Injuries In Sport
Three main issues:
1. Know what you are dealing with - if you don't then do nothing other than get assistance.
2. Do not do anything that will make an injury worse - ideally, the victim should reach a place where treatment can be given in no worse condition than in which you first saw him/her.
3. Do no more than is absolutely necessary even if it's just getting professional help:
The circulatory system consists of the heart, arteries, capillaries and veins. Blood is pushed through blood vessels by the pumping action of the heart. First it passes through arteries which become progressively smaller until the smallest arterioles finally divide into capillaries. These join to form veins which carry blood back to the heart. Arteries have thick walls made up of a fibrous tissue outer layer for protection called the tunica adventitia and the thick muscle middle layer of the tunica media. The smooth inner lining is the tunica intima. Capillaries are one cell thick and thus very fragile. It is in these capillaries that all the work of the blood is done. Giving up oxygen and taking in carbon dioxide, removing waste products and supplying nutrients between the vessel interior (vascular space) and area external to vessel (extracellular space). Veins are constructed in a similar way to arteries with the exception that the muscle layer is thinner.
Blood Flow Physics
The heart beating results in blood pressure and the first part is the systolic BP (when heart contracts) and distolic BP (between contractions). Normal values range between 120mmHg (systolic) and 60mmHg (distolic). Written '120/60'. (Hg is mercury and is measured using a sphygmomanometer). Blood pressure is kept constant in body by muscles relaxing or contracting to alter the resistance to blood passage. This ensures BP is constant throughout the body no matter how far above or below the heart the artery is situated. BP drops rapidly through smaller arterioles and capillaries and is no more than 10mm Hg in the veins.
Blood circulation is in two parts. Veinous blood returns to the right side of heart and goes to lungs (pulmonary circuit - oxygen depleted). The only function is to take up oxygen and give up carbon dioxide in a gas exchange. Blood returns to the left side and is pumped out in the (systemic circuit) arteries as oxygen enriched blood. This is distributed to muscle, skin, bone and brain. A large portion of circulation is to the stomach, intestines and abdominal organs: spleen, liver and pancreas. When digestion is active, large amount of blood are diverted through this part of the system. Any injury ruptures some blood vessels, certainly capillaries, but also (possibly) small arterioles and veins. Any blow will result in blood leaking out into the fat layer under the skin or even into muscle. This is bruising which can later be seen as discoloration of skin. Blood is a very irritating fluid outside the vessels and any injury can be quite painful. Ice-pack application can minimise the extent of bleeding.
Where skin is not broken and there is blood flow from a damaged vessel that cannot escape, bruising may occur and bleeding only stops when blood clots to seal a hole in the vessel. Capillaries and veins have low BP so this is quite rapid, but when an artery is cut, blood is under higher pressure and the muscle in its wall contracts to hold the cut open. An arterial cut will continue to bleed unless external pressure is applied. If completely cut through this muscle contraction can act to seal the artery by curling inwards. Limb severing is survivable because of this.
Severe haemorrhage is an emergency. If one and a half pints of blood are lost (from a total of eight to ten pints in the body) shock sets in and is followed by death. Possibly up to two hours for a wrist cut or two to three minutes for big femoral artery and is dependent on the depth and location of the cut. The average nosebleed is about two tablespoonfuls for comparison. Treatment is the same regardless of type: a pad over the bleeding surface. Complete clotting may take up to thirty minutes to occur. Ideally, a clean dressing should be used, but this is not important compared to stopping blood flow. Anything will do. Application of pressure on bleeding point may be necessary for some deep cuts.
Internal Bleeding cannot be seen and bleeding from abdominal organs is quite different and involves bleeding into a closed cavity. Such a situation can be suspected due to blood loss even though it cannot be seen. Consider a ruptured spleen or liver. To illustrate, a blow over the left rib area may occur and some 20-30 minutes later pain can still be apparent in this area with giddiness then fainting. Consciousness may have been regained after a minute or two, but without knowing what had happened. Hospitalisation is needed to remove probably a ruptured spleen to stop the internal bleeding. Death is then preventable. This is a well recognised scenario and is more common in repeated blows rather than single blow. Times may vary and are dependent on the blood flow. A few minutes for severe rupture to a couple of hours for slow leakage. In certain diseases (like glandular fever) the spleen is fragile and ruptures more easily.
The reason for this fainting and recovery is due to BP dropping, but the body no longer able to sustain it. Fainting will cause the head to be same level as heart by lying prone so flow to brain temporarily restored. BP continues to drop and loss of consciousness reoccurs. Death will soon follow without recovery. Strikes to lower right rib area can damage liver. Results are not so dramatic as three to four days may pass after the injury before death supervenes. Although a slower sequence the same effects and reasons apply as for spleen damage. Visibly, when upright any blood pools in lower part of abdomen. When lying down blood runs up abdominal cavity to lie beneath diaphragm where it is irritating. An insensitive area to pain will result felt in pain elsewhere, but in same anatomical segment like the tip of the shoulder. A ruptured spleen may cause pain in the left shoulder tip and liver damage in the right shoulder. This is not always an indictor of internal bleeding, but is suggestive, especially if preceded by heavy blows and persistent pain and fainting. Immediate action is necessary.
Ruptured kidneys
Kidneys are less easily damaged as they are well protected by the ribs, spinal muscles and a thick pad of fat. Nevertheless a hard blow at 'kidney angle' between spinal muscles and ribs may result in bleeding. This is usually slow and nearly always stops spontaneously, but cannot be ignored. Long term effects show blood in urine (not normally visible to naked eye) and persistent pain. A doctor is required immediately. A urine specimen will be necessary to examine for presence of blood.
Ruptured pancreas
This is rare and caused by a blow to the pit of the stomach. Pancreas lies directly across spine and pressure over it occasionally causes rupture. This releases corrosive digestive juices into abdominal area that is not designed to cope with them. This results in severe pain and inflammation: the digestion of the linings. A blow to the 'solar plexus' will increase pain and distress. Hospitalisation is needed immediately.
