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Med Sci Law OnlineFirst, published on March 9, 2015 as doi:10.1177/0025802415575590
Case report
Homicidal commotio cordis caused by domestic violence: A report of two cases
Medicine, Science and the Law 0(0) 1–4 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0025802415575590 msl.sagepub.com
Jiao Mu*, Ji Zhang*, Liang Liu and Hongmei Dong
Abstract Commotio cordis is a rare and fatal mechano-electric arrhythmogenic syndrome, occurring mainly during sports activities. The present study describes two cases of sudden death due to homicidal commotio cordis caused violence from an intimate partner. The two decedents were both young women. They suffered from physical abuse by their intimate partner and collapsed immediately after being punched in the precordium. Electrocardiograms were recorded at the hospital and showed ventricular fibrillation in one case. An autopsy was performed in each case, and no structural cardiac damage, evident lesions of other internal organs or underlying diseases were found. Combined with the negative toxicological analysis, it was concluded that the cause of death was commotio cordis due to a blunt force to the anterior chest. To the best of the authors’ knowledge, there is no published report on commotio cordis caused by physical abuse from an intimate partner. The accurate diagnosis of the cause of death is emphasised, as it is important for judicial fairness. Keywords forensic science, forensic pathology, sudden cardiac death, commotio cordis, homicide, chest trauma
Introduction Commotio cordis is a rare event consisting of sudden cardiac death triggered by a blunt, non-penetrating and often innocent-appearing unintentional blow to the chest without damage to the ribs, sternum or heart.1 The term was first used in the 18th century by Schmitz to distinguish commotio cordis from cardiac contusion.2 In recent years, most reported cases of commotio cordis have occurred during competitive and recreational sporting activites.3 Interestingly, it is now evident that commotio cordis events can occur as part of routine day-to-day living and can arise in a variety of circumstances that are unrelated to sporting activities, such as traffic accidents or violent attacks.4–6 However, there have been few published reports on commotio cordis caused by domestic violence. To the authors’ knowledge, only two commotio cordis cases related to fatal child abuse have been reported.7,8 Herein, two cases of fatal death due to commotio cordis are presented in which women suffered from domestic violence and collapsed after being punched in the precordium.
Case reports Case 1 The victim was a 24-year-old woman who was home alone with her husband. She had a fight with her
husband at 22:40. After being punched in the precordium, the victim could hardly breath and collapsed within 10 seconds. Her husband called the emergency services and recounted the course of events. Approximately 10 minutes later, emergency medical personnel arrived at the scene and found that she had no spontaneous breathing or pulse. The victim was given chest compressions and was taken to hospital. Emergency department staff delivered a 200 J biphasic shock. Simultaneously, inotropic support was undertaken with adrenaline and dobutamine. Electrocardiograms showed ventricular fibrillation (see Figure 1). Despite an hour of aggressive resuscitation, the victim died. The body was 157 cm long and weighed 47 kg. The nasolabial groove had skin-stripped abrasion measuring 0.5 cm0.2 cm. An internal examination showed no injury to the sternum, ribs, lungs, heart or arteries. The heart weighed 330 g with a thickness of 11 mm in the left ventricular wall and 3 mm in the right Department of Forensic Medicine, Tongji Medical College of Huazhong University of Science and Technology, People’s Republic of China *These authors contributed equally to this work Corresponding author: Hongmei Dong, Department of Forensic Medicine, Tongji Medical College of Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan, Hubei 430030, People’s Republic of China. Email: [email protected]
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Figure 1. Electrocardiograms showing ventricular fibrillation.
ventricular wall. The coronary arteries and cardiac valves were normal. Histologically, no abnormalities of the myocardium or conduction system were found. The remaining internal organs were normal macroscopically and microscopically. Post-mortem toxicological analysis was negative for alcohol, drugs and common toxicants.
