Damar Hamlin

[epidural man]

Commotio cordis?​

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[CubsDynasty]

seems most likely

 

[anaesthetic]

I would think so, but it’s interesting that the rhythm wouldn’t be disrupted/degenerate upon impact.

He got up and seemed okay for a second, and then you can see when he starts to feel weak and collapse. To me, it seems more in line with vasovagal syncope after getting up too quickly and some sort of bigger issue after that. They did do CPR on the field so that makes me think maybe it wasn’t a rhythm issue (if they didn’t have to defibrillate), but who knows?

 

[epidural man]

Maybe a dissected aorta - Although that usually is with high speed trauma.

 

[Gern Blansten]

I would think so, but it’s interesting that the rhythm wouldn’t be disrupted/degenerate upon impact.

He got up and seemed okay for a second, and then you can see when he starts to feel weak and collapse. To me, it seems more in line with vasovagal syncope after getting up too quickly and some sort of bigger issue after that. They did do CPR on the field so that makes me think maybe it wasn’t a rhythm issue (if they didn’t have to defibrillate), but who knows?

I heard that they did defibrillate.

 

[epidural man]

I heard that they did defibrillate.

I thought they did a chest compressions and shock therapy.

 

[DrOwnage]

Tackle didn’t look too bad, also wearing pads. My money is on some kind of arrhythmia. HCM? If so the prognosis is fairly poor. CPR for 9 minutes on a healthy guy without ROSC? Likely a shockable rhythm. If the time to defibrillation was fairly long, no bueno. Hopefully good compressions. Poor guy.

 

[Radetzky]

This looks exactly like commotio. A hit to the chest capable of producing an energy discharge, a brief period of standing and then a collapse.

 

[ryanjmy]

seems most likely

I agree. I’ve got a partner that tells a story of pacing a pt in complete heart block with precordial thumps. More or less this would be a pacer spike on a T-wave. If you look a the hit it wasn’t particularly violent but at the perfect angle for a precordial thump.

 

[GravelRider]

My initial thought was high spinal cord injury. However, replays showed that was probably unlikely. He did get hit in the chest, which makes me think commotio cordis over HOCM. I’m assuming there is an AED readily available on the sidelines. Hopefully compressions were started immediately and done appropriately. I wonder if they’ve initiated therapeutic hypothermia for him…assuming there was no traumatic injury?

 

[Ronin786]

Tackle didn’t look too bad, also wearing pads. My money is on some kind of arrhythmia. HCM? If so the prognosis is fairly poor. CPR for 9 minutes on a healthy guy without ROSC? Likely a shockable rhythm. If the time to defibrillation was fairly long, no bueno. Hopefully good compressions. Poor guy.

I can't imagine a better prognosis than a witnessed cardiac arrest in an otherwise healthy 24 year old. Apparently they got him onto a stretcher before having to start CPR so the only question is how long was he without CPR and when did they recognize he had no pulse.

If anything the fact that his vitals are stable and got ROSC rule out neck injury, transection, rupture or anything immediately fatal. My bigger concern is the fact that 12 hours later there hasn't been word about his neuro status which would likely indicate some sort of delayed neurological recovery. Probably cooling him now.

 

[gasdoc77]

Takotsubo? Physical trauma combined with catecholamine surge?

 

[Southpaw]

commotio cordis seems likely. hopefully they recognized it quickly, got him on a backboard gave good quality cpr. I doubt it's easy giving good cpr with shoulder pads on (which come across the chest) plus whatever other equipment professional football players are wearing.

 

[vector2]

I can't imagine a better prognosis than a witnessed cardiac arrest in an otherwise healthy 24 year old. Apparently they got him onto a stretcher before having to start CPR so the only question is how long was he without CPR and when did they recognize he had no pulse.

If anything the fact that his vitals are stable and got ROSC rule out neck injury, transection, rupture or anything immediately fatal. My bigger concern is the fact that 12 hours later there hasn't been word about his neuro status which would likely indicate some sort of delayed neurological recovery. Probably cooling him now.

Yeah I'm surprised they haven't announced he's woken up given how soon compressions started. One thing he has going against him as far as organ protection though is that his body temperature and metabolic rate were probably an order of magnitude higher than the average schlub who collapses while doing nothing. But again, his ischemic time must've been short given how soon they got the AED.

 

[Ronin786]

Yeah I'm surprised they haven't announced he's woken up given how soon compressions started. One thing he has going against him as far as organ protection though is that his body temperature and metabolic rate were probably an order of magnitude higher than the average schlub who collapses while doing nothing. But again, his ischemic time must've been short given how soon they got the AED.

