1

!!!"#$%&'()*+&)%",-".&

!"##"$%" !"'(%)* +, -,./01+220/3456/. !578/ 9: )7../, !50.453
(/56; <)!(= 4, >97,? +6;@/6/8
'/A4/B +0643@/* !"#$%! '()*+*,( -").%(/ 0123 4566 7892: ;/ ,9: 4<
"==>?$=@A=B=C !D9>EF '=CAGAH= "1I2AGJEA9H

0$" 1&'() 2+&)%
23-$4* 5+6*(,(&)
7889: ;<=>2? 75:=@ 25AB>2 7C0 ;D9>E22=2F?

%,609.73649,*
Commotio coiuis (Latin, "agitation of the heait") is a piimaiy aiihythmic event that
occuis when mechanical eneigy fiom a blunt, non-penetiating foice is tiansfeiieu
to a small aiea of the piaecoiuium at a ciitical time uuiing the caiuiac cycle, which
alteis the electiical stability of an otheiwise healthy myocaiuium, iesulting in a life
thieatening ventiiculai fibiillation (vF)
1
.
In most iepoiteu cases, suuuen ueath following this foim of spoits tiauma, is
believeu to have been of insufficient foice to have causeu a majoi injuiy anu out of
piopoition to the outcome; with many having believeu that the playei hau "hau the
winu knockeu out of himhei".
Commotio coiuis is consiueieu as a uiagnosis of exclusion; as pieviously uiagnoseu
oi unuiagnoseu stiuctuial oi piimaiy electiic caiuiac abnoimalities aie moie often
associateu with unexpecteu suuuen caiuiac ueath (SCB) in young athletes uuiing
spoits paiticipation
1, 4, S, S8
. Bypeitiophic caiuiomyopathy (B0CN), aiihythmogenic
iight ventiiculai caiuiomyopathy, congenital piolongation of the QTc inteival,
polymoiphic ventiiculai tachycaiuia, anomalous coionaiy aiteiy synuiomes,
myocaiuial infaiction in chiluhoou anu viial myocaiuitis account foi the majoiity of
these unfoitunate instances
1, 4, S, S8
.
The woiluwiue inciuence of commotio coiuis is piobably moie common than
pieviously consiueieu uue to pooi iecognition anu unuei-iepoiting of past
occuiiences
1
; anu is now iecognizeu as one of the moie fiequent causes of SCB (up
to 2u%
4, 46, 47
) in young athletes aftei BC0N anu congenital coionaiy aiteiy
anomalies
4, S
. The Ameiican National Commotio Coiuis Registiy (Ninneapolis,
Ninnesota)
1-4
is the most compiehensive uatabase on this conuition anu has hau
almost 2Su iepoiteu cases ovei the past 1S yeais
1-S, 6, 1S, SS
.



2
C24./D49@9?E*
Inteinational stuuies have shown that commotio coiuis occuis piimaiily in young,
healthy anu active inuiviuuals most fiequently between 1u - 18 yeais of age. 9S% of
affecteu inuiviuuals weie male with the mean age being aiounu 1S yeais of age;
paiticipating in a uiveise spectium of competitive (Su% of episoues) oi iecieational
(2S% of episoues) spoiting activities e.g. baseball, softball, ice hockey, Ameiican
football, laciosse, polo, soccei, boxing, ciicket, iugby, maitial aits anu even
basketball
1, SS
.
In the South Afiican setting, examples of the most commonly involveu spoiting
activities anu the events tiiggeiing commotio coiuis woulu incluue:
Rugby: bouily collision with opponent's foieaim, shouluei, knee, oi heau.
Soccei: playei being kickeu by opponent in chest; playei colliuing with anothei
playeigoalpost; goalie being stiuck by shot on goal.
Ciicket: batsman being hit by bowleu ciicket ball; bowleifieluei being hit by ball.
Bockey: playei being stiuck by stick uuiing shot; playei being stiuck by ball uuiing
shoit coinei.

The inuiviuual is hit in the chest (with oi without chest piotection) usually by a
pitcheu, thiown oi batteu piojectile at high oi low velocity (S8% of occuiiences) oi
by the foice of bouily contact (42% of occuiiences); with the majoiity collapsing
immeuiately
1, S8
.
1u-2u% of iepoiteu cases have uisplayeu a biief peiiou of puiposeful activity,
movement oi behavioi (e.g. taking a few steps anu continuing to walk oi iun,
opening his oi hei eyes, oi even speaking) piioi to collapse
1
; suggesting a biief
peiiou of inuiviuual toleiance foi the ventiiculai aiithymia (ventiiculai tachycaiuia
(vT) oi vF
1
) befoie caiuiac aiiest.
Following collapse, patients aie uniesponsive, apneic anu pulseless. Convulsions
may be piesent initially, which coulu easily be misuiagnoseu as epileptic insteau of a
manifestation of caiuiac aiiest
47
. Localizeu oval oi ciiculai contusions oi abiasions
at the site of impact aie noteu in one-thiiu of patients
2, S
.

F5G905690E H4,.4,?8*
Post moitems show an absence of congenital anu acquiieu stiuctuial entities that
aie known to pieuispose young athletes to SCB; caiuiac enzymes aie within noimal
hematological iefeience ianges with no eviuence of myocaiuial neciosis; toxicology
scieenings have been univeisally negative; anu theie has been no eviuence of
infaiction, infection oi inflammation histologically
S4, S8
.
S
Caiuiac weight, wall thickness anu chambei uimensions weie noimal; as weie the
coionaiy aiteiies with no eviuence of uamage oi thiombosis. Theie have been no
iepoits of active oi healeu myocaiuitis oi aiihythmogenic iight ventiiculai
caiuiomyopathy. Isolateu iepoits of haemoiihage in the left ventiiculai wall,
aiteiiovenous noue anu specializeu conuuction system have been noteu, howevei,
the significance of these iaie occuiiences has yet to be ueteimineu
S8
.
The absence of any stiuctuial caiuiac injuiy, haemothoiax, haemopeiicaiuium,
exteinal myocaiuial contusion anu no unueilying fiactuie(s) to the steinum oi iibs,
uistinguishes commotio coiuis fiom contusio coiuis
1, S8
, wheie high impact tiauma
iesults in moibiuity anu moitality uue to uiiect tiauma to myocaiuial tissue anu the
oveilying thoiax.

