Bills player with cardiac arrest. Commotio?

[Dr Mantis Toboggan]

Didn’t seem like the hit was all that hard.

Guess he was taken to UC. Hope he’s OK.

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[Apollyon]

I put up something in The Lounge about it. Don't think it was commotio - as you say, not a hard hit, and no spear to the chest, like a puck or a baseball.

He was taken to UC. Right this moment, they're reporting he's alive, but "in critical condition". Undx HOCM?

 

[Dr Mantis Toboggan]

I put up something in The Lounge about it. Don't think it was commotio - as you say, not a hard hit, and no spear to the chest, like a puck or a baseball.

He was taken to UC. Right this moment, they're reporting he's alive, but "in critical condition". Undx HOCM?

Every player gets an echo as part of the draft process was my understanding.

 

[Tiger26]

My guess is vfib/tach. The collision seemed fairly minor (for the NFL)

 

[Goro]

Latest news: "vitals normal, incubated, in critical condition"

 

[southerndoc]

A precordial thump will give you 5-10 J worth of energy. An NFL player hitting your chest is probably a lot more. R-on-T is all it takes, and barring anything else proving it otherwise, this is most likely commotio cordis. It doesn't take a small object hitting your chest. Any hit to the chest that produces enough energy to "shock" R-on-T will cause it. Football players are primed for it because they're running around the field, are already exercising enough to be anaerobic with lactate build-up making the heart muscle peri-ischemic, and are tachycardic, which shortens the cardiac cycle and makes R-on-T more likely to occur during a hit (more T waves).

 

[thegenius]

Yea could be commotio. First thing I thought of. Probably more likely HOCM or brugada or a sodium channelopathy. It's more or less the right age for that stuff.

 

[emergentmd]

I thought arrhythmia vs aortic arch tear but if he is intubated then likely arrhythmia.

Hopefully they did good CPR.

 

[Radetzky]

Looks like commotio

 

[allantois]

I understand NFL players all get echo so I doubt HOCM

 

[Apollyon]

A precordial thump will give you 5-10 J worth of energy. An NFL player hitting your chest is probably a lot more. R-on-T is all it takes, and barring anything else proving it otherwise, this is most likely commotio cordis. It doesn't take a small object hitting your chest, although that is the most common cause (namely, a baseball). Any hit to the chest that produces enough energy to "shock" R-on-T will cause it. Football players are primed for it because they're running around the field, are already exercising enough to be anaerobic with lactate build-up making the heart muscle peri-ischemic, and are tachycardic, which shortens the cardiac cycle and makes R-on-T more likely to occur during a hit (more T waves).

Just an edit to your post, for clarity. Although the commotio has occurred in gridiron football players, it is much less common than the already vanishingly rare event, due to the force not being applied in a point or small area, but diffused over a larger area.

 

[pollyspockets]

Every NFL stadium has to have an airway physician. Don’t know if Cincys is EM or gas but I can’t imagine coding someone live on Monday night football

Hope the player is ok and recovers

 

[Dr Mantis Toboggan]

Every NFL stadium has to have an airway physician. Don’t know if Cincys is EM or gas but I can’t imagine coding someone live on Monday night football

Hope the player is ok and recovers

I used to be in a fantasy football league with a sideline doc who is EM faculty. Saw him on TV when Shazier from the Steelers had his spinal injury a few years ago.

 

[smq123]

Of course, the nutjobs on social media are blaming his cardiac arrest on the COVID vaccine.

 

[NYEMMED]

Of course, the nutjobs on social media are blaming his cardiac arrest on the COVID vaccine.

I was about to say the same thing. Many are Blaming it on the COVID vaccine….

 

[wholeheartedly]

Of course, the nutjobs on social media are blaming his cardiac arrest on the COVID vaccine.

it took them a matter of minutes to start that crap.

 

[southerndoc]

it took them a matter of minutes to start that crap.

I mean they did have a decent 5G signal in the stadium. Just sayin'.

 

[RoyBasch]

Every player gets an echo as part of the draft process was my understanding.

The league's advanced cardiac screening I think makes something like HOCM/IHSS less likely. I would assume they also do an EKG making a type I Brugada unlikely as well. That being said, there are lots of cardiac sodium chanel-opathies that do not have any abnormality on the resting EKG. It could be one of those leading to a spontaneous malignant arrhythmia.