Shock Condition
This occurs when the heart cannot maintain BP. There are two kinds: ruptured abdominal organs causes internal bleeding so that an insufficient volume of blood (loss of one and a half pints) is pumped around body and cause surgical shock'. The other type of shock is caused by loss of muscle tone and consequent increase in artery volume as muscles relax. Blood pools in them so less blood returns to the heart via veins. A drop in blood pressure results. Reactions to ruptured (damaged tissue) will involve pain and apprehension. BP drops in both instances though more particularly in surgical shock. If blood pressure drops and is not restored, there is a serious threat to life. Blood is diverted from the skin so a pale colouration appears. Coldness and sweating with raised pulse (around 100 bpm) occur with apprehensive and faintness. Breathing becomes rapid and maybe develop into air hunger.
Shock may occur after any injury and when fully developed is potentially fatal. When this is the result of bleeding, the bleeding must be stopped or reduced. If this is not possible then hospitalisation needed. Laying flat is important to maintain brain blood supply and tilted if necessary to have the head blow heart level. Comfort and keeping warm (not hot) are critical. Breathing should not be impaired by placing anything heavy on the injured party and nothing should be given to drink. This may interfere with any operation if needed. Assume confident attitude even if you are not. Casualty must believe you are in control. If in any doubt get to hospital.
The Head
Scalp, skull and brain. The scalp covers the skull and is a layer of fat containing a strong sheet of fibrous tissue to which muscles are attached and is covered by skin. Lacerations are common by a blow causing tissue to split on the bone beneath. Bleeding is profuse, but can be controlled by firm pressure. Sometimes a deep split can expose the skull, but this is not always obvious and requires expert examination. The skull is several bones joined together forming a rigid box. There are holes (foramina) to allow passage of nerves and blood vessels including the large one at base of skull for the spinal cord. The skull can be fractured from a direct blow or force transmitted to a weaker part. Commonly caused by hitting an unyielding floor rather than being struck. Most skull fractures cannot be diagnosed clinically, but if the base of skull is involved watery-looking blood from ear or nose is sometimes visible. The fracture is important as a measure of force used or possibly thinness of the skull. In all head injuries the most important consequence is damage to the brain.
The brain comprises two types of tissue, the grey matter and white matter. Grey consists of nerve cells only and a thin layer covers the whole surface of the brain. Scattered about the white matter areas is grey matter (nuclei), each having a specific function with regard to brain and body activity. White matter is made up of fibres connecting the nerve cells. The brain is separated from the skull by three layers of membrane - the meninges. There is a tough outer layer in contact with inside of skull: dura mater. The thin membrane covering the brain is the pia mater and an intermediate layer known as the arachnoid mater. This last one contains blood vessels and the cerebrospinal fluid so the brain actually floats freely within the skull bathed in this fluid.
Three mechanisms can cause brain damage. Any one or all of them. Firstly the head can be accelerated by a blow. The brain does not move until it is pushed by the skull. Similarly, when the head stops moving the brain will continue to move until stopped by hitting the inside of the skull. Damage can therefore be at both the site of impact and diametrically opposite to the site of impact. Secondly, grey and white matter have different characteristics and are accelerated at different rates by the same force. This results in shearing strain where they meet, leading to tearing of the nerve fibres which cross the junction. Lastly, a blow can give rise to shock waves in the cerebrospinal fluid surrounding brain. This can cause damage at point quite distant from the point of contact. Damage is the production of small haemorrhages into the brain tissue and is usually too small to be seen with the naked eye. They are quite numerous and situated in the white matter, mostly near its junction with the grey matter.
Concussion
Defined as any state where brain function is noticeably altered by an injury to the head. A presence and the degree of concussion are assessed by testing different functions of brain. First is maintenance of consciousness. If the casualty has been unconscious, even if only momentarily, they should be diagnosed as being concussed. If conscious when examined - test memory. This is affected at the time of an injury, immediately before or after the injury. Memory is lost in this order so the more lost the more severe the concussion. Ask what happened even if you saw incident - tests memory function. Other questions like name, age, where they are, what day it is. If answered correctly memory is probably intact. However, memory can falter later as a result of concussion. Caution. Test reflex functions like balance and co-ordination. A raised finger should be followed with the eyes to left-right and up-down. Instruction is understood if eyes follow accurately. A finger-to-nose from different directions tests positional and muscle co-ordination. Any deficiency in these demonstrates some degree of concussion.
Brain damage involves some brain cells that have died and the body is perfectly capable of regenerating these cells. However, if not fully recovered from damage and sustain further injury (even after three weeks) a similar degree of injury will cause ten times the initial extent of damage. If this is repeated just a few times before healing process is complete very quickly an enormous number of cells destroyed leading to thinning of grey matter with consequent loss of more complex function like memory, balance and co-ordination: the punch-drunk condition.
If damage is to a part of the brain that serves no known function awareness of damage is not possible as everything appears OK. Damage is sustained just the same - it's just not obvious. For these reasons competition rules state any degree of concussion or suspicion of it must be followed by a ban and any contact possibility for at least four weeks. If more severe concussion has occurred (loss of consciousness) then ban should be extended to three months. Three such instance in any one year is followed immediately by a year's ban. This must be rigorously enforced if severe damage is to be avoided. In the case of strangleholds that result in a loss of consciousness, however brief, treatment is the same as for concussion since similar brain damage is caused.
Unconsciousness
A state of unconsciousness exists when a person is unaware of surroundings. Or "senselessness'. There are five senses:
The small nerve crossing the upper rim of the orbit about third way in from corner of eye is useful. It is easily felt and pressure on this is quite painful. Reaction to this will vary according to degree of unconsciousness. Normally, the hand causing the pain may grabbed, but if at some deeper level the result would be perhaps waving hands about in the air, but not removing the source - your hand. Or no reaction at the very deep level. Smell is often used - some offensive really pungent odour. This will always get a reaction.
Unconsciousness as a result of head injury results in brain damage. Other causes can be intracranial haemorrhage - bleeding inside the skull. Cardiac arrest - heart stopped beating. Epilepsy, diabetes or hysteria.
