In 2006 a 33 year old male, height 1.68 metres, weight 60 kg and body mass index (BMI) 21.3 kg·m^-2 who had completed a detailed medical questionnaire, presented himself for a medical prior to a full-contact martial arts competition. His past medical history was unremarkable.

At rest his blood pressure (BP) was 130/78 mmHg; heart rate (HR) was 72 bpm; rate pressure product (RPP) was 94 bpm. X mm.Hg x 10^-2 respiratory rate (RR) was 18 (Table 1).

Routine medical examination including central nervous system examination was satisfactory allowing competitive participation.

This individual competed for two minutes before receiving a direct kick to the head. Examination in the competitive arena revealed an individual who was unconscious. He was enduring a tonic-clonic seizure, recorded as lasting for 3 minutes 25 seconds. First aid, and paramedic support was provided immediately. Medical assessment identified the presence of vital signs. Glasgow coma scale (GCS) was recorded as 3/15 (E1, V1, M1).

A patent airway was established and a neck brace was applied. BP within 1 minute of trauma was recorded at 195/98 mm.Hg. HR was recorded at 185 bpm; the RPP was 361 bpm. X mm.Hg x 10^-2, and RR was 40 breaths·min^-1. His airway was clear and his capillary refill was < 2 seconds. Re-examination using the GCS was 3/15 (E1V1M1) every minute for the first five minutes (Table 2). Oxygen was administered via a venti-mask. The patient was conveyed to the medical area and disqualified on medical grounds.

The patient regained consciousness one minute after his seizure resolved. GCS on regaining consciousness and recorded at six minutes was 13/15 (E4, V4, M5) (Table 2).

Examination of central nervous system (CNS) revealed left sided hyper-reflexia and a left up-going plantar response. Bilateral pupillary examination revealed an equal reaction to light and accommodation response. Bilateral retinoscopy examination with direct ophthalmoscope was unremarkable. A decision was made to admit him to nearest hospital, known to have a neurosurgical unit. The British Red Cross Ambulance Service conveyed him there within five minutes of his seizure stopping.

A GCS score of 8 or less suggests a severe brain injury (Teasdale and Teasdale, 1974). The “Revised Trauma Score ”(Champion et al., 1989) in its present form does not accurately describe the relation of GCS, SBP, and RR to mortality (Moore et al., 2006). The Revised Trauma Score is a physiological scoring system, which until recently has been considered to have high inter-rater reliability and demonstrated accuracy in predicting death. It is scored from the first set of data obtained on the patient, and consists of systolic BP (SBP) and RR.

Six minutes post-competition the BP of the individual male was 173/88 mmHg; the HR was 70 bpm; the RPP was 121 and RR was 33.

A full history was difficult because the individual had a speech impediment, which had not been elicited pre-competition, but which he was lucid enough to point out. The patient complained of a headache and nausea, but had no memory of a blow to the head.

The patient was admitted to the nearest hospital with a neurosurgical unit. The hospital accident and emergency (A & E) department was contacted to advise on the patient’s history, and request a neurosurgical opinion, but the telephone line was persistently engaged. The hospital was contacted every 1-2 minutes for the next hour and every five minutes for the following hour but the hospital line remained engaged and remained engaged for the remainder of the day (a Saturday).

The patient was discharged without computerised tomography (CT), despite a letter being presented to the A & E senior house officer requesting a neurosurgical opinion.

The British Red Cross ambulance returned the patient to the karate venue so he could be taken home, by his family and acquaintances. He was taken to his sister’s house for rehabilitation and remained there for one week, before returning home. He received contact by text and telephone with the karate medical team on a daily basis until he returned to work, one week after the event. Two weeks after the trauma he resumed training and is subsequently sparring. There appeared to be no long term consequences.

Brain injuries may be graded into mild, moderate and severe depending on clinical and neuro-imaging criteria. Mild brain injuries (MBI) are usually defined by an initial unconsciousness limited to 30 minutes, a Glasgow score between 13 and 15, the absence of intra-cranial lesion on the CT scan, a post-traumatic amnesia period between one and 24 hours (Kosakevitch-Ricbourg, 2006).

GCS scores are widely used to quantify level of consciousness in the pre-hospital environment.

Values for field GCS are highly predictive of arrival GCS, and both are associated with outcome from traumatic brain injury. A change in GCS from the field to arrival is highly predictive of outcome (Davis et al., 2006). Detailed clinical examination is of no diagnostic value in detecting intracranial injuries found on head CT scan. A head CT scan is considered essential in patients with observed loss of consciousness or post-traumatic amnesia and GCS 13-15, as part of their evaluation to avoid missing an intracranial injury in the USA (Halley et al., 2004).

The British Medical Association has been campaigning vociferously to illegalise boxing for many years (Sheldon, 2003). There is an unfortunate belief within the national health service, that injuries incurred as a consequence of full contact sports, are self-inflicted and less deserving than injuries from accidents outside sport. The cost of CT scanning all head injuries is prohibitive. The decision to refer such a head injury for tertiary assessment can often lie with the most junior of medical staff in an A & E department, who may be influenced by these prohibitions and due to high work load may harbour prejudice against such “self-inflicted ”injuries. Patients with a cranial CT scan, that shows no intra-cerebral injury and who do not have other body system injuries or a persistence of any neurological finding can be safely discharged from the emergency department without a period of either inpatient or outpatient observation (Shackford et al., 1992). Implementation of this practice could result in a potential decrease of more than 500,000 hospital admissions annually in the USA (Livingston et al., 2000).

An immediate examination post trauma can not diagnose or preclude an intra-cranial haemorrhage. Because kicks to the head are the primary target for an opponent’s blows, karate practitioners are at risk of acute and chronic neurological trauma. An episode of unconsciousness and post-traumatic amnesia and a GCS < 15 should make CT scanning mandatory. Workers within the NHS framework should receive further training and education, which would help eliminate misconceptions that sports injuries are ’self-inflicted’ and hence, in some way, ‘less deserving’. This case was one of the 62% and had a successful outcome. The next case may be one of the 38% and may not!