 

[RoyBasch]

it took them a matter of minutes to start that crap.

People like this think "Never waste a good tragedy."

 

[timpview]

I’ll be curious how long it took them to recognize he was pulseless. Sounds like it wasn’t until he was being loaded into the ambulance a few minutes into it

 

[Vandalia]

I’ll be curious how long it took them to recognize he was pulseless. Sounds like it wasn’t until he was being loaded into the ambulance a few minutes into it

The ambulance didn't come out until long after they were doing CPR and using the AED.

 

[WildcatS11]

Every NFL stadium has to have an airway physician. Don’t know if Cincys is EM or gas but I can’t imagine coding someone live on Monday night football

Hope the player is ok and recovers

Multiple EM docs on the field every game in Cincy - all UCEM. Occasionally a non-EM neurocrit as well.

 

[WorkNoteEmergency]

My guess is a non traumatic dysrhythmia; he made the hit, stood up then collapsed. When I was watching I was wondering about the skill level of the medics on the field as they may not be experienced first responders (private transport service?) and may have mindset and prep for spinal immobilization rather than coding a football player. Glad to hear it’s typical to have EM/CC types on the field. Really hope he makes a full recovery and I’d be a little worried for him if he’s still on the vent tomorrow.

 

[WilcoWorld]

A precordial thump will give you 5-10 J worth of energy. An NFL player hitting your chest is probably a lot more. R-on-T is all it takes, and barring anything else proving it otherwise, this is most likely commotio cordis. It doesn't take a small object hitting your chest. Any hit to the chest that produces enough energy to "shock" R-on-T will cause it. Football players are primed for it because they're running around the field, are already exercising enough to be anaerobic with lactate build-up making the heart muscle peri-ischemic, and are tachycardic, which shortens the cardiac cycle and makes R-on-T more likely to occur during a hit (more T waves).

I agree with everything, except for having a question about the last point.

I know that tachycardia protects against torsades, and this is thought to be because the myocardium spends less time in repolarization. Thinking of the t wave as a curve - with tachycardia there's "less area under the curve" of the sum of the shorter t waves, even though there are more of them than with bradycardia and its long sloping t waves. Is this different with commotio cordis? Genuinely asking.

 

[southerndoc]

I agree with everything, except for having a question about the last point.

I know that tachycardia protects against torsades, and this is thought to be because the myocardium spends less time in repolarization. Thinking of the t wave as a curve - with tachycardia there's "less area under the curve" of the sum of the shorter t waves, even though there are more of them than with bradycardia and its long sloping t waves. Is this different with commotio cordis? Genuinely asking.

I don't think there's enough research to definitively know.

 

[Radetzky]

I agree with everything, except for having a question about the last point.

I know that tachycardia protects against torsades, and this is thought to be because the myocardium spends less time in repolarization. Thinking of the t wave as a curve - with tachycardia there's "less area under the curve" of the sum of the shorter t waves, even though there are more of them than with bradycardia and its long sloping t waves. Is this different with commotio cordis? Genuinely asking.

You are right, tachycardia is protective against R on T

 

[jwk]

You are right, tachycardia is protective against R on T

Is that simply because there is less "opportunity" to hit that already narrow window?

 

[Dred Pirate]

Multiple EM docs on the field every game in Cincy - all UCEM. Occasionally a non-EM neurocrit as well.

is this new or has it always been that way? I work near an NHL arena and it is relatively new to have a EM doc at those games (like in last 5-8 years I think). They didn't start requiring an "airway capable doc" until there was a player or coach who coded on the bench.

 

[Dr Mantis Toboggan]

is this new or has it always been that way? I work near an NHL arena and it is relatively new to have a EM doc at those games (like in last 5-8 years I think). They didn't start requiring an "airway capable doc" until there was a player or coach who coded on the bench.

The straw that broke the camels back as far as me leaving academics was when I was shut out of the roster of docs who covered the pro sports team. When I asked why I was told “we didn’t think you liked sports”. Lol. I literally was the commish of the fantasy football team. The term gaslighting didn’t exist then as I far as I know, but that’s what it was.