Intracranial haemorrhageThis may be due to laceration of the brain tissue itself or tearing of the meninges (membranes surrounding brain and spinal cord). Usually this is as the result of a severe accident and is unlikely in martial arts, unless hit head on unyielding floor, wall etc. The most common tear is the large artery lying between the dura mater (outside layer) and the skull at the side of the head: middle meningeal artery. This can be torn even when there is no skull fracture. The sequence of events causing this damage can be misleading. The original head injury causes unconsciousness, but is possibly only momentary and unnoticed. Recovery may seem complete though bleeding continues as a result of an artery tear.The blood collects between skull and dura mater causing a build up of pressure on the brain. Consciousness is lost again and the unconsciousness progressively deepens until the casualty eventually dies. The time scale quite is variable and depends on the rate of blood loss (severity of tear). The range between regaining consciousness and losing it again can be anything from 20 minutes to several hours, but is commonly one and a half to two hours with death 1-4 hours afterwards. The shorter the time between consciousness and unconsciousness the sooner death supervenes. Physical signs associated with the increase in intracranial pressure may be vomiting (pressure in skull rising) and headache (if still conscious). These two symptoms can occur in uncomplicated injury (concussion), but may be signs of intracranial injury.
An increase in pressure affects brain function and can be monitored by observing the eyes, pulse rate and breathing. The nerves controlling the pupil of the eye become irritated and the muscles contract - pupil gets smaller. This can be contrasted with the larger uninjured side. Pressure continues to increase the pupil on the affected side until it becomes paralysed when the eye muscles relax. The pupil is then widely dilated. The opposite side becomes irritated and contracts, then both pupils become dilated as the uninjured side is paralysed and pressure continues to rise. All this indicates severe intracranial pressure increase. As the pressure continues to rise the nerve centre of the brain controlling the heart rate is affected and the pulse gets slower. Breathing becomes periodic, firstly becoming more shallow then stops completely. After about 30 secs restarts and becomes deeper and deeper until back to normal. The sequence is repeated and possibly takes 2 minutes to cycle. The pulse rate and breathing are good indicators for the severity of intracranial pressure. If unconsciousness recurs or severe (and increasing) headache continues, hospitalisation should be immediate. Vomiting may start or symptoms develop for disturbed brain function (dizziness or double vision, confusion).
Sub-arachnoid haemorrhage
Sub-arachnoid haemorrhage is bleeding into the membrane covering the brain, which emanates from the arteries surrounding the brain's base. The joins of these arteries can be points of weakness and are probably present from birth. They may occur in the young adult and without warning. Sharp excrutiating pain may be felt at the base of the skull and can last for a few seconds. This may occur intermittently for several days before complete unconsciousness occurs with no warning or any injury. There will be a slow pulse rate and altered breathing with dilated pupils. All the indications of severe non-localised pressure on the brain.Very soon be death will supervene.
Severe head injuries often damage one or more of the cranial nerves. The sixth nerve controls the abducting muscle of eye so it turns inwards Damage to the eighth nerve produces deafness. Cerebral haemorrhage or stroke occurs in older people and involves bleeding actually into the brain tissue. Raised intracranial pressure may produce unconsciousness and other related symptoms, but also local ones like paralysis on one side of face and/or body, or loss of speech (if conscious). In all cases of intracranial haemorrhage, the only first aid is to get help/transport to hospital. Place in the recovery position until help arrives. Turn more or less face down with the head resting on the lower arm and the top of leg bent to chest. Any vomit or blood can them drain away from the lungs.
Cardiac arrest
The heart stops and blood pressure drops to zero as the result of cardiac arrest. The brain is deprived of oxygen and within 15 - 30 seconds consciousness is lost and vomiting and spasms similar to a fit may occur. Stoppage is due to one of two reasons: vagal inhibition or ventricular inhibition. The vagus nerve affects the heart rate and passes through the neck. One of its many functions is to control heart rate and it contains both sensory and motor fibres. It originates in the brain and finishes by supplying the nerves to the diaphragm and abdominal organs. Without nervous control the heart would beat at around 100 bpm. The vagus nerve slows this down to about 60 bpm at rest. Other mechanisms speed it up to deal with exercise. Over stimulation of the nerve slows the heart excessively and stops it beating altogether. The nerve can be stimulated by pressure on certain parts of neck or by shock. Sudden physical immersion into ice water can cause shock. A hard punch or kick to the lower, front chest can cause this over stimulation. It is vital to check pulse rate if there is a blow to the neck or pressure results from a stranglehold.
A blow to the front lower ribs can result in a knock down from which recovery seems apparent, but an epileptic-type fit and collapse can occur due to vagal inhibition. Heart may restart by itself. Lucky if it does. Ventricular fibrillation does not involve heart stoppage immediately unlessit continues for 3-4 minutes (death will supervene). The heart beats at 400 bpm caused by irritated piece of heart muscle and ventricles beating very rapidly. This is too fast to allow filing with blood so blood circulation ceases.
Ventricular fibrillation can be regarded as cardiac arrest. As with vagal inhibition the muscle spasms and vomiting may occur. The irritable heart muscle is usually a result of a previous 'coronary' (heart attack) and may have even passed unnoticed by the sufferer at an earlier time and any history of heart attack may be absent. Angina sufferers may have irritable heart muscle and so be predisposed to Ventricular fibrillation. An angina attack will normally precede ventricular fibrillation and angina is a reason to stop training immediately. In cardiac arrest there is no time to waste, and resuscitation must be started immediately or at least within 2-3 mins to prevent irreversible brain damage. After 4 mins, the heart will never restart.
Epilepsy is a disease of the brain which results in fitsand is produced by irritable areas in the brain. These can develop spontaneously (by themselves) or sometimes as the result of a head injury. The epileptic fit is preceded by some other sensory (smell) or physical (muscle twitch) impairment. Variety is immense, but is constant for an individual. It is followed by a loss of consciousness and the onset of violent muscle contractions. This may involve the entire body or only one region and then spread to become generalised. There is a probable loss of bladder control. The episode can last up to 10 mins but more commonly 3-4 mins, followed by sleep then wakefulness with no recollection of the fit. It is alarming to see, but single fits of themselves are no danger. However, one fit followed by sleep and then another without waking is more dangerous. Hospitalisation is necessary without delay as exhaustion and death may result. The patient may injure him/herself during fit and it is usually the main task in any assistance to prevent self-injury. Concrete floors and anything projecting from walls must be absent if person is known to have such fits and possibly prevented from training. It is medical opinion that epilepsy of itself is no reason for a training bar to be imposed. Sensory input may aggravate a fit so there should be minimal touch except than to prevent self- injury. Attempts to restrain must never happen and never attempt to keep the mouth open with fingers - you may lose them, but still not prevent them from biting tongue.