The thing that worries me is that there are reports of him only getting CPR after they got him on the stretcher. It's always possible that there was some confusion about what was going on, but you'd have expected CPR to be the first thing administered in that kind of situation.

 

[abolt18]

I would think so, but it’s interesting that the rhythm wouldn’t be disrupted/degenerate upon impact.

He got up and seemed okay for a second, and then you can see when he starts to feel weak and collapse. To me, it seems more in line with vasovagal syncope after getting up too quickly and some sort of bigger issue after that. They did do CPR on the field so that makes me think maybe it wasn’t a rhythm issue (if they didn’t have to defibrillate), but who knows?

I don't think him standing up rules out arrhythmia. When we to TAVRs and they start rapid pacing, I occasionally see the MAP drop to the 30s momentarily and the patient will keep talking to me, or be looking around. Sometimes they wig out for a moment (start moving head around) as the pacing stops and pressures have been low for 20 seconds.

 

[D4C]

I don't think him standing up rules out arrhythmia. When we to TAVRs and they start rapid pacing, I occasionally see the MAP drop to the 30s momentarily and the patient will keep talking to me, or be looking around. Sometimes they wig out for a moment (start moving head around) as the pacing stops and pressures have been low for 20 seconds.

Lying on a table w/ a MAP of 30 =/= standing w/ MAP of 30

 

[abolt18]

Lying on a table w/ a MAP of 30 =/= standing w/ MAP of 30

My point is, from the hit to the time he fell over was literally only a few seconds. It would not be unreasonable to assume his brain and body could have been working on a tiny bit of oxygen reserve. Additionally it could have been a progressing arrhythmia that was perfusing for a moment but degraded to an unstable arrhythmia pretty quickly.

 

[Neopolymath]

commotio cordis seems likely. hopefully they recognized it quickly, got him on a backboard gave good quality cpr. I doubt it's easy giving good cpr with shoulder pads on (which come across the chest) plus whatever other equipment professional football players are wearing.

Typically training is to cut off pads and flip them.

 

[DrOwnage]

My point is, from the hit to the time he fell over was literally only a few seconds. It would not be unreasonable to assume his brain and body could have been working on a tiny bit of oxygen reserve. Additionally it could have been a progressing arrhythmia that was perfusing for a moment but degraded to an unstable arrhythmia pretty quickly.

Agreed. Standard of care going forward should be Pre-game locker room A lines for everyone.

 

[dchz]

I saw the hit and my initial thought was vasovagal as well.

From the way the hit was it doesn't look like commotio cordis, like if you think about how the heart sits inside the chest and how he was bracing for the impact. Higgins made contact on the left shoulder and neck area and Hamlin landed on his left arm/side. None of that screams direct blunt contact to the heart to me.

More likely it's vasovagal -> apnea -> hypoxia rather than arrhythmia -> hypotension -> cardiac arrest.

But it's kinda impossible to tell. I hope he turns out ok.

Edit: I meant to say (vasovagal -> hypotension + Apnea from impact) -> cardiac arrest. This is my theory from looking at it initially. but looking at the sideline camera view it is just as plausible to have arrhythmia 2/2 the blunt impact.

 

[patriot6]

I saw the hit and my initial thought was vasovagal as well.

From the way the hit was it doesn't look like commotio cordis, like if you think about how the heart sits inside the chest and how he was bracing for the impact. Higgins made contact on the left shoulder and neck area and Hamlin landed on his left arm/side. None of that screams direct blunt contact to the heart to me.

More likely it's vasovagal -> apnea -> hypoxia rather than arrhythmia -> hypotension -> cardiac arrest.

But it's kinda impossible to tell. I hope he turns out ok.

eh, idk... vasovagal... then 9 minutes of CPR?

 

[GravelRider]

I saw the hit and my initial thought was vasovagal as well.

From the way the hit was it doesn't look like commotio cordis, like if you think about how the heart sits inside the chest and how he was bracing for the impact. Higgins made contact on the left shoulder and neck area and Hamlin landed on his left arm/side. None of that screams direct blunt contact to the heart to me.

More likely it's vasovagal -> apnea -> hypoxia rather than arrhythmia -> hypotension -> cardiac arrest.

But it's kinda impossible to tell. I hope he turns out ok.

Vasovagal resulting in syncope is plausible, but vasovagal resulting in cardiac arrest? I would assume there was some underlying cardiac disease if that was the etiology…long QT syndrome, valvular abnormality, hypertrophic cardiomyopathy, etc..