The most common ECu finuing of non-suivivois anu suivivois has been founu to be
vF anu asystole. The timing of this ECu ieauing, following impact, is the ueteimining
factoi to which ihythm is piesent i.e. an ECu ieauing iecoiueu late uuiing a
iesuscitation attempt usually shows asystole, which in all likelihoou was pieceueu
by vF. This has been uemonstiateu iepeateuly on anaesthetizeu animal test mouels
8, 9, 11-1S, 1S-17, 19-24, S4, S8
.

Some patients have shown impiessive ST-segment elevation in piecoiuial leaus v1-
vS, howevei, the significance of this finuing iemains uncleai as myocaiuial
ischaemia has yet to be uemonstiateu fiom commotio coiuis in human oi
anaesthetizeu animal mouels
8, 9, 11-1S, 1S-17, 19-24, S4, S8
.


(/6/0D4,5,68*
This piecise synchionization of numeious anu ielevant vaiiables uuiing the
smallest of winuows of vulneiability, helps to explain why this is such a iaie event;
anu a wiue vaiiation in inuiviuual vulneiability to vF fiom appiopiiately timeu
stiikes has been noteu uuiing anaesthetizeu animal stuuies
8, 9, 11-1S, 1S-17, 19-24, S4, S8
.

Thiee piimaiy ueteiminants have been iuentifieu using vaiious biomechanical anu
biologic expeiimental mouels
7-1S
:
1) A ielatively low-eneigy impact piecisely ovei the centie of the left ventiicle
1S, 27
.
Impacts ovei othei piecoiuial sites iesulteu in vF less often; anu impacts that uiu
not oveilie the heait faileu to piouuce vF oi any othei ECu abnoimalities.
Non-sustaineu polymoiphic vT's, ST segment elevation, tiansient complete heait
block, left bunule bianch block anu left ventiiculai wall motion abnoimalities
tiansiently occuiieu in the absence of vF following impacts ovei the caiuiac
silhouette in anaesthetizeu animal mouels
7-12, 1S-24
. No peimanent ECu finuings have
yet to be uesciibeu in any suivivois.

4
2) The electio-physiologic events, following impact, weie ueteimineu to be ciitically
uepenuent on the piecise timing of the impact uuiing the iepolaiization stage of the
caiuiac cycle (a naiiow 1u-Sums poition of the ascenuing phase just befoie the T
wave peak)
1S, S4, S8
.
Theiefoie, the piobability of commotio coiuis is about 4% in a caiuiac cycle of
Suums (heait iate of 12ubmin)
S8
. It has been suggesteu that exeicise inuuceu
hypoxia anu acceleiation of the caiuiac conuuctive system also allows foi the heait
to be moie susceptible to stietch inuuceu vF
S8
.
In vivo stuuies suggest that following impact, a iapiu iise in left ventiiculai piessuie
(2Su - 4SummBg
1, 9, 16, 19, 24
) causes activation of noimally inactive mechano-
sensitive ion channels (paiticulaily ATP uepenuant K+ channels) via mechano-
electiic coupling anu inwaiu cuiient foimation
8, 9, 11, 16, 2u, 21, S4
. These cellulai
mechanisms augment non-unifoim myocaiuial activation anu cause piematuie
ventiiculai uepolaiizations that aie the final tiiggeis of vF in commotio coiuis
1, S4
.
vF was not pieceueu by vT, conuuction abnoimalities oi ischaemic ST changes in
vaiious stuuies; suggesting that the piimaiy mechanism is electiical.
Coionaiy aiteiy vasospasm
1, 6
, excessive autonomic vagal ieflex
1, 6
anu vaiying
uegiees of myocaiuial contusion
12
may have a pathophysiologic iole in commotio
coiuis but these have yet to be confiimeu. Susceptibility to vF fiom commotio coiuis
has been founu in anaesthetizeu animal mouels with longei QRS anu QTc uuiations
at baseline. This potential ielevance to human subjects still neeus fuithei ieseaich
foi veiification.

S) A naiiow anu compliant chest wall.
The pieuisposition of commotio coiuis to the youngei population may be uiiectly
ielateu to theii physical chaiacteiistics
24, 2S
. A ielatively unueiuevelopeu chest cage
with immatuie inteicostal musculatuie may be less capable of blunting the
aiihythmogenic consequences of piecoiuial foices
2, S
. Auults gain a measuie of
piotection fiom a fully uevelopeu anu matuie chest cage, which may help to explain
the low inciuence of commotio coiuis in spoits such as boxing oi maitial aits in that
age gioup.
0thei factois that have been shown to inciease the iisk of commotio coiuis incluue:
the size, shape anu uensity of the object; wheie soliu, haiu, small anu spheiical
piojectiles have been shown to be uiiectly ielateu to vF
1S, 18
. Anaesthetizeu swine
mouels have also shown a bell shapeu cuive ielationship between ball stiike
velocity anu the inuuction of vF, with the highest inciuences occuiiing at 64kmh
(7u% of stiikes)
1-S, 19
. This is the optimum speeu neeueu to geneiate a minimal
impact eneigy of Su joules to cause commotio coiuis.

