CONTENT: Commotio cordis is blunt, nonpenetrating trauma to the chest resulting 
in irregular heart rhythm and often leading to sudden death. This article 
presents the epidemiology, variables leading to commotio cordis, theories on 
predisposing factors, diagnosis, treatment, treatment outcomes, and 
return-to-play recommendations.
EVIDENCE ACQUISITION: A PubMed (MEDLINE) search for commotio cordis was 
conducted on July 1, 2008, and it yielded 106 results, of which 26 were used for 
this review, including experimental models, simulation studies, case analysis 
studies, case reports, general recommendation, review articles, and editorials.
RESULTS: There are more than 190 reported cases of commotio cordis in the United 
States. Forty-seven percent of reported cases occurred during athletic 
participation. Commotio cordis is the second-most common cause of sudden cardiac 
death in athletes. Occurrence of commotio cordis is related to time of impact 
during the cardiac cycle, direct impact over the heart, the hardness and speed 
of the projectile, and the ineffectiveness of chest barriers. As a result, the 
US Consumer Product Safety Commission recommends that softer "safety" baseballs 
be used for youth baseball. Resuscitation using defibrillation was effective in 
only 15% of cases. Resuscitation within 3 minutes resulted in a survival rate of 
25% (17 of 68 cases). Survival drops to 3% when resuscitation is delayed beyond 
3 minutes. Survival of commotio cordis has risen from 10% to 15% since 2001. 
Reduced ventricular ejection fraction has been identified in some commotio 
cordis survivors.
CONCLUSION: Preventive measures, such as using soft "safety" balls and making 
automated external defibrillators available at sporting venues, can reduce 
commotio cordis morbidity and mortality. Chest protector designs can be improved 
to enhance protection. Return to play is best left to clinical judgment given 
that data are lacking with regard to susceptibility for reoccurrence.