236 LEADERS Br J Med: first published as 10.1136/bjsm.36.4.236 on 1 August 2002. Downloaded from Sudden death in be “near miss” cases of commotio cordis...... This may have happened in 1998 to St Louis Blues hockey captain Chris Pronger, when he collapsed briefly, then Commotio cordis spontaneously regained consciousness, after being struck on the left side of his P McCrory chest by a puck during a playoff game.21 ...... It is possible that other near miss cases have gone undetected because the ar- Instantaneous caused by a blow to the chest rhythmias were too brief to cause loss of consciousness. depends on the timing of the blow relative to the cardiac cycle In another part of their study, Link et al18 examined whether the use of safety 15 udden death following a sharp but established. In many ways, the concept , which are softer than regula- seemingly inconsequential blow to of commotio cordis paralleled that of tion balls, could reduce the risk of Sthe chest is a frightening occur- commotio cerebri (brain concussion) for arrhythmia in the animal model. They rence known as “commotio cordis” or which the issue of structural injury has found that the risk was proportional to “concussion of the .” Although been controversial since the early 1700s the hardness of the ball. This finding commotio cordis is considered rare by and terminological inexactitude has may have implications for the prevention some authors, it represents one of the plagued the medical literature up to the 16 of commotio cordis in young most common mechanisms of sudden present day. players, as properly designed safety 1 death in sport seen in young athletes. baseballs are feasible for use in recrea- PATHOPHYSIOLOGY Commotio cordis is generally under- tional baseball and Little League. An- The most comprehensive early experi- stood to mean “instantaneous cardiac other approach to prevention is the use mental physiological studies of this condi- arrest produced by non-penetrating of chest protectors specifically designed tion were performed by Georg Schlomka chest blows in the absence of heart to cushion the precordium. As not all at Bonn University in the early 1930s.17 On disease or identifiable morphologic in- cases will be preventable, it is important 23 the basis of more than 800 experiments jury to the chest wall or heart”. Most to emphasise that rapid cardiopulmon- cases report accidental death of other- on anaesthetised animals, he identified three factors that determined the induc- ary resuscitation, including a precordial wise healthy children or adolescents “thump” and immediate defibrillation after chest impact during recreational or tion of arrhythmias by moderate precor- dial impact: type of impact, location of when possible, may be lifesaving. competitive sport or, less commonly, Both early and contemporary research during road traffic accidents.4–9 impact, and force of impact. Schlomka disproved the vagal reflex theory and pro- into commotio cordis appears to have Such fatalities receive extensive media posed the “vascular crisis” concept of been motivated by case reports of sud- coverage, provoke legal debate, and may mechanically induced coronary vasos- den death. It is sobering that a seemingly stimulate research into the public health pasms to explain commotio cordis. minor chest impact at an instant when aspects of this condition—for example, The risk factors identified by the heart is suspended in diastole can the capacity of protective gear to prevent Schlomka in the 1930s are still relevant, have such devastating consequences. commotio cordis or the possibility of 10 whereas the identification of a fourth Br J Sports Med 2002;36:236–237 http://bjsm.bmj.com/ developing safer sporting equipment. factor (timing of impact) had to wait for technological advances. Contemporary ...... HISTORY experimental investigations into com- The current concept of commotio cordis Author’s affiliations motio cordis with anaesthetised pigs P McCrory, Centre for Sports Medicine is often ascribed to a review of 70 cases Research and Education and the Brain Research 2 confirmed the existence of such a vul- by Maron et al. Their report portrays nerable period during early ventricular Institute, University of Melbourne, Melbourne, commotio cordis as a rare but dangerous repolarisation and showed the involve- Australia condition in which there is usually a ment of ATP dependent potassium chan- Correspondence to: Dr McCrory, PO Box 93, poor response to resuscitatory measures. nels in the electrophysiological genesis Shoreham, Victoria 3916, Australia; on September 28, 2021 by guest. Protected copyright. Most of those affected were young of this condition.18–20 [email protected] (mean age 12 years), male (all but one), When the precordial impacts were and, at the time of accident, engaged in delivered within a narrow temporal win- REFERENCES sport (>90%). The event leading to sud- 1 McCrory P, Berkovic S, Cordner S. Deaths dow between 30 and 15 milliseconds due to brain injury among footballers in den death was a precordial impact, most before the peak of the T wave, ventricular Victoria, from 1968 to 1998. Med J Aust commonly by projectiles such as base- fibrillation was reproducibly induced. 