Diabetes mellitus
Diabetes mellitus is an endocrine disorder. Many mechanisms are probable, but all result in the prevention of glucose getting into the target cells. As a consequence, blood sugar rises and brings about the condition of hyperglycemia. The insulin level may be optimal, but something prevents the glucose entry, nevertheless. Non-insulin dependent diabetes mellitus (NIDDM) is age related (usually 40 and over) and generally in the overweight population. Food elevates blood sugar levels so insulin is used to balance the level to within fairly narrow limits. The insulin level is affected by exercise and the level of adrenalin. Most diabetics compensate for this, but mistakes can be made. High blood levels usually take some days to develop. Low sugar levels are much more sudden (minutes) and can cause the insulin coma (loss of consciousness). There is usually a warning by way of light headedness/weakness. Symptoms can be very variable. Perhaps a change in personality though not noticed by diabetic. It is suggested that a person is deliberately placed in a diabetic coma so they can recognise the onset of a non-planned one.
Initial symptoms are followed by unconsciousness (after many hours) and noticeably profuse sweating. First aid is the rapid administration of sugar or glusose. Diabetics usually carry glucose or sweets for self administration and must be given if unconscious. Best to give glucose as a drink. Even if not swallowed sufficient may be absorbed through lining of mouth to effect recovery from unconsciousness. More then given. If state continues for a few mins only, professional health must be sought.
Hysteria
Hysteria is a mental change caused by overreaction or underaction of some part of the nervous system. Maybe some part is failing to work at all. Convulsive seizure, spasms, contraction of limbs, paralysis, affectation of various internal organs, derangement of joints or any combination of these. This includes (deep) loss of consciousness. It is unwise to diagnose hysteria as the range of symptoms is so wide. A more serious problem may be overlooked.
Resuscitation
Profuse bleeding, shock, breathing or heart stoppage only four situations requiring urgent action. Artificial respiration and cardiac massage cannot be learned from a book and requires practise on a dummy to learn the techniques properly. The Resuscitation Certificate should be a requirement of every instructor. Nevertheless, check:
Check breathing by listening at nose/mouth. Air movement may be felt or the chest seen moving. Check airway by opening the mouth wide and look inside. If necessary finger down back of throat. A single false tooth or gumshield may be found. Absolute caution here. Vomiting can occur at time of cardiac arrest and it would be catastrophic if blown down lungs. The digestive juices are very corrosive and immediately begin to digest the lining of breathing tubes. This is a well known condition and carries a mortality rate of 50%. Start artificial respiration. Mouth-to-mouth needs practise after learning the technique. Even when the heart has stopped blow some air into the lungs so to some extent the blood remains oxygenated. At no point attempt to circulate non-oxygenated blood to brain.
External cardiac massage
Aim to squeeze the heart between the (back of) sternum and (front of) the spinal column. The sternum should be depressed by between one and a half to two inches (4-5cm). This takes a lot of energy and there is good chance some ribs will be broken. Don't ever simulate this level of pressure in practise. Keep it up. It may be 15 mins or more that mouth-to-mouth resuscitation and external cardiac massage is required before help arrives. Recommend two breaths to 15 pumps. This recommendation may continue to change (from between one/four, one/five, one/seven). Pick a rhythm and stick to it.
(Contact Sport) Training
Training accidents happen, but can be minimised. An instructor should tailor training to suit all. The pressures involved with training should be well understood. Likewise any injury/condition should be made known to the instructor. This is especially important in children. The injury may be slight, but exist nonetheless. It may have even happened elsewhere. Muscle stretching tears could go unnoticed by novices and not all injuries are reported. Few students dedicate themselves to real training, but train for reasons of self-defense, recreation and social. Many will have diseases or illnesses such as epilepsy, diabetes or asthma and even more serious disabilities. Few though need to be prevented from training as long as the instructor is informed. Except haemophilia. This is a defective blood clotting mechanism. The instructor should tailor training schedule to suit students - not the other way around. The training hall should be of an adequate size to prevent clashes or the number of students limited to the hall size. Hard areas should be padded. Games are useful to entertain children, but must be made safe. Turning points in running should be padded. Lighting must be adequate.
No one should doubt the quality of boxing training as highly effective. Fitness and technique are both excellent. However, the reason behind boxing may require close questioning regarding motives. The overall requirement is to win the bout - fair enough. But, the method used to defeat the opponent can be considered barbaric in that to end the fight as quickly as possible it is a must to attempt to inflict severe damage on the opponent. In effect to try to kill him. The requirement (theoretically) in Taekwon-do is not to inflict needless damage, but to demonstrate superior skill toward the defeat. The technical superiority will always triumph over the brutal onslaught. It doesn’t take much skill to use brutality, but to dissect an opponent does need skill. Fitness is a precept of training, but of most importance is the development of the skill. Fitness improves as the bi-product of training.
1. Know what you are dealing with - if you don't then do nothing other than get assistance.
2. Do not do anything that will make an injury worse - ideally, the victim should reach a place where treatment can be given in no worse condition than in which you first saw him/her.
3. Do no more than is absolutely necessary even if it's just getting professional help:
Get Help
- The most important piece of equipment is the telephone. A supply of ice is useful (ice box or plastic bags in which to put ice). History and examination are two major things to determine. Events leading up to injury is vital and even if you saw the incident ask about what happened as you may not have seen all of it.
- Use your eyes first. Have a good look before you touch and feel for the injury. You may be able to decide or list what might be wrong, but think the worst as it may not be so bad. At least you will not overlook something more serious. It's better to be over cautious than potentially reckless.
- Items taken (especially) abroad should include:
- a diarrhoea treatment
- mild analgesic (painkiller)
- indigestion tablets
- a few compression ('Lyoband' type) and some waterproof adhesive dressings
- each member should also have a tube of 'Hirudoid' or 'Lasonil' for bruises
- a 'PR' (pain relief) spray or similar cold spray for mild sprains and bruises
- Paracetamol tablets
- bandages or medication that an individual would normally use (includes travel sickness). Sickness lasting more than 24 hours should be referred to a local doctor
- many 'cold cures' and similar over-the-counter preparations contain banned (in sports) drugs such as codeine or caffeine
- European Health Insurance Card
The circulatory system consists of the heart, arteries, capillaries and veins. Blood is pushed through blood vessels by the pumping action of the heart. First it passes through arteries which become progressively smaller until the smallest arterioles finally divide into capillaries. These join to form veins which carry blood back to the heart. Arteries have thick walls made up of a fibrous tissue outer layer for protection called the tunica adventitia and the thick muscle middle layer of the tunica media. The smooth inner lining is the tunica intima. Capillaries are one cell thick and thus very fragile. It is in these capillaries that all the work of the blood is done. Giving up oxygen and taking in carbon dioxide, removing waste products and supplying nutrients between the vessel interior (vascular space) and area external to vessel (extracellular space). Veins are constructed in a similar way to arteries with the exception that the muscle layer is thinner.