Case 2 A 26-year-old woman was assaulted by her husband because of household issues. She developed pallor and collapsed within three minutes of impact in the precordium by her husband’s knee. Their 4-year-old daughter witnessed the events. Resuscitation was not performed at the scene. She was immediately transported to the local community hospital. Upon arrival, she was pronounced dead. An autopsy showed that the women appeared to be moderately nourished and well-developed. The body was 153 cm long and weighed 45 kg. On gross examination of the body, no finding was identified, except for a bruise and subcutaneous haemorrhage in the anterior side of the chest. An internal examination was unremarkable. The sternum was intact, and no fractures were found in the bilateral ribs. The heart was normal in size, weighing 250 g, with a thickness of 11 mm in the left ventricular wall and 3 mm in the right ventricular wall. No abnormalities were detected in the coronary arteries, cardiac valves or pericardium. No congenital anomalies or myocardial injuries were found in the heart. Post-mortem toxicological analysis was negative for alcohol, drugs and common toxicants.
Discussion Violence by an intimate partner affects individuals all over the world regardless of financial status, age, race,
religion, nationality and educational background, and women are often the victims of assault by their partners.9 The physical abuse can sometimes be life-threatening. To the authors’ knowledge, there is no reported case of commotio cordis caused by domestic violence. Commotio cordis is a recognised rare cause of sudden death in which an apparently minor blow to the chest causes ventricular fibrillation. The low incidence is associated with the specificity of the risk factors. Kohl et al.10 proposed that at least four risk factors determine the severity of mechanically induced dysrhythmia: (1) the type of mechanical stimulus: swift, impulse-like impact to a small contact area; (2) the strength of the impact: medium-to-high subcontusion levels; (3) the impact site: precordial area with emphasis on the ventricular projection; and (4) the timing of the impact relative to the cardiac cycle: early T-wave. The type, strength and site of the impact in the two cases presented meet these risk factors. Extensive research has provided data to support the hypothesis that impact to the precordium will transiently increase left ventricle pressure with deformation of the cell membrane, which could activate mechanosensitive channels, and eventually lead to abnormal repolarisation and ventricular fibrillation.11 According to the literature, a blow from a ball, kick, fist, knee or even a stick could trigger the ventricular fibrillation of commotio cordis.12 In contrast to most decedents of commotio cordis who are usually men,13 the victims in the presented cases were young women. In general, the lower incidence of commotion cordis in women is likely influenced by the fact that they are less likely to participate in ball-related sports or fights. However, it is proposed that women may be the high-risk group when commotio cordis occurs as a result of violent
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Mu et al. attack from an intimate partner. The age and habitus (body mass index 19 kg/m2) of the victims in the two presented cases are consistent with reports that commotio cordis occurs more commonly in adolescents with a thin and compliant chest wall, which allows greater transmission of energy to the heart after impact.14 Commotio cordis is usually fatal. According to statistics, the mortality rate approaches 97% when resuscitative efforts are delayed for more than three minutes.15 Unfortunately, the victims in the case studies presented here did not receive effective and immediate rescue at the scene. Currently, an accurate diagnosis of commotio cordis is still difficult in forensic practice. Maron et al.3 reported 128 confirmed cases which fulfilled the following inclusion criteria: a witnessed event of a blunt, non-penetrating blow to the chest that immediately preceded cardiovascular collapse; detailed documentation of the circumstances from available newspaper articles, police reports and telephone interviews with family members or other witnesses; absence of structural damage to the sternum, ribs or heart itself; and absence of any underlying cardiovascular abnormalities. In the two cases presented, the perpetrators detailed and admitted the circumstances in which the victim collapsed immediately after being impacted in the precordium. Moreover, testimony from the emergency medical staff in case 1 and the daughter in case 2 also supported the event of a precordial blunt blow. The victim in case 1 did show mild cardiac hypertrophy. However, it did not prove to be fatal during normal day-to-day activities, and it seems unlikely to have been the immediate cause of death. Therefore, neither structural damage nor disease could explain the victim’s instantaneous death. Combined with the negative toxicological analysis, it was concluded that the cause of death in each case was commotio cordis due to a blunt force to the anterior chest. Commotio cordis in domestic violence is not easily recognised due to the lack of obvious physical findings and clear witness evidence; often the perpetrator is the only witness. It is necessary to differentiate commotio cordis from other pathological entities without obvious physical findings, such as smothering. Death due to smothering without obvious autopsy findings usually occurs when the victims are infants, elderly or asleep. However, it is usually accompanied by a defence wound and abrasion or subcutaneous haemorrhage around the nose when the victims are healthy and conscious. In the presented cases, the victims were healthy young women who were conscious at the time of the assault, and none of the above-mentioned injuries mentioned were found. Hence, smothering as the cause of death was not considered. Moreover, electrocardiograms showing ventricular fibrillation in case 1 and the autopsy findings of injuries in the precordium in case 2 also supported the diagnosis of commotio cordis.