 

[Apollyon]

The straw that broke the camels back as far as me leaving academics was when I was shut out of the roster of docs who covered the pro sports team. When I asked why I was told “we didn’t think you liked sports”. Lol. I literally was the commish of the fantasy football team. The term gaslighting didn’t exist then as I far as I know, but that’s what it was.

1944 movie, Gaslight, Charles Boyer, Ingrid Bergman.

 

[Lawpy]

I’m actually really surprised if this is commotio and not something underlying like HCM-related arrhythmias that through bad timing got turned into VT/VF. All the more reason why heart screenings for athletes are important

 

[thegenius]

I’m actually really surprised if this is commotio and not something underlying like HCM-related arrhythmias that through bad timing got turned into VT/VF. All the more reason why heart screenings for athletes are important

I thought they have studied whether heart screenings for athletes is a waste. I'm talking about all screenings from middle school all the way to professional sports. The professional ones will do whatever they want to do, and at the end of the day testing 1500 NFL players is not a big deal. But to screen all athletes from age 12-24 for underlying cardiac disease seems like a huge waste of money.

How many times are NFL players hit each year? I reckon it's probably something like 16 games/week * 17 weeks * 300 hits/game * 3-4x hits from other sources = 200,000 - 300,000 times/year. This kind of thing happens once every 25 years. It's a total freak accident.

Funny too it was a totally benign hit. I've tackled my kids like that before roughhousing with them.

 

[Apollyon]

The dearth of official information gives rise to so much speculation. It's evident to us how much the layman doesn't know. From what I've been able to glean, I wonder if he aspirated, with the talk of him remaining tubed, and "breathing difficulties". Moreover, the report of a second code in hospital leans against commotio. I am still on the side of @thegenius as to an undiagnosed sodium channelopathy, something idiosyncratic.

 

[Dred Pirate]

if he re-arrested at the hospital like was reported - does that make it more or less likely to

The dearth of official information gives rise to so much speculation. It's evident to us how much the layman doesn't know. From what I've been able to glean, I wonder if he aspirated, with the talk of him remaining tubed, and "breathing difficulties". Moreover, the report of a second code in hospital leans against commotio. I am still on the side of @thegenius as to an undiagnosed sodium channelopathy, something idiosyncratic.

I was going to bring up the second code - that would make me think something else - or could be a sign of serious lasting damage from the first code (but then again I am not a cardiologist or even a physician)/ Sounds like they are proneing him as well- already have ARDS?

 

[Lawpy]

I thought they have studied whether heart screenings for athletes is a waste. I'm talking about all screenings from middle school all the way to professional sports. The professional ones will do whatever they want to do, and at the end of the day testing 1500 NFL players is not a big deal. But to screen all athletes from age 12-24 for underlying cardiac disease seems like a huge waste of money.

How many times are NFL players hit each year? I reckon it's probably something like 16 games/week * 17 weeks * 300 hits/game * 3-4x hits from other sources = 200,000 - 300,000 times/year. This kind of thing happens once every 25 years. It's a total freak accident.

Funny too it was a totally benign hit. I've tackled my kids like that before roughhousing with them.

I’m for screenings for college and professional football. And for baseball, hockey, soccer, lacrosse.

And the fact that it’s a benign hit is all the more reason why commotio is so strange to me

 

[Vandalia]

if he re-arrested at the hospital like was reported - does that make it more or less likely to

I was going to bring up the second code - that would make me think something else - or could be a sign of serious lasting damage from the first code (but then again I am not a cardiologist or even a physician)/ Sounds like they are proneing him as well- already have ARDS?

Latest reports are that there was no second code.

 

[forchinet121]

My guess is vfib/tach. The collision seemed fairly minor (for the NFL)

Yeah vfib but from what? Do people just randomly go into vfib for no reason?

 

[CleverAlias]

Of course, the nutjobs on social media are blaming his cardiac arrest on the COVID vaccine.

I mean if we put aside the whole "vaccines good vs vaccines bad" controversy for the time being, the probability that this particular freak event was a result of vaccine mediated subclinical myocarditis causing malignant arrhythmia on exertion is probably at least as likely as any other potential rarity such as commotio cordis or HOCM not seen on echo. The truth of the matter is that regardless of how uncommon MRNA vaccine related myocarditis may be, it is still orders of magnitude more common than commotio cordis from a football tackle.