Blood Flow Physics
The heart beating results in blood pressure and the first part is the systolic BP (when heart contracts) and distolic BP (between contractions). Normal values range between 120mmHg (systolic) and 60mmHg (distolic). Written '120/60'. (Hg is mercury and is measured using a sphygmomanometer). Blood pressure is kept constant in body by muscles relaxing or contracting to alter the resistance to blood passage. This ensures BP is constant throughout the body no matter how far above or below the heart the artery is situated. BP drops rapidly through smaller arterioles and capillaries and is no more than 10mm Hg in the veins.
Blood circulation is in two parts. Veinous blood returns to the right side of heart and goes to lungs (pulmonary circuit - oxygen depleted). The only function is to take up oxygen and give up carbon dioxide in a gas exchange. Blood returns to the left side and is pumped out in the (systemic circuit) arteries as oxygen enriched blood. This is distributed to muscle, skin, bone and brain. A large portion of circulation is to the stomach, intestines and abdominal organs: spleen, liver and pancreas. When digestion is active, large amount of blood are diverted through this part of the system. Any injury ruptures some blood vessels, certainly capillaries, but also (possibly) small arterioles and veins. Any blow will result in blood leaking out into the fat layer under the skin or even into muscle. This is bruising which can later be seen as discoloration of skin. Blood is a very irritating fluid outside the vessels and any injury can be quite painful. Ice-pack application can minimise the extent of bleeding.
Where skin is not broken and there is blood flow from a damaged vessel that cannot escape, bruising may occur and bleeding only stops when blood clots to seal a hole in the vessel. Capillaries and veins have low BP so this is quite rapid, but when an artery is cut, blood is under higher pressure and the muscle in its wall contracts to hold the cut open. An arterial cut will continue to bleed unless external pressure is applied. If completely cut through this muscle contraction can act to seal the artery by curling inwards. Limb severing is survivable because of this.
Severe haemorrhage is an emergency. If one and a half pints of blood are lost (from a total of eight to ten pints in the body) shock sets in and is followed by death. Possibly up to two hours for a wrist cut or two to three minutes for big femoral artery and is dependent on the depth and location of the cut. The average nosebleed is about two tablespoonfuls for comparison. Treatment is the same regardless of type: a pad over the bleeding surface. Complete clotting may take up to thirty minutes to occur. Ideally, a clean dressing should be used, but this is not important compared to stopping blood flow. Anything will do. Application of pressure on bleeding point may be necessary for some deep cuts.
Internal Bleeding cannot be seen and bleeding from abdominal organs is quite different and involves bleeding into a closed cavity. Such a situation can be suspected due to blood loss even though it cannot be seen. Consider a ruptured spleen or liver. To illustrate, a blow over the left rib area may occur and some 20-30 minutes later pain can still be apparent in this area with giddiness then fainting. Consciousness may have been regained after a minute or two, but without knowing what had happened. Hospitalisation is needed to remove probably a ruptured spleen to stop the internal bleeding. Death is then preventable. This is a well recognised scenario and is more common in repeated blows rather than single blow. Times may vary and are dependent on the blood flow. A few minutes for severe rupture to a couple of hours for slow leakage. In certain diseases (like glandular fever) the spleen is fragile and ruptures more easily.
The reason for this fainting and recovery is due to BP dropping, but the body no longer able to sustain it. Fainting will cause the head to be same level as heart by lying prone so flow to brain temporarily restored. BP continues to drop and loss of consciousness reoccurs. Death will soon follow without recovery. Strikes to lower right rib area can damage liver. Results are not so dramatic as three to four days may pass after the injury before death supervenes. Although a slower sequence the same effects and reasons apply as for spleen damage. Visibly, when upright any blood pools in lower part of abdomen. When lying down blood runs up abdominal cavity to lie beneath diaphragm where it is irritating. An insensitive area to pain will result felt in pain elsewhere, but in same anatomical segment like the tip of the shoulder. A ruptured spleen may cause pain in the left shoulder tip and liver damage in the right shoulder. This is not always an indictor of internal bleeding, but is suggestive, especially if preceded by heavy blows and persistent pain and fainting. Immediate action is necessary.
Ruptured kidneys
Kidneys are less easily damaged as they are well protected by the ribs, spinal muscles and a thick pad of fat. Nevertheless a hard blow at 'kidney angle' between spinal muscles and ribs may result in bleeding. This is usually slow and nearly always stops spontaneously, but cannot be ignored. Long term effects show blood in urine (not normally visible to naked eye) and persistent pain. A doctor is required immediately. A urine specimen will be necessary to examine for presence of blood.
Ruptured pancreas
This is rare and caused by a blow to the pit of the stomach. Pancreas lies directly across spine and pressure over it occasionally causes rupture. This releases corrosive digestive juices into abdominal area that is not designed to cope with them. This results in severe pain and inflammation: the digestion of the linings. A blow to the 'solar plexus' will increase pain and distress. Hospitalisation is needed immediately.
Shock Condition
This occurs when the heart cannot maintain BP. There are two kinds: ruptured abdominal organs causes internal bleeding so that an insufficient volume of blood (loss of one and a half pints) is pumped around body and cause surgical shock'. The other type of shock is caused by loss of muscle tone and consequent increase in artery volume as muscles relax. Blood pools in them so less blood returns to the heart via veins. A drop in blood pressure results. Reactions to ruptured (damaged tissue) will involve pain and apprehension. BP drops in both instances though more particularly in surgical shock. If blood pressure drops and is not restored, there is a serious threat to life. Blood is diverted from the skin so a pale colouration appears. Coldness and sweating with raised pulse (around 100 bpm) occur with apprehensive and faintness. Breathing becomes rapid and maybe develop into air hunger.