3 Considering the difficulty in diagnosing commotion cordis, an immediate and thorough investigation is warranted. An accurate history of events preceding the death must be obtained as far as possible, especially from the perpetrator, family member, emergency medical personnel and potential witness who arrived first at the scene. Simultaneously, a complete and detailed autopsy is very important in order to exclude other pathological entities. Even a minor injury, which may reveal the crime, should not be neglected in the autopsy. Moreover, it is important to make judicial authorities understand how a minor blow to the chest can result in the death of a young and healthy person.16
Conclusion This report highlights the relatively infrequent occurrence of commotio cordis as a result of physical abuse by an intimate partner. Women may be a high-risk group when commotio cordis occurs because of domestic violence. The report reminds us to be aware of the importance of a systematic and careful autopsy combined with a thorough investigation of blunt trauma death without obvious injury. A correct diagnosis is significant for judicial fairness, especially in terms of the conviction and severity of the sentence. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Declaration of conflicting interests The authors declare that they have no conflict of interest.
References 1. Maron BJ, Poliac LC, Kaplan JA, et al. Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. New Engl J Med 1995; 333: 337–342. 2. Schlomka G and Hinrichs A. Experimentelle Untersuchungen u¨ber den Einfluß stumpfer Brustkorbverletzungen auf das Elektrokardiogramm. Res Exp Med 1932; 81: 43–61. 3. Maron BJ and Estes NM III. Commotio cordis. New Engl J Med 2010; 362: 917–927. 4. Hamilton S, Sunter J and Cooper P. Commotio cordis – a report of three cases. Int J Legal Med 2005; 119: 88–90. 5. Miyazaki T, Ihama Y and Fuke C. An autopsy case of commotio cordis from a motor scooter accident. Legal Med 2008; 10: 264–267. 6. Zheng N, Liang M, Liu Y, et al. Commotio cordis – a report of two similar cases. J Forensic Sci 2013; 58: 245–247. 7. Baker AM, Craig BR and Lonergan GJ. Homicidal commotio cordis: the final blow in a battered infant. Child Abuse Neglect 2003; 27: 125–130. 8. Denton J and Kalelkar M. Homicidal commotio cordis in two children. J Forensic Sci 2000; 45: 734–735.
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4 9. Karangelis D, Karkos CD, Tagarakis GI, et al. Thoracic injuries resulting from intimate partner violence. J Forensic Leg Med 2011; 18: 119–120. 10. Kohl P, Nesbitt AD, Cooper PJ, et al. Sudden cardiac death by commotio cordis: role of mechano-electric feedback. Cardiovasc Res 2001; 50: 280–289. 11. Maron BJ, Roberts WC, McAllister HA, et al. Sudden death in young athletes. Circulation 1980; 62: 218–229. 12. Zheng N, Liang M, Liu Y, et al. Imprudent blow, catastrophic consequence: a case of commotio cordis associated with violence. Soc Sci Med 2012; 52: 119–121.
Medicine, Science and the Law 0(0) 13. Link MS. Commotio cordis ventricular fibrillation triggered by chest impact-induced abnormalities in repolarization. Circ Arrhythmia Elec 2012; 5: 425–432. 14. Spencer RJ, Sugumar H, Jones E, et al. Commotio cordis: a case of ventricular fibrillation caused by a cricket ball strike to the chest. Lancet 2014; 383: 1358. 15. Wurzelbacher JR, Manning AD, Hendricks-Vesel JC, et al. A 33-year-old soldier with blunt cardiac arrest. J Emerg Nurs 2012; 38: 537–538. 16. Lucena JS, Rico A, Salguero M, et al. Commotio cordis as a result of a fight: report of a case considered to be imprudent homicide. Forensic Sci Int 2008; 177: e1–e4.