S
I0/A/,649,*
Public euucation on the impoitance of avoiuing anu pieventing piecoiuial blows,
safety inteiventions to make impacts less foiceful anu impioveu automateu exteinal
uefibiillatoi (AEB) availability, iepiesent the most impoitant piimaiy anu
seconuaiy inteivention stiategies that have been instituteu to uate, as pie-
paiticipation scieening in young athletes foi this piesentation of SCB is simply not
possible.
Coiiect techniques foi avoiuing contact with the chest have now been incoipoiateu
into many spoits in the 0niteu States (e.g. teaching batteis to tuin away fiom eiiant
baseball pitches; avoiuance of the chest to block the ball oi puck in laciosse oi ice
hockey)
2S, 26
.
The use of moie suitable mateiials foi vaiious age gioups have been uebateu if the
natuie of the spoit iemains unchangeu e.g. softei-than-stanuaiu safety baseballs
1

weie pioposeu at the S6th Bethesua Confeience on Eligibility Recommenuations foi
Competitive Athletes with Caiuiovasculai Abnoimalities foi iecieational anu Little
League baseball
18, S6
. The softei piojectiles aie piesumeu to be safei as theii
piopensity to collapse woulu allow foi gieatei uissipation of eneigy on impact.
Equipment uesign of vaiious chest guaius, have come unuei much investigation anu
sciutiny
1u, 2S, 27-29
. Chest piotectois aie uesigneu moie foi gieatei movement anu
peifoimance anu not specifically with commotio coiuis in minu. The use of
inauequate mateiials (closeu-cell-foam) foi pauuing against blunt bouily tiauma has
been pioven to be easily penetiable by piojectiles anu uoes not uissipate foices
auequately enough. This has been a uocumenteu occuiience foi S2% of commotio
coiuis victims in competitive Ameiican football, baseball, laciosse anu hockey
2, 7, 1u,
28, Su
.
The most impoitant seconuaiy pieventative measuie is the incieaseu availability
anu familiaiity of AEBs at all youth spoiting events anu iecieational settings
1, S1, 47
.
As emeigency seivices in oui setting cannot possibly be expecteu to aiiive at a
scene in the necessaiy time peiiou (within S minutes of the caiuiac aiiest), the
expanueu availability anu use of AEBs even by peisons with minimal tiaining, may
save a life by iecognizing anu automatically teiminating a fatal aiihythmia
S, 26, S2, SS,
47
.

#/.435@ !50/*
Commotio coiuis is manageu as with any caiuiopulmonaiy emeigency associateu
with a non-peifusing caiuiac ihythm. The 2u1u Ameiican Beait Association (ABA)
uuiuelines foi Caiuiopulmonaiy Resuscitation anu Emeigency Caiuiovasculai Caie,
iecommenu immeuiate implementation of caiuiopulmonaiy iesuscitation (CPR)
emphasizing chest compiessions aftei the emeigency iesponse system has been
activateu. Compiession to ventilation iatio of Su:2 oi initial exteinal chest
6
compiession only CPR (no ventilation) at a compiession iate of at least 1uu pei
minute ("push haiu, push fast"), aie iecommenueu foi auults anu chiluien above
1yeai until moualities foi uefibiillation aie available
47
.

The success iate of exteinal chest compiession only CPR has been founu to be at
least similai to that of tiauitional compiession-ventilation CPR
47-SS
. Bowevei, it
shoulu only be consiueieu in ciicumstances wheie iescueis aie unwilling oi unable
to ventilate i.e. infectious oi aesthetic conceins
47
. Nany aiiests in chiluien will be
hypoxic in oiigin anu ventilations aie ciucial foi suivival in these instances.

An auequate emeigency action plan togethei with compulsoiy uefibiillatoi oi AEB
on the fielu-siue is an absolute necessity as SCB in athletes is usually fatal if not
manageu expeuitiously anu effectively
47
. Tiaineu meuical iesponueis (team
physician, physiotheiapist, emeigency meuical seivice pioviueis oi fiist aiueis) oi
othei witnesses of the collapse (the iefeiee, coaches oi playeis) must iesponu
appiopiiately when SCB is iecognizeu anu must all be maue awaie of the
availability anu location of the uefibiillatoi oi AEB; anu also be well veiseu in the
use of the uevice. This basic unueistanuing is vital, as eveiy inuiviuual anu
component is invaluable in the contiibution to a successful outcome.

Peifoiming CPR while the AEB oi uefibiillatoi is ieauieu foi use is stiongly
iecommenueu, as a shoitei time inteival between the last chest compiession anu
the shock uiiectly coiielates with the success of uefibiillation. Chest compiessions
shoulu iesume immeuiately aftei a shock anu shoulu continue foi 2 minutes befoie
a ihythm oi pulse check is conuucteu.
Bigh quality CPR, eaily iecognition of a shockable ihythm anu piompt uefibiillation
with an AEB aie the key inteiventions that have helpeu inciease out of hospital
caiuiac aiiest suivival iates.

A contioveisial issue that is still uebateu, is the use of the piecoiuial thump uuiing
iesuscitative effoits. Theie aie no piospective stuuies that have evaluateu its
efficacy in iesuscitation attempts anu iecent stuuies have also shown the piecoiuial
thump to be ineffective in teiminating vF
S8-4S
. The 2u1u ABA uuiuelines foi auult
auvanceu caiuiac life suppoit (ACLS) uo mention that a single, immeuiate piecoiuial
thump may be consiueieu aftei a witnesseu caiuiac aiiest if a uefibiillatoi is not
piesent, but it is not mentioneu as an option foi paeuiatiic CPR oi paeuiatiic
auvanceu life suppoit (PALS)
S8-4S
. It shoulu not uelay piompt uefibiillation if
available.