Shock may occur after any injury and when fully developed is potentially fatal. When this is the result of bleeding, the bleeding must be stopped or reduced. If this is not possible then hospitalisation needed. Laying flat is important to maintain brain blood supply and tilted if necessary to have the head blow heart level. Comfort and keeping warm (not hot) are critical. Breathing should not be impaired by placing anything heavy on the injured party and nothing should be given to drink. This may interfere with any operation if needed. Assume confident attitude even if you are not. Casualty must believe you are in control. If in any doubt get to hospital.
The Head
Scalp, skull and brain. The scalp covers the skull and is a layer of fat containing a strong sheet of fibrous tissue to which muscles are attached and is covered by skin. Lacerations are common by a blow causing tissue to split on the bone beneath. Bleeding is profuse, but can be controlled by firm pressure. Sometimes a deep split can expose the skull, but this is not always obvious and requires expert examination. The skull is several bones joined together forming a rigid box. There are holes (foramina) to allow passage of nerves and blood vessels including the large one at base of skull for the spinal cord. The skull can be fractured from a direct blow or force transmitted to a weaker part. Commonly caused by hitting an unyielding floor rather than being struck. Most skull fractures cannot be diagnosed clinically, but if the base of skull is involved watery-looking blood from ear or nose is sometimes visible. The fracture is important as a measure of force used or possibly thinness of the skull. In all head injuries the most important consequence is damage to the brain.
The brain comprises two types of tissue, the grey matter and white matter. Grey consists of nerve cells only and a thin layer covers the whole surface of the brain. Scattered about the white matter areas is grey matter (nuclei), each having a specific function with regard to brain and body activity. White matter is made up of fibres connecting the nerve cells. The brain is separated from the skull by three layers of membrane - the meninges. There is a tough outer layer in contact with inside of skull: dura mater. The thin membrane covering the brain is the pia mater and an intermediate layer known as the arachnoid mater. This last one contains blood vessels and the cerebrospinal fluid so the brain actually floats freely within the skull bathed in this fluid.
Three mechanisms can cause brain damage. Any one or all of them. Firstly the head can be accelerated by a blow. The brain does not move until it is pushed by the skull. Similarly, when the head stops moving the brain will continue to move until stopped by hitting the inside of the skull. Damage can therefore be at both the site of impact and diametrically opposite to the site of impact. Secondly, grey and white matter have different characteristics and are accelerated at different rates by the same force. This results in shearing strain where they meet, leading to tearing of the nerve fibres which cross the junction. Lastly, a blow can give rise to shock waves in the cerebrospinal fluid surrounding brain. This can cause damage at point quite distant from the point of contact. Damage is the production of small haemorrhages into the brain tissue and is usually too small to be seen with the naked eye. They are quite numerous and situated in the white matter, mostly near its junction with the grey matter.
Concussion
Defined as any state where brain function is noticeably altered by an injury to the head. A presence and the degree of concussion are assessed by testing different functions of brain. First is maintenance of consciousness. If the casualty has been unconscious, even if only momentarily, they should be diagnosed as being concussed. If conscious when examined - test memory. This is affected at the time of an injury, immediately before or after the injury. Memory is lost in this order so the more lost the more severe the concussion. Ask what happened even if you saw incident - tests memory function. Other questions like name, age, where they are, what day it is. If answered correctly memory is probably intact. However, memory can falter later as a result of concussion. Caution. Test reflex functions like balance and co-ordination. A raised finger should be followed with the eyes to left-right and up-down. Instruction is understood if eyes follow accurately. A finger-to-nose from different directions tests positional and muscle co-ordination. Any deficiency in these demonstrates some degree of concussion.
Brain damage involves some brain cells that have died and the body is perfectly capable of regenerating these cells. However, if not fully recovered from damage and sustain further injury (even after three weeks) a similar degree of injury will cause ten times the initial extent of damage. If this is repeated just a few times before healing process is complete very quickly an enormous number of cells destroyed leading to thinning of grey matter with consequent loss of more complex function like memory, balance and co-ordination: the punch-drunk condition.
If damage is to a part of the brain that serves no known function awareness of damage is not possible as everything appears OK. Damage is sustained just the same - it's just not obvious. For these reasons competition rules state any degree of concussion or suspicion of it must be followed by a ban and any contact possibility for at least four weeks. If more severe concussion has occurred (loss of consciousness) then ban should be extended to three months. Three such instance in any one year is followed immediately by a year's ban. This must be rigorously enforced if severe damage is to be avoided. In the case of strangleholds that result in a loss of consciousness, however brief, treatment is the same as for concussion since similar brain damage is caused.
Unconsciousness
A state of unconsciousness exists when a person is unaware of surroundings. Or "senselessness'. There are five senses:
- Sight
- Hearing
- Touch
- Smell
- Taste
The small nerve crossing the upper rim of the orbit about third way in from corner of eye is useful. It is easily felt and pressure on this is quite painful. Reaction to this will vary according to degree of unconsciousness. Normally, the hand causing the pain may grabbed, but if at some deeper level the result would be perhaps waving hands about in the air, but not removing the source - your hand. Or no reaction at the very deep level. Smell is often used - some offensive really pungent odour. This will always get a reaction.
Unconsciousness as a result of head injury results in brain damage. Other causes can be intracranial haemorrhage - bleeding inside the skull. Cardiac arrest - heart stopped beating. Epilepsy, diabetes or hysteria.
Intracranial haemorrhageThis may be due to laceration of the brain tissue itself or tearing of the meninges (membranes surrounding brain and spinal cord). Usually this is as the result of a severe accident and is unlikely in martial arts, unless hit head on unyielding floor, wall etc. The most common tear is the large artery lying between the dura mater (outside layer) and the skull at the side of the head: middle meningeal artery. This can be torn even when there is no skull fracture. The sequence of events causing this damage can be misleading. The original head injury causes unconsciousness, but is possibly only momentary and unnoticed. Recovery may seem complete though bleeding continues as a result of an artery tear.The blood collects between skull and dura mater causing a build up of pressure on the brain. Consciousness is lost again and the unconsciousness progressively deepens until the casualty eventually dies. The time scale quite is variable and depends on the rate of blood loss (severity of tear). The range between regaining consciousness and losing it again can be anything from 20 minutes to several hours, but is commonly one and a half to two hours with death 1-4 hours afterwards. The shorter the time between consciousness and unconsciousness the sooner death supervenes. Physical signs associated with the increase in intracranial pressure may be vomiting (pressure in skull rising) and headache (if still conscious). These two symptoms can occur in uncomplicated injury (concussion), but may be signs of intracranial injury.