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[1–4] [PREPRINTER stage]
Med Sci Law OnlineFirst, published on March 9, 2015 as doi:10.1177/0025802415575590
Case report
Homicidal commotio cordis caused by domestic violence: A report of two cases
Medicine, Science and the Law 0(0) 1–4 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0025802415575590 msl.sagepub.com
Jiao Mu*, Ji Zhang*, Liang Liu and Hongmei Dong
Abstract Commotio cordis is a rare and fatal mechano-electric arrhythmogenic syndrome, occurring mainly during sports activities. The present study describes two cases of sudden death due to homicidal commotio cordis caused violence from an intimate partner. The two decedents were both young women. They suffered from physical abuse by their intimate partner and collapsed immediately after being punched in the precordium. Electrocardiograms were recorded at the hospital and showed ventricular fibrillation in one case. An autopsy was performed in each case, and no structural cardiac damage, evident lesions of other internal organs or underlying diseases were found. Combined with the negative toxicological analysis, it was concluded that the cause of death was commotio cordis due to a blunt force to the anterior chest. To the best of the authors’ knowledge, there is no published report on commotio cordis caused by physical abuse from an intimate partner. The accurate diagnosis of the cause of death is emphasised, as it is important for judicial fairness. Keywords forensic science, forensic pathology, sudden cardiac death, commotio cordis, homicide, chest trauma
Introduction Commotio cordis is a rare event consisting of sudden cardiac death triggered by a blunt, non-penetrating and often innocent-appearing unintentional blow to the chest without damage to the ribs, sternum or heart.1 The term was first used in the 18th century by Schmitz to distinguish commotio cordis from cardiac contusion.2 In recent years, most reported cases of commotio cordis have occurred during competitive and recreational sporting activites.3 Interestingly, it is now evident that commotio cordis events can occur as part of routine day-to-day living and can arise in a variety of circumstances that are unrelated to sporting activities, such as traffic accidents or violent attacks.4–6 However, there have been few published reports on commotio cordis caused by domestic violence. To the authors’ knowledge, only two commotio cordis cases related to fatal child abuse have been reported.7,8 Herein, two cases of fatal death due to commotio cordis are presented in which women suffered from domestic violence and collapsed after being punched in the precordium.
Case reports Case 1 The victim was a 24-year-old woman who was home alone with her husband. She had a fight with her
husband at 22:40. After being punched in the precordium, the victim could hardly breath and collapsed within 10 seconds. Her husband called the emergency services and recounted the course of events. Approximately 10 minutes later, emergency medical personnel arrived at the scene and found that she had no spontaneous breathing or pulse. The victim was given chest compressions and was taken to hospital. Emergency department staff delivered a 200 J biphasic shock. Simultaneously, inotropic support was undertaken with adrenaline and dobutamine. Electrocardiograms showed ventricular fibrillation (see Figure 1). Despite an hour of aggressive resuscitation, the victim died. The body was 157 cm long and weighed 47 kg. The nasolabial groove had skin-stripped abrasion measuring 0.5 cm0.2 cm. An internal examination showed no injury to the sternum, ribs, lungs, heart or arteries. The heart weighed 330 g with a thickness of 11 mm in the left ventricular wall and 3 mm in the right Department of Forensic Medicine, Tongji Medical College of Huazhong University of Science and Technology, People’s Republic of China *These authors contributed equally to this work Corresponding author: Hongmei Dong, Department of Forensic Medicine, Tongji Medical College of Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan, Hubei 430030, People’s Republic of China. Email: [email protected]
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Figure 1. Electrocardiograms showing ventricular fibrillation.
ventricular wall. The coronary arteries and cardiac valves were normal. Histologically, no abnormalities of the myocardium or conduction system were found. The remaining internal organs were normal macroscopically and microscopically. Post-mortem toxicological analysis was negative for alcohol, drugs and common toxicants.
