When I first saw the video of Damar Hamlin’s collapse during Monday Night Football this week, before any real information was available, my first reaction was that he had a cardiac arrest.
There aren’t many things that make someone lose consciousness so rapidly that they lead to a collapse like that, and a life threatening irregular heartbeat is at the top of the list.
You can see the video here. He’s part of a seemingly innocuous tackle, gets up, and then collapses to the ground:
I’m really happy to hear that he seems to be recovering, which is amazing and probably reflective of the fact that he received prompt CPR and early defibrillation.
Obviously, I’m not the doctor that’s taking care of him, so I don’t know any of the specifics about what is happening, but there are some things I suspect based on what we’ve heard.
It’s been reported and confirmed that Hamlin had a cardiac arrest, which refers to a sudden loss of heart function, which totally fits the clinical picture from the video.
Hearing that his collapse was confirmed as a cardiac arrest doesn’t tell us much about the cause, since there are many different conditions that can potentially lead to a cardiac arrest.
What I think we can infer about this case
There’s a ton we don’t know here, and anyone who suggests they know much definitively is kind of full of it.
But based on what I watched and some of the published reports that I’ve seen, there’s actually a decent amount of information that we can reasonably think is true.
He received CPR for about 10 minutes on the field, which suggests that he had a fairly prompt return of circulation.
For a young person without previously life threatening medical conditions, no one would stop CPR after such a short period of time unless the patient had regained circulation - the short duration of CPR suggests that he promptly got a heartbeat back.
We also know that he wasn’t breathing on his own and required a breathing tube.
That suggests that he didn’t have complete and immediate recovery of his mental status.
The reason we do CPR during a cardiac arrest is to preserve brain function, and anything other than immediate normalization of mental status would usually lead to a patient being placed on something called “therapeutic hypothermia,” which means that the body temperature is gradually cooled for a period of about 24 hours before being rewarmed.
Cooling the body is thought to preserve brain function, although most of the benefit there is probably from preventing fever.
So it’s not surprising that we haven’t heard that much about details of recovery for a patient with a cardiac arrest who needed a breathing tube - he spent 24 hours being cooled and then another 24 hours being warmed back up.
The signs that we’re seeing are promising so far - he’s communicating and seems to have pretty intact cognition.
And the fact that he got such early CPR and recovered circulation so quickly really make me think that his chances of full neurologic recovery are quite good.
The cause of this remains uncertain
If you’ve been following the story, you’ve probably heard a lot of people speculating that the diagnosis here is commotio cordis which is a sudden blow to the chest leading to ventricular fibrillation, an irregular heartbeat that is not compatible with normal bloodflow to the brain:
This is a rare diagnosis, but it’s not unheard of.
On first pass watching the video of his collapse, I had suspected that this wasn’t the right diagnosis because a correctly timed blow to the heart causes ventricular fibrillation basically instantly, and he had time to get up before collapsing.
As I’ve read more about commotio cordis, I’ve learned that there’s significant variability in the timing of passing out, even if the irregular heartbeat happens instantly:
“Although cardiovascular collapse is virtually instantaneous, 20% of victims remain physically active for a few seconds after the blow (e.g., continuing to walk, run, skate, throw a ball, or even speak), which may reflect individual tolerance for sustained ventricular tachyarrhythmias.”
But as I said above, we’re just speculating about what caused this.
He’s going to go through a huge battery of tests - looking at bloodflow to the heart, the structure of his heart, his EKG, his echocardiogram, probably genetic testing, maybe even a look at his blood vessels throughout the body in more detail.
It may be some time before we know exactly what happened.
This case reminds me of why passing is one of my most feared complaints to hear from patients
The medical term for fainting is syncope, and when I hear syncope, I get worried.
If you were to ask to a primary care doctor, an internal medicine resident, a cardiology fellow, or a hospitalist, you’d probably hear that most syncope is nonsense, meaning it isn’t anything to be worried about.
The reason for that is tons of people pass out, and the vast majority of the time it’s for completely benign reasons - they’re dehydrated, they had a vasovagal episode, they lost some weight and now their high blood pressure medication dose is a bit too high.
But what Damar Hamlin experienced is what we call “lights out syncope,” which means that he hit the ground without being able to brace himself.
Coming in after passing out with head or facial trauma makes me worried that someone passed out because of a life threatening irregular heartbeat.
Some of my worst patient cases have happened in patients who had episodes of passing out without a warning and without being able to brace themselves.
That’s a very different type of passing out than feeling nauseated, lightheaded, and then slumping to the ground or a chair.
If you hear about a friend or family member (or you personally experience) this kind of “lights out syncope” that means it’s time to seek out prompt medical attention.
The most important take home from this case: CPR works, and everyone should know how to do it
Prompt CPR saves lives and you knowing CPR can be the difference between a loved one surviving from a cardiac arrest or dying from it.
The things that make the biggest difference in brain recovery following a cardiac arrest are:
Time between collapse and start of CPR/defibrillation
Quality of CPR/defibrillation
That’s really all we can control. And luckily, CPR is easy to learn.
Someone who has had a cardiac arrest is unresponsive, and once you’ve identified that someone isn’t answering you, the steps here are simple:
Call 9-1-1
Start CPR
CPR is easy to do - take a look:
If you prefer to read rather than watch:
Put the person on his or her back on a firm surface and kneel next to their shoulders.
Place the lower palm of your hand over the center of the person's chest, between the nipples. Place your other hand on top of the first hand. Keep your elbows straight and position your shoulders directly above your hands.
Push straight down on (compress) the chest about 2 inches. Use your entire body weight (not just your arms) when doing compressions. Allow the chest to recoil.
Push hard at a rate of 100 to 120 compressions a minute. The American Heart Association suggests performing compressions to the beat of the song "Stayin' Alive." Allow the chest to spring back (recoil) after each push.
Continue chest compressions until there are signs of movement or until emergency medical personnel take over.
Knowing CPR is easy - you don’t need to think about rescue breaths, you don’t need to remember ratios.
Just starting chest compressions and calling for help can save a life.
Here’s to hoping that Damar Hamlin continues to have a full, speedy recovery.