Must be sent to hospital without delay
An increase in pressure affects brain function and can be monitored by observing the eyes, pulse rate and breathing. The nerves controlling the pupil of the eye become irritated and the muscles contract - pupil gets smaller. This can be contrasted with the larger uninjured side. Pressure continues to increase the pupil on the affected side until it becomes paralysed when the eye muscles relax. The pupil is then widely dilated. The opposite side becomes irritated and contracts, then both pupils become dilated as the uninjured side is paralysed and pressure continues to rise. All this indicates severe intracranial pressure increase. As the pressure continues to rise the nerve centre of the brain controlling the heart rate is affected and the pulse gets slower. Breathing becomes periodic, firstly becoming more shallow then stops completely. After about 30 secs restarts and becomes deeper and deeper until back to normal. The sequence is repeated and possibly takes 2 minutes to cycle. The pulse rate and breathing are good indicators for the severity of intracranial pressure. If unconsciousness recurs or severe (and increasing) headache continues, hospitalisation should be immediate. Vomiting may start or symptoms develop for disturbed brain function (dizziness or double vision, confusion).
Sub-arachnoid haemorrhage
Sub-arachnoid haemorrhage is bleeding into the membrane covering the brain, which emanates from the arteries surrounding the brain's base. The joins of these arteries can be points of weakness and are probably present from birth. They may occur in the young adult and without warning. Sharp excrutiating pain may be felt at the base of the skull and can last for a few seconds. This may occur intermittently for several days before complete unconsciousness occurs with no warning or any injury. There will be a slow pulse rate and altered breathing with dilated pupils. All the indications of severe non-localised pressure on the brain.Very soon be death will supervene.
Severe head injuries often damage one or more of the cranial nerves. The sixth nerve controls the abducting muscle of eye so it turns inwards Damage to the eighth nerve produces deafness. Cerebral haemorrhage or stroke occurs in older people and involves bleeding actually into the brain tissue. Raised intracranial pressure may produce unconsciousness and other related symptoms, but also local ones like paralysis on one side of face and/or body, or loss of speech (if conscious). In all cases of intracranial haemorrhage, the only first aid is to get help/transport to hospital. Place in the recovery position until help arrives. Turn more or less face down with the head resting on the lower arm and the top of leg bent to chest. Any vomit or blood can them drain away from the lungs.
Cardiac arrest
The heart stops and blood pressure drops to zero as the result of cardiac arrest. The brain is deprived of oxygen and within 15 - 30 seconds consciousness is lost and vomiting and spasms similar to a fit may occur. Stoppage is due to one of two reasons: vagal inhibition or ventricular inhibition. The vagus nerve affects the heart rate and passes through the neck. One of its many functions is to control heart rate and it contains both sensory and motor fibres. It originates in the brain and finishes by supplying the nerves to the diaphragm and abdominal organs. Without nervous control the heart would beat at around 100 bpm. The vagus nerve slows this down to about 60 bpm at rest. Other mechanisms speed it up to deal with exercise. Over stimulation of the nerve slows the heart excessively and stops it beating altogether. The nerve can be stimulated by pressure on certain parts of neck or by shock. Sudden physical immersion into ice water can cause shock. A hard punch or kick to the lower, front chest can cause this over stimulation. It is vital to check pulse rate if there is a blow to the neck or pressure results from a stranglehold.
A blow to the front lower ribs can result in a knock down from which recovery seems apparent, but an epileptic-type fit and collapse can occur due to vagal inhibition. Heart may restart by itself. Lucky if it does. Ventricular fibrillation does not involve heart stoppage immediately unlessit continues for 3-4 minutes (death will supervene). The heart beats at 400 bpm caused by irritated piece of heart muscle and ventricles beating very rapidly. This is too fast to allow filing with blood so blood circulation ceases.
Ventricular fibrillation can be regarded as cardiac arrest. As with vagal inhibition the muscle spasms and vomiting may occur. The irritable heart muscle is usually a result of a previous 'coronary' (heart attack) and may have even passed unnoticed by the sufferer at an earlier time and any history of heart attack may be absent. Angina sufferers may have irritable heart muscle and so be predisposed to Ventricular fibrillation. An angina attack will normally precede ventricular fibrillation and angina is a reason to stop training immediately. In cardiac arrest there is no time to waste, and resuscitation must be started immediately or at least within 2-3 mins to prevent irreversible brain damage. After 4 mins, the heart will never restart.
Epilepsy is a disease of the brain which results in fitsand is produced by irritable areas in the brain. These can develop spontaneously (by themselves) or sometimes as the result of a head injury. The epileptic fit is preceded by some other sensory (smell) or physical (muscle twitch) impairment. Variety is immense, but is constant for an individual. It is followed by a loss of consciousness and the onset of violent muscle contractions. This may involve the entire body or only one region and then spread to become generalised. There is a probable loss of bladder control. The episode can last up to 10 mins but more commonly 3-4 mins, followed by sleep then wakefulness with no recollection of the fit. It is alarming to see, but single fits of themselves are no danger. However, one fit followed by sleep and then another without waking is more dangerous. Hospitalisation is necessary without delay as exhaustion and death may result. The patient may injure him/herself during fit and it is usually the main task in any assistance to prevent self-injury. Concrete floors and anything projecting from walls must be absent if person is known to have such fits and possibly prevented from training. It is medical opinion that epilepsy of itself is no reason for a training bar to be imposed. Sensory input may aggravate a fit so there should be minimal touch except than to prevent self- injury. Attempts to restrain must never happen and never attempt to keep the mouth open with fingers - you may lose them, but still not prevent them from biting tongue.
Diabetes mellitus
Diabetes mellitus is an endocrine disorder. Many mechanisms are probable, but all result in the prevention of glucose getting into the target cells. As a consequence, blood sugar rises and brings about the condition of hyperglycemia. The insulin level may be optimal, but something prevents the glucose entry, nevertheless. Non-insulin dependent diabetes mellitus (NIDDM) is age related (usually 40 and over) and generally in the overweight population. Food elevates blood sugar levels so insulin is used to balance the level to within fairly narrow limits. The insulin level is affected by exercise and the level of adrenalin. Most diabetics compensate for this, but mistakes can be made. High blood levels usually take some days to develop. Low sugar levels are much more sudden (minutes) and can cause the insulin coma (loss of consciousness). There is usually a warning by way of light headedness/weakness. Symptoms can be very variable. Perhaps a change in personality though not noticed by diabetic. It is suggested that a person is deliberately placed in a diabetic coma so they can recognise the onset of a non-planned one.