2000;172:217–20. balls, , or hockey pucks, probably The vulnerable period of the cardiac 2 Maron BJ, Link MS, Wang PJ, et al. Clinical profile of commotio cordis: an under occurring during an electrically vulner- cycle amounted to just over 1/100th of a 11 appreciated cause of sudden death in the able phase of the cardiac cycle. second. Remarkably, ventricular fibrilla- young during sports and other activities. J Interestingly, the term commotio tion was immediate, occurring on the Cardiovasc Electrophysiol 1999;10:114–20. cordis was in use as early as 1857.12 13 A 3 Curfman D. Fatal impact: concussion of the very next heart beat. The arrhythmia was heart. N Engl J Med 1998;338:1841–3. review from 1896 shows that the term not produced by impacts at any other 4 Frazer M, Mirchandani H. Commotio cordis, was applied to various forms (both lethal time during the cardiac cycle, although revisited. Am J Forensic Med Pathol and non-lethal) of cardiovascular disor- transient complete heart block was 1984;5:249–51. 5 Kaplan JA, Karofsky PS, Volturo GA. der caused by mechanical impact to the sometimes observed with impacts dur- Commotio cordis in two amateur chest (both in the presence and absence ing the QRS complex. Occasionally, with players despite the use of commercial chest of minor cardiac bruising).14 impacts delivered just outside the 15 protectors: case reports. J Trauma Commotio cordis underwent a con- 1993;34:151–3. millisecond period of vulnerability, un- 6 Edlich RF, Jr, Mayer NE, Fariss BL, et al. ceptual modification at the turn of the sustained polymorphic ventricular Commotio cordis in a goalie. J Emerg century whereby a distinction between was seen.18 19 Med 1987;5:181–4. non-penetrating precordial impact in the The observation that transient rhythm 7 Dikman G, Hassan A, Luckstead E. following baseball presence (contusion) or absence (com- disturbances may occur with chest im- injury. Physician and Sports Medicine motion) of cardiac bruising was pact raises the possibility that there may 1978;6:85–6.

www.bjsportmed.com LEADERS 237 Br J Sports Med: first published as 10.1136/bjsm.36.4.236 on 1 August 2002. Downloaded from 8 Green E, Simpson L, Kellerman H, et al. 13 Nesbitt AD, Cooper PJ, Kohl P. Rediscovering 18 Link MS, Wang PJ, Pandian NG, et al.An Cardiac concussion following blow to commotio cordis. Lancet 2001;357:1195–7. experimental model of sudden death due to the chest. Ann Emerg Med 1980;9:155–7. 14 Bernstein R. Uber die durch Contusion und low-energy chest-wall impact (commotio 9 Michalodimitrakis EN, Tsatsakis AM. Erschutterung entstehenden Krankenheiten des cordis). N Engl J Med 1998;338:1805–11. Vehicular accidents and cardiac concussion. Herzens. Z Klin Med 1896;29:519–55. 19 Link MS, Wang PJ, VanderBrink BA, et al. A traumatic connection. Am J Forensic Med 15 Riedinger F, Kummell H. Die verletzungen Selective activation of the K(+)(ATP) channel is Pathol 1997;18:282–4. und Erkrankungen des und seines a mechanism by which sudden death is 10 Froede RC, Lindsey D, Steinbronn K. Sudden Inhaltes. In: von Bergman E, P vB, eds. produced by low-energy chest-wall impact unexpected death from cardiac concussion Handbuch der praktischen cirurgie. 2nd ed. (Commotio cordis). Circulation (commotio cordis) with unusual legal complications. J Forensic Sci 1979;24:752–6. Stuttgart: Enke, 1903:373–456. 1999;100:413–18. 11 Maron BJ, Poliac LC, Kaplan JA, et al. Blunt 16 McCrory P, Berkovic S. Concussion: historical 20 Cooper G, Pearce B, Stainer M, et al. The impact to the chest leading to sudden death development of clinical and biomechanical response of the thorax from cardiac arrest during sports activities. N pathophysiological concepts and tonon-penetrating impact with particular Engl J Med 1995;333:337–42. misconceptions. Neurology 2001;57:2283–9 reference to cardiac injuries. J Trauma 12 Casper J. Practisches handbuch der 17 Schlomka G. Commotio cordis und ihre 1982;22:994–1008. gerichtlichen Medicine. 1st ed. Berlin: Verlag Folgen. Ergebn Inn Med Kinderheilkd 21 Luecking D. Pronger relives a scary incident. von August Hirschwald, 1857. 1934;47:1–91. St Louis Post-Dispatch 1998 May 12;sect C:1.