 

[Beeftenderloin]

I saw the hit and my initial thought was vasovagal as well.

From the way the hit was it doesn't look like commotio cordis, like if you think about how the heart sits inside the chest and how he was bracing for the impact. Higgins made contact on the left shoulder and neck area and Hamlin landed on his left arm/side. None of that screams direct blunt contact to the heart to me.

More likely it's vasovagal -> apnea -> hypoxia rather than arrhythmia -> hypotension -> cardiac arrest.

But it's kinda impossible to tell. I hope he turns out ok.

Vasovagal hard enough to break all that sympathetic tone? His HR was prob 110-120 at the time of the hit. And even if he did vasovagal > syncopize, why would he have prolonged apnea? Something else would have to be wrong for him to stop breathing. I watched the hit on replay a bunch of times. I don’t think it was when they hit the ground, it was when his opponents helmet first made contact with his chest. That was the “commotio cordis” moment. And as others have said, a relatively minor hit can generate the joules necessary to elicit a “pacer spike”, and in this instance it hit at just the right millisecond to cause an R on T. That’s my hypothesis at least. As you said though, no way to really know.

 

[Radetzky]

Goodness some of the theories put forward in this thread are bizarre. Vasovagal? What exactly was the vagal stimulus. How does that lead to 9 minutes of CPR?

Cessation of cerebral blood flow is not instantaneous, whether sitting or standing.

There are a bunch of videos you can find on YouTube of this phenomenon- dude gets hit in chest, staggers around for a bit, then collapses a few seconds later

 

[Radetzky]

 

[Southpaw]

eh, idk... vasovagal... then 9 minutes of CPR?

+ intubated and sedated in ICU currently

It’s not vasovagal folks

 

[dchz]

Vasovagal? What exactly was the vagal stimulus. How does that lead to 9 minutes of CPR?

Helmet to carotid body on a 23 year old.

 

[dchz]

Upon looking further, I agree with the above and think it is more likely that commotio occured during the initial impact.

It is more noticeable from the sideline camera view.

 

[BobLoblaw78]

Good vascular tone will get you perfusion without cardiac output. Just think of patients that are awake and get Adenosine (esp if you have seen it without sedation).

+1 on commotio

 

[GravelRider]

If I remember my CCU days from IM correctly, hypothermia protocols are usually around 48hrs….24hrs at goal hypothermia temperature followed by a day of slow rewarming. We probably won’t know status for at least another day or two.

There was another Bills player about 15 years ago that was cooled after a spinal cord injury. The role hypothermia played in his recovery has been controversial.

Doctors on the Scene Acted Quickly to Treat Everett With Cold Therapy (Published 2007)

In the moments after a serious spinal cord injury paralyzed Kevin Everett of the Buffalo Bills below the shoulders, doctors began an innovative treatment based on a familiar premise.

www.nytimes.com

 

[Vandalia]

The thing that worries me is that there are reports of him only getting CPR after they got him on the stretcher. It's always possible that there was some confusion about what was going on, but you'd have expected CPR to be the first thing administered in that kind of situation.

Just listening to an interview with one of the NFL physicians that CPR started immediately and the AED was used before the ambulance arrived on the field.

There are reports that they had to resume CPR as they were loading him on the ambulance, which has its own possible interpretations, and may account for the confusion.

 

[Vandalia]

I saw the hit and my initial thought was vasovagal as well.

From the way the hit was it doesn't look like commotio cordis, like if you think about how the heart sits inside the chest and how he was bracing for the impact. Higgins made contact on the left shoulder and neck area and Hamlin landed on his left arm/side. None of that screams direct blunt contact to the heart to me.

Looking at the video, the football was between Hamlin's chest and the WR when he was tackled. It is possible the football may have provided the source for the more focused blunt contact.

 

[dchz]

Upon looking further, I agree with the above and think it is more likely that commotio occured during the initial impact.

It is more noticeable from the sideline camera view.

Looking at the video, the football was between Hamlin's chest and the WR when he was tackled. It is possible the football may have provided the source for the more focused blunt contact.

 

[ERRES2288]

I wonder how much oxygen he using at that particular time that could have led to faster anoxic brain injury? Just a theory

 

[anaesthetic]

Goodness some of the theories put forward in this thread are bizarre. Vasovagal? What exactly was the vagal stimulus. How does that lead to 9 minutes of CPR?

Cessation of cerebral blood flow is not instantaneous, whether sitting or standing.

There are a bunch of videos you can find on YouTube of this phenomenon- dude gets hit in chest, staggers around for a bit, then collapses a few seconds later

Relax, buddy. It’s all going to be okay.

 

[GassYous]

Young people have high vagal tone and it's not impossible for someone to start bleeding in a small enclosed area

 

[dchz]

I wonder how much oxygen he using at that particular time that could have led to faster anoxic brain injury? Just a theory

I agree that his particular metabolic state would probably cause him to be somewhat hypoxic.

But I would imagine effective CPR would give him ample oxygen supply given his lungs are probably top notch.

The time between circ arrest and start of quality CPR is probably gonna determine how well he does long term.

 

[epidural man]

I agree that his particular metabolic state would probably cause him to be somewhat hypoxic.

But I would imagine effective CPR would give him ample oxygen supply given his lungs are probably top notch.

The time between circ arrest and start of quality CPR is probably gonna determine how well he does long term.

He has the blessing of youth.

 

[anes121508]

haven't been in the unit in years now but what are the requirements for hypothermia? any minimum exam findings or anything that excludes you from being cooled?

 

[Radetzky]

haven't been in the unit in years now but what are the requirements for hypothermia? any minimum exam findings or anything that excludes you from being cooled?

No, anybody whose ventilated post arrest. Besides which hypothermia is rarely practiced anymore- mostly TTM (35-36 degrees).

 

[anes121508]

No, anybody whose ventilated post arrest. Besides which hypothermia is rarely practiced anymore- mostly TTM (35-36 degrees).

my guess given would be they are doing some cooling protocol hence the lack of updates but who knows

 

[Ronin786]

No, anybody whose ventilated post arrest. Besides which hypothermia is rarely practiced anymore- mostly TTM (35-36 degrees).

I don't do TTM for everybody that's vented. I just shut off sedation immediately and if I get a neuro status avoid fevers. Data is way too murky.

Reports out there are showing he's down to 50% FiO2 from 100% so I'm guessing he may have had some contusion and pulmonary edema contributing

 

[anes121508]

any updates on how long till they initiated cpr? looking at replay videos I don't see cpr by the first folks out there at 2 min mark

correct me if i'm wrong but the out of hospital witnessed arrest stats aren't great, especially if cardiac in nature and especially if >2-3 min till cpr initiated

feel like folks in media and news are more hopeful and not many people mentioning stats perhaps for obvious gruesome reasons

 

[anes121508]

I don't do TTM for everybody that's vented. I just shut off sedation immediately and if I get a neuro status avoid fevers. Data is way too murky.

Reports out there are showing he's down to 50% FiO2 from 100% so I'm guessing he may have had some contusion and pulmonary edema contributing

or just he never never needed the 100% fio2 or maybe he did from the cpr itself

 

[anes121508]

I don't do TTM for everybody that's vented. I just shut off sedation immediately and if I get a neuro status avoid fevers. Data is way too murky.

Reports out there are showing he's down to 50% FiO2 from 100% so I'm guessing he may have had some contusion and pulmonary edema contributing

what do you quote people in terms of outcome for witnessed arrest given time to cpr and time till rosc?

so much data out there and haven't read this in a while

 

[Iso4ane]

I know people think the hit was ‘minor’, but we’re talking about elite athletes on both ends. There probably more than enough energy to cause commotio cord is. And with regards to a vagal response and prolonged hypoxia, granted these guys probably had a elevated metabolism, but I would imagine the time required to cause arrhythmia from apnea would be a decent amount of time in the athletes.

 

[gcc322]

Wouldn’t immediate defib correct the arrhythmia from commotio? Saw a report that he arrested again in the ambulance or upon arrival to the hospital.

 

[vector2]

haven't been in the unit in years now but what are the requirements for hypothermia? any minimum exam findings or anything that excludes you from being cooled?

Very large trial (called TTM2) came out recently which has settled the question for many ICUs. Essentially the data showed that maintenance of normothermia (avoidance of fever) has similar outcomes to therapeutic hypothermia but with fewer side effects (arrhythmia, hypotension). It's also cheaper and less labor intensive.

 

[aneftp]

I had ob patient during c/s down for 20 minutes before we got rhythm back. No pulse. Cpr. We were about to call it and she came back. It was crazy during c/s. Obviously some type of Pe

She was 20. Survived. Discharged 1 week later walked out the door

What was funny was when she woke up 2 days later. We were concern her speech was “off”. So thinking stroke. Or incoherent. And then her dad came in and said “oh this is how she normally is “. Sometimes u get lucky with young patients coding.