The documented rate of myocarditis in young men receiving the moderna vaccine is 23/100,000 doses. This number is in all likelihood much greater if you account for cases which are subclinical and never diagnosed. So while using this event as an argument against vaccination may be wrongheaded, speculating that the vaccine may have caused it is not, in all objective reality, any dumber than bringing up other rare etiologies. Unfortunately the discourse over the vaccines have become so toxic that neither side is willing to think about the issue critically.

 

[RoyBasch]

Yeah vfib but from what? Do people just randomly go into vfib for no reason?

They can. But it’s because they have an undiagnosed underlying cardiac rhythm disorder like Brugada syndrome. In his case it’s not specifically brugada because it would have been uncovered in the nfl cardiac screening as the rest EKG is abnormal.

However, there are other similar disorders with no easily discernible evidence you can screen for and unfortunately sometimes present with sudden cardiac death as the initial symptom.

 

[Apollyon]

Yeah vfib but from what? Do people just randomly go into vfib for no reason?

Yes. It's somewhere between 30 and 50 percent, bit I believe closer to, or at, 50, of people that find out they have heart trouble when they suffer sudden cardiac death - that's death within one hour of the onset of symptoms. 1 of 2 people find out they have heart problems when they drop dead.

But, more granularly, just idiopathic V Fib? That I do not believe occurs, although I could very easily be wrong. Something precipitates it. I should have said, from undiagnosed conditions. If you have undiagnosed Brugada syndrome, then, it would seem like like it was random.

 

[Apollyon]

They can. But it’s because they have an undiagnosed underlying cardiac rhythm disorder like Brugada syndrome. In his case it’s not specifically brugada because it would have been uncovered in the nfl cardiac screening as the rest EKG is abnormal.

However, there are other similar disorders with no easily discernible evidence you can screen for and unfortunately sometimes present with sudden cardiac death as the initial symptom.

Jinx!

 

[niblet]

I mean if we put aside the whole "vaccines good vs vaccines bad" controversy for the time being, the probability that this particular freak event was a result of vaccine mediated subclinical myocarditis causing malignant arrhythmia on exertion is probably at least as likely as any other potential rarity such as commotio cordis or HOCM not seen on echo. The truth of the matter is that regardless of how uncommon MRNA vaccine related myocarditis may be, it is still orders of magnitude more common than commotio cordis from a football tackle.

The documented rate of myocarditis in young men receiving the moderna vaccine is 23/100,000 doses. This number is in all likelihood much greater if you account for cases which are subclinical and never diagnosed. So while using this event as an argument against vaccination may be wrongheaded, speculating that the vaccine may have caused it is not, in all objective reality, any dumber than bringing up other rare etiologies. Unfortunately the discourse over the vaccines have become so toxic that neither side is willing to think about the issue critically.

Probability of commotio cordis goes up exponentially when cardiac arrest occurs immediately after sustaining a hit to the chest.

No one's randomly picking it out of a hat as one of the million things that can cause sudden death, like some people want to with vaccine-induced myocarditis.

 

[Radetzky]

I mean if we put aside the whole "vaccines good vs vaccines bad" controversy for the time being, the probability that this particular freak event was a result of vaccine mediated subclinical myocarditis causing malignant arrhythmia on exertion is probably at least as likely as any other potential rarity such as commotio cordis or HOCM not seen on echo. The truth of the matter is that regardless of how uncommon MRNA vaccine related myocarditis may be, it is still orders of magnitude more common than commotio cordis from a football tackle.

The documented rate of myocarditis in young men receiving the moderna vaccine is 23/100,000 doses. This number is in all likelihood much greater if you account for cases which are subclinical and never diagnosed. So while using this event as an argument against vaccination may be wrongheaded, speculating that the vaccine may have caused it is not, in all objective reality, any dumber than bringing up other rare etiologies. Unfortunately the discourse over the vaccines have become so toxic that neither side is willing to think about the issue critically.

Except with so many people vaccinated, you’d see at least some signal of increased sudden death, which, short of made up statistics, there isn’t.

 

[thegenius]

Yeah vfib but from what? Do people just randomly go into vfib for no reason?