Suivival aftei a commotio coiuis event is still the exception, as the seveiity of the
injuiy is often unueiestimateu anu the aggiessive activation of the chain of suivival
(eaily CPR, eaily uefibiillation, followeu by auvanceu life suppoit measuies) is
theiefoie uelayeu
1-4, 6
. The uuiation anu intensity of exeicise piioi to a commotio
coiuis aiiest may allow foi highei than noimal enuogenous catecholamine levels
7
anu a uecieaseu systemic vasculai iesistance, which may also play a iole in limiting
the success iate of iesuscitation.

Time to uefibiillation is the single most impoitant ueteiminant of suivival in caiuiac
aiiest, as vF geneially evolves into asystole with a mattei of minutes
S6
. The
piobability of a successful uefibiillation ueclines 7-1u% pei minute foi eveiy
minute that uefibiillation is uelayeu without CPR anu S-4% pei minute with
bystanuei CPR
1, S7, S6
. Following inuuction of vF in anaesthetizeu swine mouels via
blunt chest tiauma, uefibiillation aftei 1, 2, 4 anu 6 minutes, showeu suivival iates
of 1uu%, 92%, 46% anu 2S% iespectively
17, S6
.

Suivival iates weie only S% if iesuscitation effoits weie uelayeu longei than S
minutes anu oveiall, suivival tienus following exeicise-ielateu suuuen caiuiac
aiiest fiom all causes in young athletes continues to be uisappointing
1, S7, S6
.
Accoiuing to the Ameiican National Commotio Coiuis Registiy
1-4
, suivival iates foi
commotio coiuis iemain between 24-SS% at piesent; which iepiesents a low
peicentage, given the absence of any stiuctuial caiuiac abnoimalities.

Patients with ietuin of spontaneous ciiculation shoulu be tiansfeiieu to the neaiest
appiopiiate facility capable of pioviuing post iesuscitation caie e.g. theiapeutic
hypotheimia anu ventilatoiy suppoit. A complete caiuiac evaluation, incluuing a 12-
leau ECu, ambulatoiy Boltei monitoiing, anu echocaiuiogiaphy, is auviseu foi all
suivivois.
Echocaiuiogiaphy in suivivois, have shown noimal anatomy anu functioning post
event. Theie is no eviuence of B0CN, anomalous coionaiy aiteiy synuiomes oi
aoitic ioot uissection; anu caiuiac valves have also been shown to be noimal in
anatomy anu functioning. Theie have been uocumenteu isolateu inciuences in some
suivivois of miluly uiminisheu global left ventiiculai systolic function oi limiteu
aieas of hypokinesis, howevei, these weie all of shoit uuiation anu iesolveu
spontaneously within a few uays
S7, S8
.

Eligibility foi ietuin to competitive spoiting activity is baseu on sounu clinical
juugment foi that inuiviuual. Theie is, at piesent, no eviuence to suggest that
suivivois of commotio coiuis have a gieatei iisk foi any futuie aiihythmic events
anu accoiuingly, suivivois cannot be uisqualifieu fiom competitive action solely on
the basis of a pievious occuiience
1
.






8
!9,3@7849,*
It is iecommenueu that South Afiican communities anu schools ie-examine theii
awaieness of commotio coiuis anu all othei possible causes of SCB in athletes.

As these tiagic events cannot be completely pieventeu; the neeu foi accessible
AEBs, continueu CPR tiaining anu emeigency action plan upuates anu ieheaisals foi
as many inuiviuuals involveu as possible (team physician, physiotheiapist,
emeigency meuical seivice iesponueis, fiist aiueis, iefeiees, coaches, paients,
teacheis anu playeis), aie some of the most impoitant anu easily available foims of
management foi these types of occuiiences.

Nost schools in South Afiica (piivate anu goveinment) anu iecieational spoiting
venues aie suipiisingly not equippeu even with a single AEB uevice on theii entiie
piemises. If they aie piesent, the location, availability, accessibility anu piopei use
of the uevice also neeus to be known.

Emeigency meuical seivices anu the piesence of a uefibiillatoi aie usually only
piesent at oiganizeu events, if they have been pait of the school's meuical
piepaiation plan anu if they aie affoiuable foi those few houis.

AEBs aie wiuely uispeiseu at aiipoits, shopping centies, laige spoiting aienas anu
at most gym facilities; in most pait uue to iegulations foi the FIFA 2u1u Woilu Cup
anu some piivate initiatives that have alloweu foi this incieaseu uistiibution. If this
can be uone foi the laigei population in case of caiuiac aiiest fiom any numbei of
causes, I see no ieason why othei aieas wheie these uevices aie still neeueu cannot
be equippeu accoiuingly.

Even though these events aie iaie, all spoiting venues foi piactices anu matches
shoulu have access to an AEB, as the necessity foi theii piesence cannot be
unueiestimateu anu ciitical ieasons foi minimal uelays in piompt uefibiillation
have been noteu in this ieview aiticle.

Combining continueu euucation with these stiategies anu effoits; will help to
pioviue safei enviionments foi all oui young inuiviuuals paiticipating in all spoiting
activities.