Case 2 A 26-year-old woman was assaulted by her husband because of household issues. She developed pallor and collapsed within three minutes of impact in the precordium by her husband’s knee. Their 4-year-old daughter witnessed the events. Resuscitation was not performed at the scene. She was immediately transported to the local community hospital. Upon arrival, she was pronounced dead. An autopsy showed that the women appeared to be moderately nourished and well-developed. The body was 153 cm long and weighed 45 kg. On gross examination of the body, no finding was identified, except for a bruise and subcutaneous haemorrhage in the anterior side of the chest. An internal examination was unremarkable. The sternum was intact, and no fractures were found in the bilateral ribs. The heart was normal in size, weighing 250 g, with a thickness of 11 mm in the left ventricular wall and 3 mm in the right ventricular wall. No abnormalities were detected in the coronary arteries, cardiac valves or pericardium. No congenital anomalies or myocardial injuries were found in the heart. Post-mortem toxicological analysis was negative for alcohol, drugs and common toxicants.
Discussion Violence by an intimate partner affects individuals all over the world regardless of financial status, age, race,
religion, nationality and educational background, and women are often the victims of assault by their partners.9 The physical abuse can sometimes be life-threatening. To the authors’ knowledge, there is no reported case of commotio cordis caused by domestic violence. Commotio cordis is a recognised rare cause of sudden death in which an apparently minor blow to the chest causes ventricular fibrillation. The low incidence is associated with the specificity of the risk factors. Kohl et al.10 proposed that at least four risk factors determine the severity of mechanically induced dysrhythmia: (1) the type of mechanical stimulus: swift, impulse-like impact to a small contact area; (2) the strength of the impact: medium-to-high subcontusion levels; (3) the impact site: precordial area with emphasis on the ventricular projection; and (4) the timing of the impact relative to the cardiac cycle: early T-wave. The type, strength and site of the impact in the two cases presented meet these risk factors. Extensive research has provided data to support the hypothesis that impact to the precordium will transiently increase left ventricle pressure with deformation of the cell membrane, which could activate mechanosensitive channels, and eventually lead to abnormal repolarisation and ventricular fibrillation.11 According to the literature, a blow from a ball, kick, fist, knee or even a stick could trigger the ventricular fibrillation of commotio cordis.12 In contrast to most decedents of commotio cordis who are usually men,13 the victims in the presented cases were young women. In general, the lower incidence of commotion cordis in women is likely influenced by the fact that they are less likely to participate in ball-related sports or fights. However, it is proposed that women may be the high-risk group when commotio cordis occurs as a result of violent
XML Template (2015) [5.3.2015–10:05am] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/MSLJ/Vol00000/150002/APPFile/SG-MSLJ150002.3d
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[1–4] [PREPRINTER stage]
Mu et al. attack from an intimate partner. The age and habitus (body mass index 19 kg/m2) of the victims in the two presented cases are consistent with reports that commotio cordis occurs more commonly in adolescents with a thin and compliant chest wall, which allows greater transmission of energy to the heart after impact.14 Commotio cordis is usually fatal. According to statistics, the mortality rate approaches 97% when resuscitative efforts are delayed for more than three minutes.15 Unfortunately, the victims in the case studies presented here did not receive effective and immediate rescue at the scene. Currently, an accurate diagnosis of commotio cordis is still difficult in forensic practice. Maron et al.3 reported 128 confirmed cases which fulfilled the following inclusion criteria: a witnessed event of a blunt, non-penetrating blow to the chest that immediately preceded cardiovascular collapse; detailed documentation of the circumstances from available newspaper articles, police reports and telephone interviews with family members or other witnesses; absence of structural damage to the sternum, ribs or heart itself; and absence of any underlying cardiovascular abnormalities. In the two cases presented, the perpetrators detailed and admitted the circumstances in which the victim collapsed immediately after being impacted in the precordium. Moreover, testimony from the emergency medical staff in case 1 and the daughter in case 2 also supported the event of a precordial blunt blow. The victim in case 1 did show mild cardiac hypertrophy. However, it did not prove to be fatal during normal day-to-day activities, and it seems unlikely to have been the immediate cause of death. Therefore, neither structural damage nor disease could explain the victim’s instantaneous death. Combined with the negative toxicological analysis, it was concluded that the cause of death in each case was commotio cordis due to a blunt force to the anterior chest. Commotio cordis in domestic violence is not easily recognised due to the lack of obvious physical findings and clear witness evidence; often the perpetrator is the only witness. It is necessary to differentiate commotio cordis from other pathological entities without obvious physical findings, such as smothering. Death due to smothering without obvious autopsy findings usually occurs when the victims are infants, elderly or asleep. However, it is usually accompanied by a defence wound and abrasion or subcutaneous haemorrhage around the nose when the victims are healthy and conscious. In the presented cases, the victims were healthy young women who were conscious at the time of the assault, and none of the above-mentioned injuries mentioned were found. Hence, smothering as the cause of death was not considered. Moreover, electrocardiograms showing ventricular fibrillation in case 1 and the autopsy findings of injuries in the precordium in case 2 also supported the diagnosis of commotio cordis.