Revalidation SECTION 2: WHAT YOU DO ...... This section will describe what you do and where you do it. It must cover all aspects of your medical practice, paid or Revalidation in sport and exercise voluntary, including private practice, insurance and medicolegal work, teach- medicine ing, research, administration, and man- agement. This section should give a clear D A D Macleod, M E Batt, S Sheard outline of your caseload and case-mix in ...... all aspects of your clinical practice. It should include a job description and role The proposed annual appraisal of practitioners of sport and profile where available. exercise medicine is outlined SECTION 3: INFORMATION ON YOUR PRACTICE n 1999 the General Medical Council Doctors who are already Members or This section will be based on the GMC (GMC) of the United Kingdom agreed Fellows of a Faculty or Medical Royal publication Good medical practice and will Ithat “all doctors must be able to dem- College recognised by the Academy of require careful preparation and annual onstrate regularly that they continue to Medical Royal Colleges will be able to review to ensure its accuracy.3 1 be fit to practice in their chosen field”. obtain revalidation with the support of The portfolio should show good profes- This process is termed revalidation. Doc- their parent college. All doctors who sional standards of clinical care, record http://bjsm.bmj.com/ tors who complete revalidation will be practice sport and exercise medicine on keeping—for example, contemporaneous, granted a “licence to practice”, affording either a part time or full time basis will legible, and signed notes—and availabil- them the rights and privileges currently have to meet all the GMC requirements. ity to patients including out of hours and associated with being included on the There are many doctors in the United when dealing with emergencies. general register of the GMC. Kingdom who are independent practi- You will be expected to demonstrate Each individual doctor’s revalidation tioners and currently practice sport and that you are maintaining and developing will be reviewed every five years by two exercise medicine without being Mem- good standards of clinical practice by doctors and a single lay person. This team

bers or Fellows of a Medical Royal undertaking audits and showing how on September 28, 2021 by guest. Protected copyright. will be drawn from a local revalidation the audits have influenced your practice. pool of trained people. Revalidation will College or Faculty. It will be particularly You will be expected to record adverse be based on the contents of the individual important for this group of sport and clinical events and how they were doctor’s revalidation portfolio. Each doc- exercise medicine practitioners to ensure resolved. All complaints should also be tor’s portfolio, irrespective of their spe- that they undergo annual appraisal and documented and their outcome re- cialty, will follow a standardised format. are in a secure position to meet the The relevant guidelines describing appro- requirements of revalidation. corded. priate standards of practice will be drawn We here outline the contents of the Communication skills will be assessed up by the Medical Royal Colleges. This revalidation portfolio recommended by by administration of patient surveys, the immediately creates a challenge for sport the GMC. Establishing a portfolio and results of which will be incorporated in and exercise medicine which does not preparing for annual appraisal will be- the portfolio. Sport and exercise medi- have a single parent Medical Royal Col- come an increasingly important aspect cine practitioners involved with a team lege and is not widely recognised as a spe- of the professional lifestyle of all doctors. cialty, although a small number of doctors The revalidation folder recommended Section 3: Information on your have already been placed on the GMC by the GMC is divided into four practice specialist register. sections.2 The Intercollegiate Academic Board of Sport and Exercise Medicine (IABSEM) • Good professional practice is responsible to its parent Medical Royal • Maintaining good clinical practice SECTION 1: YOUR PERSONAL • Relations with patients Colleges and Faculties for setting stand- AND REGISTRATION DETAILS • Working with colleagues ards in sport and exercise medicine and • Teaching and training would seem to be the appropriate body to This section will record personal bio- • Honesty draw up relevant guidelines to meet graphical and educational details, in- • Health revalidation standards. cluding your current GMC number.

