A. Commotio Cordis
Blunt, nonpenetrating blows to the chest are known to produce ventricular fibrillation, albeit rarely, without associated injury to the ribs, sternum, or heart. This condition is a more common cause of sudden death in athletes than all other conditions except hypertrophic cardiomyopathy. Commotio (disturbance, concussion) cordis is most common in individuals less than 16 years of age, because at this age the chest wall is still pliable and probably enhances transmission of the energy from the chest blow to the myocardium. Survival after commotio cordis occurs in less than 15% and may be achieved if cardiopulmonary resuscitation and defibrillation are readily applied.
In commotio cordis the blow may not be considered intense enough to cause death. Blows of sufficient magni¬tude may be produced by a blow from sports projectiles like a pitched baseball, hockey puck, or lacrosse ball; a karate blow or a blow delivered to relieve hiccups, or a collision between outfielders during baseball. Other injuries include a nonpenetrating blow to the neck that may rupture a vertebral artery and result in death from hemorrhage.
B. Cocaine, Anabolic Steroids, and Herbal Stimulants
The use of cocaine, anabolic steroids, and dietary supple¬ments, particularly those containing ephedrine/ephedra (ma huang), are potent cardiac stimulants and may precipitate life-threatening arrhythmias.

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