9
'CHC'CJ!C F%)$ 5,. 'C)"-'!C)*
6: KJ>>3 0: 'J>9H/ ':): JHC ,:.: 'J>L (FE=F ***/ ':): +9MM9EA9 G9>CAFN '=CAGJ2 ">9O>=FF/ >=@A=B J>EAG2=: ,
(HO2 0 '=C 4565P QR4NS6T?4T:
4: 'J>9H K0/ "92AJG U/ VJD2JH 0./ '1=22=> W#: K21HE AMDJGE E9 EX= GX=FE 2=JCAHO E9 F1CC=H C=JEX Y>9M GJ>CAJG
J>>=FE C1>AHO FD9>EF JGEA@AEA=F: , (HO2 0 '=C 6SSZPQQQN QQT?;4:
Q: 'J>9H K0/ [9XMJH %(/ V32= !K/ (FE=F ,.' ***/ UAHL '!: +2AHAGJ2 D>9YA2= JHC FD=GE>1M 9Y G9MM9EA9 G9>CAF:
0.'. 4554P 4\TN66;4?R:
;: 'J>9H K0: !1CC=H C=JEX AH 391HO JEX2=E=F: , (HO2 0 '=C 455QP Q;SN65R;?TZ:
Z: 'J>9H K0/ )9=>=> 00/ ]JJF %!/ %A=>H=3 )'/ '1=22=> W#: !1CC=H C=JEXF AH 391HO G9MD=EAEA@= JEX2=E=FN
JHJ23FAF 9Y 6\RR C=JEXF AH EX= -HAE=C !EJE=F/ 6S\5?455R: +A>G12JEA9H 455SP 66SN65\Z?S4:
R: 'J>9H K0/ )9=>=> 00/ ]JJF %!/ (FE=F ,.' ***/ ]9CO=F 0!/ UAHL '!: +9MM9EA9 G9>CAF JHC EX= =DAC=MA929O3 9Y
F1CC=H C=JEX AH G9MD=EAEA@= 2JG>9FF=: "=CAJE>AGF 455SP 64;NSRR?T6:
T: ^=AHFE9GL 0/ 'J>9H K0/ !9HO +/ 'JH= ""/ (FE=F ,.' ***/ UAHL '!: WJA21>= 9Y G9MM=>GAJ223 J@JA2JI2= GX=FE
BJ22 D>9E=GE9>F E9 D>=@=HE F1CC=H GJ>CAJG C=JEX AHC1G=C I3 GX=FE BJ22 I29BF AH JH =_D=>AM=HEJ2 M9C=2 9Y
G9MM9EA9 G9>CAF: "=CAJE>AGF 455RP 66T7;<N =RZR?=RR4:
\: V9X2 "/ ,=FIAEE .)/ +99D=> "0/ U=A ': !1CC=H GJ>CAJG C=JEX I3 G9MM9EA9 G9>CAFN >92= 9Y M=GXJH9?=2=GE>AG
Y==CIJGL: +J>CA9@JFG $=F 4556P Z5N4\5?S:
S: K9C= W/ W>JH` '$/ ^A2L= */ K9HH=M=A=> ]/ !GX1HL=>E ]/ ^A=OJHC -V: 8=HE>AG12J> YAI>A22JEA9H AHC1G=C I3
FE>=EGX D12F=N AMD2AGJEA9HF Y9> F1CC=H C=JEX C1= E9 G9MM9EA9 G9>CAF: 0 +J>CA9@JFG (2=GE>9?DX3FA92 455RP
6TN6566?T:
65: 8AJH9 )+/ KA> +./ +X=H=3 .V/ 0JHCJ )]: ">=@=HEA9H 9Y G9MM9EA9 G9>CAF AH IJF=IJ22N JH =@J21JEA9H 9Y GX=FE
D>9E=GE9>F: 0 %>J1MJ 4555P ;SN654Q?\:
66: UA=CEL= .0/ [J12E 0]/ )=M1EX ^(: (2=GE>9GJ>CA9O>JDXAG JHC X=M9C3HJMAG GXJHO=F Y9229BAHO H9H?
D=H=E>JEAHO GX=FE E>J1MJ AH EX= =_D=>AM=HEJ2 JHAMJ2: .M 0 "X3FA92 6ST;P 44RNQTT?\4:
64: 8AJH9 )+/ .HC>`=aJL )8/ "922=3 %b/ VAHO .*: '=GXJHAFM 9Y YJEJ2 GX=FE AHa1>3 I3 IJF=IJ22 AMDJGEN
C=@=29DM=HE 9Y JH =_D=>AM=HEJ2 M9C=2: +2AH 0 !D9>E '=C 6SS4P 4N6RR?T6:
6Q: KA> +./ 8AJH9 )+: KA9M=GXJHAGJ2 D>=CAGE9> 9Y G9MM9EA9 G9>CAF AH XAOX?FD==C GX=FE AMDJGE: 0 %>J1MJ 6SSSP
;TN;R\?TQ:
6;: ,=FIAEE .)/ +99D=> "0/ V9X2 ": $=CAFG9@=>AHO G9MM9EA9 G9>CAF: UJHG=E 4556P QZTN66SZ?T:
6Z: UAHL '!/ ^JHO "0/ "JHCAJH ,[/ =E J2: .H =_D=>AM=HEJ2 M9C=2 9Y F1CC=H C=JEX C1= E9 29B?=H=>O3 GX=FE?BJ22
AMDJGE 7G9MM9EA9 G9>CAF<: , (HO2 0 '=C 6SS\P QQ\N6\5Z?66:
6R: UAHL '!/ ^JHO "0/ 8JHC=> K>AHL K./ =E J2: !=2=GEA@= JGEA@JEA9H 9Y EX= Vc.%" GXJHH=2 AF J M=GXJHAFM I3
BXAGX F1CC=H C=JEX AF D>9C1G=C I3 29B =H=>O3 GX=FE BJ22 AMDJGE 7G9MM9EA9 G9>CAF<: +A>G12JEA9H 6SSSP
655N ;6Q?\:
6T: UAHL '!/ 'J>9H K0/ !EAGLH=3 $(/ =E J2: .1E9MJE=C =_E=>HJ2 C=YAI>A22JE9> J>>X3EXMAJ C=E=GEA9H AH J M9C=2 9Y
GJ>CAJG J>>=FE C1= E9 G9MM9EA9 G9>CAF: 0 +J>CA9@JFG (2=GE>9DX3FA92 455QP 6;N\Q?T:
6\: UAHL '!/ 'J>9H K0/ ^JHO "0/ "JHCAJH ,[/ 8JHC=> K>AHL K./ (FE=F ,.' ***: $=C1G=C >AFL 9Y F1CC=H C=JEX
Y>9M GX=FE BJ22 I29BF 7G9MM9EA9 G9>CAF< BAEX FJY=E3 IJF=IJ22F: "=CAJE>AGF 4554P 65SN\TQ?T:
6S: UAHL '!/ 'J>9H K0/ ^JHO "0/ 8JHC=> K>AHL K./ bX1 ^/ (FE=F ,.' ***: -DD=> JHC 29B=> 2AMAEF 9Y