www.bjsportmed.com 238 LEADERS Br J Sports Med: first published as 10.1136/bjsm.36.4.236 on 1 August 2002. Downloaded from or group of athletes may find that SECTION 4: APPRAISAL Preparing for appraisal surveys of the manager, , or sports Mandatory annual appraisal of all as- participant for whom they are responsi- pects of every doctor’s practice will be the ble will be expected. basis of the revalidation process. The • How good a doctor am I? • How well do I perform You must record continuing profes- quality of the annual appraisal should ? • How up to date am I? sional development covering all aspects of highlight deficiencies or potential prob- • How well do I work in a team? your professional activities as outlined in lems that may restrict or prevent revali- • What resources and support do I Section 2 of your folder. The Academy of dation, thereby giving the doctor con- need? Medical Royal Colleges has issued a cerned the opportunity to ensure that • How well am I meeting my service framework on this aspect of the they are addressed before any subse- objectives? portfolio.4 quent appraisal. • What are my development needs? The Academy believes its framework Section 2 of the revalidation folder will will improve the safety and quality of outline all aspects of medical practice for medical practice by encouraging life long which information must be recorded in to establish a revalidation portfolio as learning and making transparent the Section 3. outlined above and identify how their processes required for successful imple- The person to be appraised will be annual appraisal will take place. mentation of continuing professional expected to ensure that their folder is Br J Sports Med 2002;36:237–238 development and audit. accurate and up to date. The appraiser, The GMC places great emphasis on the who would normally be appointed by ...... ability of every doctor to work effectively either a primary health care or employ- Authors’ affiliations in teams with colleagues, nurses, profes- ing hospital trust, would be expected to D A D Macleod, Intercollegiate Academic sions allied to medicine, clerical staff, Board of Sport and Exercise Medicine, ensure that appropriate audits or surveys Edinburgh, Scotland, UK and other professionals as well as lay of the doctor’s team working and com- M E Batt, Centre for Sports Medicine, University people. This includes placing responsibil- munication skills have been completed. Hospital, Department of Orthopaedic and ity on colleagues to be aware of each The appraiser would be a doctor Accident Surgery, Queens Medical Centre, Nottingham NG7 2UG, UK other’s standards of practice, conduct, or trained and experienced in this aspect of S Sheard, BMI Health Services, Greyfriars, 10 health if they may in any way be putting maintaining professional standards of Queen Victoria Road, Coventry CV1 3PJ, UK patients at risk. practice. The appraisal interview will Any doctor who teaches or trains jun- Correspondence to: Dr Macleod, Chairman of become a crucial component of every the Intercollegiate Academic Board of Sport and ior medical staff, or other professionals, doctor’s professional development and Exercise Medicine, Nicolson Street, Edinburgh will be expected to show a commitment will be based on a 360º review of every EH8 9DW, Scotland, UK; [email protected] to developing educational standards and aspect of a doctor’s practice.5 recording feedback on the teaching pro- At the end of the interview the doctor REFERENCES grammes in which they are involved. and his or her appraiser should record the 1 General Medical Council. Revalidating doctors. London: General Medical Council, Good medical practice also identifies outcome, highlighting any areas of con- 2000. honesty in clinical, research, and finan- cern that may interfere, in due course, 2 General Medical Council. Pilot revalidation cial matters as being criteria against with revalidation. Potential solutions for folder and piloting guidance. London: General Medical Council, 2001. which revalidation will be measured. any problems should be outlined. Signifi- 3 General Medical Council. Good medical

This includes honesty in writing reports cant concerns identified by an appraiser practice. 3rd ed. London: General Medical http://bjsm.bmj.com/ and in the provision of references. should be forwarded to the relevant trust Council, 2000. 4 Academy of Medical Royal Colleges and Finally this section of the revalidation or other appropriate bodies. their Faculties. A Framework for Continuing portfolio requires the doctor to confirm Professional Development. London: Academy that his or her own health, whether CONCLUSION of Medical Royal Colleges and their Faculties, 2001. physical or psychological, is such that they All doctors involved in sport and exercise 5 J King. 360° appraisal. BMJ are fit to practice in their chosen field(s). medicine on a full or part time basis need 2002;324:s195. on September 28, 2021 by guest. Protected copyright.

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