Football is unique out of the major sports because you can’t just squeeze in another game. It’s not safe to play a game without recovery time. The World Series was easy because there is no time crunch. Just push back the end of the season. If it didn’t happen at the World Series have a double header or take away one off day. This isn’t the end of the season or even the playoffs. There isn’t a lot of free time available without both teams playing on very little rest. It’s a question that doesn’t have an easy answer
Thanks for writing the post I was about to write. 
I hope that his doctors are eventually able to talk more about the case, just out of medical curiosity.
I’d bet that they’re keeping him in hypothermia right now. After an arrest like this dropping the body temperature to around 33 degrees C (91 F) for 24-48 hours can help prevent long-term neurologic damage. The evidence on it is mixed, but it’s still very common to do.
Those first 48-72 hours after a code like this are frustrating for everybody because you really don’t know how it’s going to turn out. Families think that we know and just don’t want to say, but it really is impossible to know at that point. The overall numbers are against him, but being young and a pro athlete are in his favor.
1960’s cartoon portends the future:
Too soon?
Um, yes.
Not much to add to some excellent posts. Although arrhythmia secondary to cardiac contusion, and possible pulmonary contusion remain the most likely things, there are a couple things to add for the sake of completeness.
Young healthy athletes sometimes die due to undiagnosed heart conditions. Hypertrophic cardiomyopathy is the most commonly discussed one and is a clinical diagnosis rather than an EKG finding. It could be subtle (does your doctor listen for murmurs while making you strain, or in sitting and standing positions?) and therefore easily missed. Covid and genetic, infective and other things can also cause myocarditis and several syndromes (such as Brugada - easy to miss on EKG) may predispose people to arrhythmias. These can also be affected by (unlikely in this case) use of steroids, alcohol, street drugs, dehydration, extreme climates and many other things. A number of genetic things also can cause blood clotting problems which can result in emergent situations.
No EMT would diagnose brain death in the field with an EEG (as said above) but tests like cephalic and ocular reflexes are still commonly used. In the absence of possible neck injury, one might look for appropriate Doll’s Eye movements, for example, and there are several similar things. In the ER an ultrasound of the heart is useful in this context.
That last part is surprising. My father went into A-fib and was given an implant, but he’s old and was going into spontaneous A-fib after some monitoring. What’s the rationale for putting one into a young person like him if the cause was in fact blunt force trauma? To this layman, it seems unlikely to be a recurrent problem. Is the logic that the damage sustained makes an arrythmia more common going forward or is the suspicion that he has a predisposition in spite of the apparent triggering event? I certainly would hope that the rationale is more considered than “most people who have cardiac arrest need one”.
psychobunny, aren’t there some nerves in the neck near the carotid artery that affect heart rate if struck? His helmet started to come off and he reached up to his helmet before he passed out. I was wondering if he got tagged in the neck along with the chest. Trying to look up what a medical person called it. Baroreceptor? I’ve been hit in the neck before and it felt like I got shocked in the chest.
Massaging the carotid sinus in the neck can slow the heart rate. It is a technique used in certain atrial arrythmias in order to stop them. However, it is a transient effect that stops when the pressure is lifted. The major side effect is that if you have plaque in the artery, it can break free and cause a stroke. Contrary to popular opinion, strokes do not usually result in loss of consciousness. They cause weakness and numbness and can cause a person to fall but they are usually conscious. Only in very severe strokes or brainstem strokes are patients completely unresponsive. A direct hit to the carotid sinus is unlikely to cause the situation seen.
As far an an implantable defibrillator goes, you need to distinguish between atrial fibrillation and ventricular fibrillation. The atria are the top chambers of the heart and fire first. The ventricles are the bottom chambers and are supposed to respond to the electrical signals from the atria. In either type of fibrillation, the electrical signals are off and the part of the heart basically just quivers.
In atrial fibrillation the ventricles, or main pumping chambers of the heart, are working but they are not getting a regular signal. Therefore, they sometimes fire randomly and sometimes can sense every little quiver as a beat and fire too fast. You can treat atrial fibrillation by cardioversion, which is converting the atria to a normal rhythm. This is similar to defibrillation but uses a much lower amount of energy. However, you can also treat it by essentially ignoring the atria and giving medications to make sure the ventricles don’t fire too quickly. If they are firing too slowly, you can put in a pacemaker. The point is that while there are many ways to treat the atrial fibrillation (such as cardioversion, medications and electrical ablation) as long as your ventricles are pumping normally, you can live for years with chronic atrial fibrillation, and many people do. Therefore, there is not usually a need for an implantable defibrillator in atrial fibrillation, although the pacemakers they have these days can actually overdrive pace people out of atrial fibrillation.
In ventricular fibrillation, however, it is the main pumping chambers that are fibrillating and so there is no effective blood flow. You have to resume a normal rhythm or the person will die. The presumption is that anyone who goes into ventricular fibrillation may have an underlying irritability of the heart that predisposes to this happening again. In addition, the damage caused by cardiac arrest and restarting the heart can also lead to an increased risk of recurrent ventricular fibrillation.
An implantable defibrillator senses ventricular fibrillation and can immediately delivery a small focused shock to the heart. The benefit is that you use much lower amounts of energy because you are applying current directly to the heart and the treatment is immediate, often before the patient loses consciousness, so brain damage is minimized. These defibrillators are also used for ventricular tachycardia which is also a dangerous, but more regular arrhythmia. It is amazingly cool what these devices can do. Way back in residency, we had a patient develop chest pain, caused by ventricular tachycardia which was at a rate just below the cut off rate on his defibrillator. The cardiologist let me do the reprogramming. There is nothing quite like saving a patient’s life by tapping a few computer keys and watching him get shocked back into normal rhythm while you sit at the computer. Arrhythmia specialists are totally cool and I am not even a general cardiologist much less an arrhythmia subspecialist so believe me when I say that this is the most basic of explanations and they understand this much much more than I do. (Also, the local arrhythmia doctors totally rock. Literally. As in they have a rock band. I have their CD and have been to a few shows at the local bar.I am comforted in the fact that they have good rhythm.)
Thank you. You’ve posted some great information.
In fact it used to be thought people in atrial fibrillation did need to be restored to regular rhythm if possible. Certainly many prefer this, but the AFFIRM trial showed only rate control was required to reduce the risk of stroke. I remember when it was published, maybe 2002?
It may be that blunt trauma caused ventricular fibrillation. It is likely that was the rhythm involved but I am unaware someone has said this definitively and there are other possibilities. Since this arrhythmia is so dangerous and other predisposing causes and risk factors may exist I agree an implantable defibrillator seems reasonable. Occasionally implantable pacemakers and fibrillation go haywire and you have to comb the ER looking for a magnet until they can be reprogrammed.
Many arrhythmia specialists are level headed, but a few of them have a fearsome tempo. The ones I know won’t be getting the band back together anytime soon.
Thanks for all the detail. My question is based on a couple assumptions. One, that this is in fact commotio cordis and that the kid doesn’t have some pre-existing heart issue. Two, that if he avoids blunt force trauma to the chest this situation is unlikely to recur spontaneously.
Based on both your responses (I understand it’s all speculative) I’m inferring that implanting a defibrillator is a thing that would be done as a prophylactic measure. Even if there’s no concrete evidence of a pre-existing condition or notable risk factor, it would still be considered routine to install a device “just in case”. Is that a fair reading of your replies?
According to both my sister and nephew, both of whom have implantable defibrillators that have gone off, because it kicks in before you lose consciousness you get to “enjoy” the shock, which apparently does not feel that small to the person receiving it. But they both agree it’s better than dying. These devices have absolutely saved their lives, my sister’s more than once. They are pretty amazing.
(Unfortunately, we have discovered a bad gene in my family that predisposes to sudden, fatal arrhythmia that is not readily detectable by other tests.)
The only downside is that folks with implantable defibrillators have some restrictions, but most people just go about their lives. For the young man in question, Mr. Hamlin, if he winds up with such a device he will not be able to continue to play football.
No matter what happens, he won’t be able to play football.
Even if Hamlin didn’t need such a device, he would probably be too psychologically traumatized/wary to ever play a down of football again.
That’s assuming he’d even remember the tackle. It’s not unusual for someone suffering such a serious incident/injury to have no memory of the event.
At this point, my wishes are that he recovers sufficiently for a normal life. Whether or not he could continue to be an elite athlete (of any sort) is an additional step beyond that.
I guess anything is possible. I felt the same way about Tedy Bruschi, to the point that I had trouble watching him play after his stroke.
Hopeful news for Hamlin, based on a statement issued by the Bills this morning:
Great to hear!
I wonder how he’s “demonstrated that he appears to be neurologically intact.” Does that mean he’s awake and communicating, or is it based on tests that can be performed while he’s unconscious?
Based on how the statement is worded, I kind of suspect it’s more the latter.
Yes, my first thought was, does that mean grossly intact?