3 Considering the difficulty in diagnosing commotion cordis, an immediate and thorough investigation is warranted. An accurate history of events preceding the death must be obtained as far as possible, especially from the perpetrator, family member, emergency medical personnel and potential witness who arrived first at the scene. Simultaneously, a complete and detailed autopsy is very important in order to exclude other pathological entities. Even a minor injury, which may reveal the crime, should not be neglected in the autopsy. Moreover, it is important to make judicial authorities understand how a minor blow to the chest can result in the death of a young and healthy person.16
Conclusion This report highlights the relatively infrequent occurrence of commotio cordis as a result of physical abuse by an intimate partner. Women may be a high-risk group when commotio cordis occurs because of domestic violence. The report reminds us to be aware of the importance of a systematic and careful autopsy combined with a thorough investigation of blunt trauma death without obvious injury. A correct diagnosis is significant for judicial fairness, especially in terms of the conviction and severity of the sentence. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Declaration of conflicting interests The authors declare that they have no conflict of interest.
References 1. Maron BJ, Poliac LC, Kaplan JA, et al. Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. New Engl J Med 1995; 333: 337–342. 2. Schlomka G and Hinrichs A. Experimentelle Untersuchungen u¨ber den Einfluß stumpfer Brustkorbverletzungen auf das Elektrokardiogramm. Res Exp Med 1932; 81: 43–61. 3. Maron BJ and Estes NM III. Commotio cordis. New Engl J Med 2010; 362: 917–927. 4. Hamilton S, Sunter J and Cooper P. Commotio cordis – a report of three cases. Int J Legal Med 2005; 119: 88–90. 5. Miyazaki T, Ihama Y and Fuke C. An autopsy case of commotio cordis from a motor scooter accident. Legal Med 2008; 10: 264–267. 6. Zheng N, Liang M, Liu Y, et al. Commotio cordis – a report of two similar cases. J Forensic Sci 2013; 58: 245–247. 7. Baker AM, Craig BR and Lonergan GJ. Homicidal commotio cordis: the final blow in a battered infant. Child Abuse Neglect 2003; 27: 125–130. 8. Denton J and Kalelkar M. Homicidal commotio cordis in two children. J Forensic Sci 2000; 45: 734–735.
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4 9. Karangelis D, Karkos CD, Tagarakis GI, et al. Thoracic injuries resulting from intimate partner violence. J Forensic Leg Med 2011; 18: 119–120. 10. Kohl P, Nesbitt AD, Cooper PJ, et al. Sudden cardiac death by commotio cordis: role of mechano-electric feedback. Cardiovasc Res 2001; 50: 280–289. 11. Maron BJ, Roberts WC, McAllister HA, et al. Sudden death in young athletes. Circulation 1980; 62: 218–229. 12. Zheng N, Liang M, Liu Y, et al. Imprudent blow, catastrophic consequence: a case of commotio cordis associated with violence. Soc Sci Med 2012; 52: 119–121.
Medicine, Science and the Law 0(0) 13. Link MS. Commotio cordis ventricular fibrillation triggered by chest impact-induced abnormalities in repolarization. Circ Arrhythmia Elec 2012; 5: 425–432. 14. Spencer RJ, Sugumar H, Jones E, et al. Commotio cordis: a case of ventricular fibrillation caused by a cricket ball strike to the chest. Lancet 2014; 383: 1358. 15. Wurzelbacher JR, Manning AD, Hendricks-Vesel JC, et al. A 33-year-old soldier with blunt cardiac arrest. J Emerg Nurs 2012; 38: 537–538. 16. Lucena JS, Rico A, Salguero M, et al. Commotio cordis as a result of a fight: report of a case considered to be imprudent homicide. Forensic Sci Int 2008; 177: e1–e4.