No

 

[thegenius]

I mean if we put aside the whole "vaccines good vs vaccines bad" controversy for the time being, the probability that this particular freak event was a result of vaccine mediated subclinical myocarditis causing malignant arrhythmia on exertion is probably at least as likely as any other potential rarity such as commotio cordis or HOCM not seen on echo. The truth of the matter is that regardless of how uncommon MRNA vaccine related myocarditis may be, it is still orders of magnitude more common than commotio cordis from a football tackle.

The documented rate of myocarditis in young men receiving the moderna vaccine is 23/100,000 doses. This number is in all likelihood much greater if you account for cases which are subclinical and never diagnosed. So while using this event as an argument against vaccination may be wrongheaded, speculating that the vaccine may have caused it is not, in all objective reality, any dumber than bringing up other rare etiologies. Unfortunately the discourse over the vaccines have become so toxic that neither side is willing to think about the issue critically.

Why is the vaccine an issue anyway. Did he just get a COVID vaccine a few days prior?

 

[thegenius]

Yes. It's somewhere between 30 and 50 percent, bit I believe closer to, or at, 50, of people that find out they have heart trouble when they suffer sudden cardiac death - that's death within one hour of the onset of symptoms. 1 of 2 people find out they have heart problems when they drop dead.

But, more granularly, just idiopathic V Fib? That I do not believe occurs, although I could very easily be wrong. Something precipitates it. I should have said, from undiagnosed conditions. If you have undiagnosed Brugada syndrome, then, it would seem like like it was random.

I read this as "30-50% of people randomly go into vfib" LOL

 

[WilcoWorld]

Why is the vaccine an issue anyway. Did he just get a COVID vaccine a few days prior?

The vaccine is an "issue" because people have an axe to grind.

Statistical hand waving aside - myocarditis doesn't fit the history. You don't go from NFL game ready to cardiac arrest in seconds from myocarditis.

 

[southerndoc]

Yeah vfib but from what? Do people just randomly go into vfib for no reason?

Yes when they have major electrolyte abnormalities. Maybe his mag was 0.5 or K was 2. We may not ever know the full details.

Clarification: People usually progress from VT to VF.

Regarding electrolyte abnormalities, I've seen several cases (primary and transfers) that get ROSC and are discharged without a defibrillator because EP says it was all electrolyte related (I'm talking potassium and mag levels as cited above).

 

[greatnt249]

I’m for screenings for college and professional football. And for baseball, hockey, soccer, lacrosse.

And the fact that it’s a benign hit is all the more reason why commotio is so strange to me

The hit doesn't have to be hard enough to cause a cardiac contusion, only hard enough to deliver enough energy to the right area of the heart at the wrong time.

 

[greatnt249]

I mean if we put aside the whole "vaccines good vs vaccines bad" controversy for the time being, the probability that this particular freak event was a result of vaccine mediated subclinical myocarditis causing malignant arrhythmia on exertion is probably at least as likely as any other potential rarity such as commotio cordis or HOCM not seen on echo. The truth of the matter is that regardless of how uncommon MRNA vaccine related myocarditis may be, it is still orders of magnitude more common than commotio cordis from a football tackle.

The documented rate of myocarditis in young men receiving the moderna vaccine is 23/100,000 doses. This number is in all likelihood much greater if you account for cases which are subclinical and never diagnosed. So while using this event as an argument against vaccination may be wrongheaded, speculating that the vaccine may have caused it is not, in all objective reality, any dumber than bringing up other rare etiologies. Unfortunately the discourse over the vaccines have become so toxic that neither side is willing to think about the issue critically.

Why complicate the diagnosis by speculating vaccine involvement? You don't need to have myocarditis for commotio cordis to happen. The replays all show a direct chest wall impact and within seconds, he collapsed. The impact doesn't have to be hard enough to cause direct cardiac injury, just hard enough to deliver a sufficient amount of energy to the heart within a very narrow window of time. Also contrary to popular belief, people don't necessarily lose consciousness the second the heart goes into VT/VF; it can take a few seconds for cerebral perfusion to drop from the loss of cardiac output.

As to whether there's another underlying issue such as a channelopathy or HCM, it's pretty irrelevant in the grand scheme of things at this point in his care. It will be looked into, but I as I see it now, commotio is the simplest explanation for everything we witnessed.