@12H=>JIA2AE3 E9 F1CC=H J>>X3EXMAG C=JEX BAEX GX=FE BJ22 AMDJGE 7G9MM9EA9 G9>CAF<: 0 .M +922 +J>CA92
455QP ;6NSS?65;:
1u
45: UA=CEL= .0/ .22=H $"/ ,=22AF !]: (YY=GEF 9Y I21HE GJ>CAJG E>J1MJ 9H G9>9HJ>3 @JF9M9EA9H/ D=>Y1FA9H/
M39GJ>CAJ2 M=GXJHAGF/ JHC M=EJI92AFM: 0 %>J1MJ 6S\5P 45NTTT?\Z:
46: 'JCAJF +/ 'J>9H K0/ !1D>9H !/ (FE=F ,.' ***/ UAHL '!: +=22 M=MI>JH= FE>=EGX JHC GX=FE I29B?AHC1G=C
@=HE>AG12J> YAI>A22JEA9H 7G9MM9EA9 G9>CAF<: 0 +J>CA9@JFG (2=GE>9DX3FA92 455\P 6SN6Q5;?S:
44: [J>JH .$/ 'J>9H K0/ ^JHO "0/ (FE=F ,.' ***/ UAHL '!: $92= 9Y FE>=DE9M3GAH F=HFAEA@= FE>=EGX JGEA@JE=C
GXJHH=2 AH GX=FE BJ22 AMDJGE AHC1G=C F1CC=H C=JEX 7G9MM9EA9 G9>CAF<: 0 +J>CA9@JFG (2=GE>9DX3FA92 455ZP
6RN;QQ?\:
4Q: !E91E +^/ 'J>9H K0/ 8JHC=> K>AHL K./ (FE=F ,.' ***/ UAHL '!: *MD9>EJHG= 9Y EX= J1E9H9MAG H=>@91F
F3FE=M AH JH =_D=>AM=HEJ2 M9C=2 9Y G9MM9EA9 G9>CAF: '=C !GA '9HAE 455TP 6QNK$66?K$6Z:
4;: UAHL '!/ 'J>9H K0/ 8JHC=> K>AHL K./ =E J2: *MDJGE CA>=GE23 9@=> EX= GJ>CAJG FA2X91=EE= AF H=G=FFJ>3 E9
D>9C1G= @=HE>AG12J> YAI>A22JEA9H AH JH =_D=>AM=HEJ2 M9C=2 9Y G9MM9EA9 G9>CAF: 0 .M +922 +J>CA92 4556P
QTNR;S?Z;:
4Z: UAHL '!/ KA> +/ )J1 ,/ 'JCAJF +/ (FE=F ,.' ***/ 'J>9H K0: ">9E=GEAHO 91> GXA2C>=H Y>9M EX= G9HF=d1=HG=F
9Y GX=FE I29BF 9H EX= D2J3AHO YA=2CN J EAM= Y9> FGA=HG= 9@=> MJ>L=EAHO: "=CAJE>AGF 455\P 644N ;QT?S:
4R: !E>JFI1>O=> 0W/ 'J>9H K0: +9MM9EA9 G9>CAF: , (HO2 0 '=C 4554P Q;TN64;\:
4T: )>=BHAJL (*/ !D=HGAH=> )K/ +>AFG9 00: '=GXJHAGJ2 D>9D=>EA=F 9Y GX=FE D>9E=GE9>F JHC EX= 2AL=2AX99C 9Y
@=HE>AG12J> YAI>A22JEA9H C1= E9 G9MM9EA9 G9>CAF: 0 .DD2 KA9M=GX 455TP 4QN4\4?\:
4\: )9=>=> 00/ ]JJF %!/ (FE=F ,.' ***/ UAHL '!/ 'J>9H K0: (@J21JEA9H 9Y GX=FE IJ>>A=>F Y9> D>9E=GEA9H JOJAHFE
F1CC=H C=JEX C1= E9 G9MM9EA9 G9>CAF: .M 0 +J>CA92 455TP SSN\ZT?S:
4S: 0JHCJ )]/ 8AJH9 )+/ .HC>`=aJL )8/ ]=HFAHO=> $,: .H JHJ23FAF 9Y D>=@=HEA@= M=EX9CF Y9> IJF=IJ22?AHC1G=C
GX=FE AMDJGE AHa1>A=F: +2AH 0 !D9>E '=C 6SS4P 4N 6T4?S:
Q5: VJD2JH 0./ VJ>9YFL3 "!/ 892E1>9 [.: +9MM9EA9 G9>CAF AH EB9 JMJE=1> AG= X9GL=3 D2J3=>F C=FDAE= EX= 1F= 9Y
G9MM=>GAJ2 GX=FE D>9E=GE9>FN GJF= >=D9>EF: 0 %>J1MJ 6SSQP Q;N6Z6?Q:
Q6: '3=>I1>O $0/ (FE=F ,.' ***/ W9HEJAH= 0'/ UAHL '!/ bAD=F )": %JFL W9>G= 65N J1E9MJE=C =_E=>HJ2
C=YAI>A22JE9>F: 0 .M +922 +J>CA92 455ZP ;ZN6QRS?T6:
Q4: U== +?+/ +XJHO ^?%/ +X=H !?+/ e=H b?!/ +X=H ^?0: !1GG=FFY12 >=F1FGAEJEA9H JYE=> F1CC=H C=JEX AH J 9H= 3=J>
92C AHYJHE BX9 F1FEJAH=C J I21HE GX=FE AHa1>3 Y>9M J YJ22 Y>9M 65 M: $=F1FGAEJEA9H 455ZP R;N 4;6?Q:
QQ: !J2AI (./ +3>JH !(/ +A22=3 $(/ 'J>9H K0/ %X9MJF ,0: (YYAGJG3 9Y I3FEJHC=> GJ>CA9D12M9HJ>3 >=F1FGAEJEA9H
JHC 91E?9Y? X9FDAEJ2 J1E9MJE=C =_E=>HJ2 C=YAI>A22JEA9H JF 2AY=?FJ@AHO EX=>JD3 AH G9MM9EA9 G9>CAF: 0 "=CAJE>
455ZP 6;TN\RQ?R:
Q;: 'JCAJF/ ':):P KJ>>3 0: 'J>9H/ ':):P 09HJEXJH ^=AHFE9GL/ ':):P ,: .: 'J>L (FE=F ***/ ':):P 'J>L !: UAHLP 0
+J>CA9@JFG (2=GE>9DX3FA92: 455TP 6\76<N 66Z?644: ?? !1CC=H +J>CAJG )=JEX ^AEX +X=FE ^J22 *MDJGE:
QZ: 'J>9H/ K0N +2AHAGJ2 W=JE1>=F 9Y +9MM9EA9 +9>CAF: ">=F=HEJEA9H 9Y $=OAFE>3 )JEJ JE ]=J>E $X3EXM !9GA=E3
!GA=HEAYAG !=FFA9HF: K9FE9H/ 'JFFJGX1F=EEFN 'J3 6Z/ 455S:

QR: 'J>9H K0/ (FE=F ,.'/ UAHL '!: QREX K=EX=FCJ +9HY=>=HG=N (2AOAIA2AE3 >=G9MM=HCJEA9HF Y9> G9MD=EAEA@=
JEX2=E=F BAEX GJ>CA9@JFG12J> JIH9>MJ2AEA=F: %JFL W9>G= 66N +9MM9EA9 +9>CAF: 0 .M +922 +J>CA92: .D> 6S
455ZP ;Z7\<N 6QT6?Q:

QT: )>=`H=> 0./ +X1H 0!/ ]J>M9H V[/ )=>MAH=> U: !1>@A@J2 E>=HCF AH EX= -HAE=C !EJE=F Y9229BAHO =_=>GAF=?
>=2JE=C F1CC=H GJ>CAJG J>>=FE AH EX= 391EXN 4555?455R: ]=J>E $X3EXM: 01H 455\P Z7R<N TS;?S:

Q\: eJI=L !'/ [=FFH=> *]/ ^AHC2= 'U/ .22=H ])/ ]=>`I=>O [b/ K=>O=> !: +9MM9EA9 +9>CAF: (M=CAGAH=/
'=CFGJD= .>EAG2=: 'J> 6\ 4566P S54NZ5;:

QS: .MA> #/ !GX2AJMF=> 0(/ ,=M=> !/ .>A= ': *H=YY=GEA@=H=FF 9Y D>=G9>CAJ2 EX1MD Y9> GJ>CA9@=>FA9H 9Y MJ2AOHJHE
@=HE>AG12J> EJGX3J>>X3EXMAJfF: "JGAHO +2AH (2=GE>9DX3FA92: W=I 455TP Q574<N 6ZQ?R:
11

;5: .2FX=ALX?.2A ../ 'JCAJF +/ !1D>JH !/ UAHL/ '!: 'J>L=C 8J>AJIA2AE3 AH !1FG=DEAIA2AE3 E9 8=HE>AG12J>
WAI>A22JEA9H AH JH (_D=>AM=HEJ2 +9MM9EA9 +9>CAF '9C=2: +A>G12JEA9H: )=G 6; 4565P 644 74;<N 4;SS ? 4Z5;:

;6: (YAM9@ *$/ W=C9>9@ 88: ">=G9>CAJ2 EX1MD JHC G9MM9EA9 G9>CAFN EX= 3AH JHC 3JHO 9Y M=GXJH9=2=GE>AG
Y==CIJGL AH EX= X=J>E: ]=J>E $X3EXM 455RP QN6\T?\:

;4: 'A22=> 0'/ KXJLEJ ): %X= D>=G9>CAJ2 EX1MDN G9H@=>EA9 G9>CAF/ G9MM9EA9 G9>CAF/ 9> H=AEX=>g "JGAHO +2AH
(2=GE>9DX3FA92 455TP Q5N6Z6?4:

;Q: "=22AF %/ V=EE= W/ U9@AFJ )/ =E J2: -EA2AE3 9Y D>=?G9>CAJ2 EX1MD Y9> E>=JEM=HE 9Y 91E 9Y X9FDAEJ2 GJ>CAJG J>>=FEN
J D>9FD=GEA@= FE1C3: $=F1FGAEJEA9H 455SP \5N6T?4Q:

;;: ]JMJH U/ "J>A`=L "/ 89aJG=L 0: ">=G9>CAJ2 EX1MD =YYAGJG3 AH E=>MAHJEA9H 9Y AHC1G=C @=HE>AG12J>
J>>X3EXMAJF: $=F1FGAEJEA9H 455SP \5N6;?R:

;Z: 'JCAJF +/ 'J>9H K0/ .2FX=ALX?.2A ../ $JaJI '/ (FE=F ,.' ***/ UAHL '!: ">=G9>CAJ2 EX1MD Y9> GJ>CAJG J>>=FE
AF =YY=GEA@= Y9> JF3FE92= I1E H9E Y9> @=HE>AG12J> YAI>A22JEA9H: ]=J>E $X3EXM 455SP RN6;SZ?Z55:

;R: ">A9>A ![/ .2A9E (/ K2hMFE>9M?U1HCd@AFE +/ =E J2:P (1>9D=JH !9GA=E3 9Y +J>CA929O3: %JFL Y9>G= 9H F1CC=H
GJ>CAJG C=JEX: (1>9DJG= 4554P ;NQi6\:

;T: V>JM=> (/ )@9>JL 0/ V29=GL ^: K> 0 !D9>EF '=C 4565N $=@A=B 9Y EX= MJHJO=M=HE 9Y F1CC=H GJ>CAJG J>>=FE
9H EX= Y99EIJ22 YA=2C: ;;N Z;5?Z;Z:

;\: K=>O $./ V=>H VK/ !JHC=>F .K/ =E J2: K3FEJHC=> GJ>CA9D12M9HJ>3 >=F1FGAEJEA9H: *F @=HEA2JEA9H H=G=FFJ>3g
+A>G12JEA9H 6SSQP \\N6S5Ti6Z:

;S: K=>O $./ !JHC=>F .K/ V=>H VK/ =E J2: .C@=>F= X=M9C3HJMAG =YY=GEF 9Y AHE=>>1DEAHO GX=FE G9MD>=FFA9HF Y9>
>=FG1= I>=JEXAHO C1>AHO GJ>CA9D12M9HJ>3 >=F1FGAEJEA9H Y9> @=HE>AG12J> YAI>A22JEA9H GJ>CAJG J>>=FE:
+A>G12JEA9H 4556P 65;N4;RZiT5:

Z5: K=>O $./ V=>H VK/ ]A2BAO $^/ =E J2: .FFAFE=C @=HEA2JEA9H C1>AHO jI3FEJHC=>f +"$ AH J FBAH= JG1E=
M39GJ>CAJ2 AHYJ>GEA9H M9C=2 C9=F H9E AMD>9@= 91EG9M=: +A>G12JEA9H 6SSTP SRN;QR;iT6:

Z6: !E==H ".: )9=F JGEA@= >=FG1=> @=HEA2JEA9H XJ@= J D2JG= C1>AHO IJFAG GJ>CA9D12M9HJ>3 >=F1FGAEJEA9Hg
+A>G12JEA9H 455TP 66RN4Z6;i6R:

Z4: (B3 [.: +9HEAH191F?GX=FE?G9MD>=FFA9H GJ>CA9D12M9HJ>3 >=F1FGAEJEA9H Y9> GJ>CAJG J>>=FE: +A>G12JEA9H
455TP 66RN4\S;iR:

ZQ: K9XM V/ $9F=Hd1AFE '/ ]=>2AE` 0/ =E J2: !1>@A@J2 AF FAMA2J> JYE=> FEJHCJ>C E>=JEM=HE JHC GX=FE G9MD>=FFA9H
9H23 AH 91E?9Y?X9FDAEJ2 I3FEJHC=> GJ>CA9D12M9HJ>3 >=F1FGAEJEA9H: +A>G12JEA9H 455TP 66RN4S\5i64:

Z;: !J3>= '$/ K=>O $./ +J@= )'/ =E J2: ]JHCF?9H23 7G9MD>=FFA9H?9H23< GJ>CA9D12M9HJ>3 >=F1FGAEJEA9HN J GJ22
E9 JGEA9H Y9> I3FEJHC=> >=FD9HF= E9 JC12EF BX9 =_D=>A=HG= 91E?9Y?X9FDAEJ2 F1CC=H GJ>CAJG J>>=FEN J FGA=HG=
JC@AF9>3 Y9> EX= D1I2AG Y>9M EX= .M=>AGJH X=J>E JFF9GAJEA9H =M=>O=HG3 GJ>CA9@JFG12J> GJ>= G9MMAEE==:
+A>G12JEA9H 455\P 66TN46R4iT:

ZZ: .M=>AGJH ]=J>E .FF9GAJEA9H: ]JHCF?#H23 +"$: XEEDNkkXJHCF9H23GD>:9>Ok 7.GG=FF=C 4T )=G=MI=> 455S<:

ZR: )>=`H=> 0./ +91>F9H $^/ $9I=>EF #'/ '9F=FF9 8,/ UAHL '!/ 'J>9H K0: *HE=>?.FF9GAJEA9H %JFL W9>G=
$=G9MM=HCJEA9HF 9H (M=>O=HG3 ">=DJ>=CH=FF JHC 'JHJO=M=HE 9Y !1CC=H +J>CAJG .>>=FE AH ]AOX !GX992
JHC +922=O= .EX2=EAG ">9O>JMFN . +9HF=HF1F !EJE=M=HE: +2AH 0 !D9>E '=C 6TN4P 'J>GX 455T:


! +#"e$*[]% )$[.8*,!].,[ 74564<: .22 >AOXEF >=F=>@=C: ,9 DJ>E 9Y EXAF D1I2AGJEA9H
MJ3 I= >=D>9C1G=C 9> CAFE>AI1E=C AH JH3 Y9>M 9> I3 JH3 M=JHF BAEX91E D>A9> B>AEE=H
D=>MAFFA9H: