heart, research engineers then developed a mechanical chest that mimics the human response of the human. All this led to NOCSAE creating the first commotio cordis-specific chest protection standard. NOCSAE looks to reduce the risk of death significantly from commotio cordis for athletes using equipment certified to this new standard.
Chest Protector Certifications By SEI
The Safety Equipment Institute (SEI) issued the first certifications for chest protectors that meet NOCSAE’s new standard. The NOCSAE criteria support a test method that produces reliable measurements to evaluate various types of chest protectors.
Chest protector manufacturers participating in SEI’s certification program must also have their facility and operations audited for quality assurance. Additionally, all products labeled SEI and NOCSAE-certified must be recertified annually. Yes, all products have to be retested, and the manufacturing facility successfully meets all SEI quality-assurance requirements each year. SEI serves as the world’s premier certification organization for safety and protective products.
High School Rule Change in Baseball For Catchers
The standard update for chest protectors resulted in a rule change by the Baseball Rules Committee of the National Federation of State High School Associations (NFHS). Rule 1-5-3, effective January 1, 2020, requires catchers wear chest protectors that meet the NOCSAE standard as the time of manufacture. Knowing that catchers are wearing equipment certified by the latest safety standards provides players, coaches, parents and school administrators assurance that athletes have the best heart protection possible, said Elliot Hopkins, NFHS director of sports and student services. Other youth baseball organizations will need to address whether or not they will follow the lead of NFHS.
No Guarantees of Protection and Opponents of New Standard
It’s important to note that neither NOCSAE nor SEI offer any guarantees of protection from the certified chest protectors. They clearly state that no thoracic or chest protector can prevent all cardiac injuries, and that catastrophic injury and death may occur to a wearer of a NOCSAE and SEI-certified protector.
Opponents of the new standard point out that neither NOCSAE, SEI, nor any manufacturer can say affirmatively that their product does prevent commotio cordis. Also, many question if the additional expense of compliance is worth protecting the very low number of athletes impacted by this rare condition, especially since there are no guarantees. Others wonder if the new chest protectors may cause unintended consequences such as adding an additional heat layer that may contribute to heat illness.
If you found this blog on commotio cordis to be beneficial, please check out our other sports risk management content, and other risk management blog posts.