This should be confirmed by your medical advisor
Initial symptoms are followed by unconsciousness (after many hours) and noticeably profuse sweating. First aid is the rapid administration of sugar or glusose. Diabetics usually carry glucose or sweets for self administration and must be given if unconscious. Best to give glucose as a drink. Even if not swallowed sufficient may be absorbed through lining of mouth to effect recovery from unconsciousness. More then given. If state continues for a few mins only, professional health must be sought.
Hysteria
Hysteria is a mental change caused by overreaction or underaction of some part of the nervous system. Maybe some part is failing to work at all. Convulsive seizure, spasms, contraction of limbs, paralysis, affectation of various internal organs, derangement of joints or any combination of these. This includes (deep) loss of consciousness. It is unwise to diagnose hysteria as the range of symptoms is so wide. A more serious problem may be overlooked.
Resuscitation
Profuse bleeding, shock, breathing or heart stoppage only four situations requiring urgent action. Artificial respiration and cardiac massage cannot be learned from a book and requires practise on a dummy to learn the techniques properly. The Resuscitation Certificate should be a requirement of every instructor. Nevertheless, check:
- Pulse
- Breathing
- Airway
Check breathing by listening at nose/mouth. Air movement may be felt or the chest seen moving. Check airway by opening the mouth wide and look inside. If necessary finger down back of throat. A single false tooth or gumshield may be found. Absolute caution here. Vomiting can occur at time of cardiac arrest and it would be catastrophic if blown down lungs. The digestive juices are very corrosive and immediately begin to digest the lining of breathing tubes. This is a well known condition and carries a mortality rate of 50%. Start artificial respiration. Mouth-to-mouth needs practise after learning the technique. Even when the heart has stopped blow some air into the lungs so to some extent the blood remains oxygenated. At no point attempt to circulate non-oxygenated blood to brain.
External cardiac massage
Aim to squeeze the heart between the (back of) sternum and (front of) the spinal column. The sternum should be depressed by between one and a half to two inches (4-5cm). This takes a lot of energy and there is good chance some ribs will be broken. Don't ever simulate this level of pressure in practise. Keep it up. It may be 15 mins or more that mouth-to-mouth resuscitation and external cardiac massage is required before help arrives. Recommend two breaths to 15 pumps. This recommendation may continue to change (from between one/four, one/five, one/seven). Pick a rhythm and stick to it.
(Contact Sport) Training
Training accidents happen, but can be minimised. An instructor should tailor training to suit all. The pressures involved with training should be well understood. Likewise any injury/condition should be made known to the instructor. This is especially important in children. The injury may be slight, but exist nonetheless. It may have even happened elsewhere. Muscle stretching tears could go unnoticed by novices and not all injuries are reported. Few students dedicate themselves to real training, but train for reasons of self-defense, recreation and social. Many will have diseases or illnesses such as epilepsy, diabetes or asthma and even more serious disabilities. Few though need to be prevented from training as long as the instructor is informed. Except haemophilia. This is a defective blood clotting mechanism. The instructor should tailor training schedule to suit students - not the other way around. The training hall should be of an adequate size to prevent clashes or the number of students limited to the hall size. Hard areas should be padded. Games are useful to entertain children, but must be made safe. Turning points in running should be padded. Lighting must be adequate.
- Safety in competitions usually concerns organisers, referees and competitors. Organisers for adequacy of competition areas. Opponents matched for size and experience similarities. Medical certificate for fitness in international competitions advisable. Referees responsible for conduct of each fight. As well as awarding points and watching for illegalities, responsibility to keep control. Poor refereeing does lead to more injury. It is preventable. Disqualify if necessary.
- Proper protective equipment. It can be regarded that safety equipment leads to less control. Conversely, safety equipment can prevent accidents. No item should be defective like damaged gloves. Vision must not be restricted and freedom of movement not restricted. The referee's task should not be made more difficult by any item.
- Gloves/mitts: use can lead to heavier contact. No protection hurts the user as much if not more than victim and confers self-regulating control. Gloved hand will diffuse heavy one/two knuckle blow and conditioned hands make gloves more important. Easy to give heavy blow without personal injury. Gloves are probably desirable on balance even if they are not compulsory. A well-padded glove can mask evidence of heavy contact and a concussive blow could be delivered without damage to the skin of the hand. There should be sufficient coverage of a smooth padding to minimise damage, but not too much that heavy contact cannot be felt. Bag gloves must not to be used except on bags: they have an incorrect covering. Bags are not covered with skin. Conditioned use of well padded gloves then conversion to sensible gloves will result in heavy contact. This should be expected.
- Gum shields. Prevents lacerations on inside of lips (bruising not prevented). Restricts damage to facial bones/jaw and concussive effects if the mouth is kept firmly closed (biting hard).
- Groin protectors. Women should have a minimum perineal guard to give adequate all round protection. Large sanitary towel gives virtually 100% protection. Most kicks are upwards so box type do not prevent damage: the contents get squashed between the box and the hard pelvic bones. Better is the hip placed model, but this does restrict mobility. Breast protectors are advisable, but is still personal preference.
- Head guards. Some safeguard against heavy (accidental) kicks to head. Vision not to be impaired so can see oncoming blow. More useful against training incidents against others (head clashes). Argument goes that can spread concussive blow and can therefore not offer the expected level of protection. Body armour has its objections. Movement restriction and encouragement of less control - heavier contact. Ruptured spleen is not an uncommon injury. They do not offer complete protection.
No one should doubt the quality of boxing training as highly effective. Fitness and technique are both excellent. However, the reason behind boxing may require close questioning regarding motives. The overall requirement is to win the bout - fair enough. But, the method used to defeat the opponent can be considered barbaric in that to end the fight as quickly as possible it is a must to attempt to inflict severe damage on the opponent. In effect to try to kill him. The requirement (theoretically) in Taekwon-do is not to inflict needless damage, but to demonstrate superior skill toward the defeat. The technical superiority will always triumph over the brutal onslaught. It doesn’t take much skill to use brutality, but to dissect an opponent does need skill. Fitness is a precept of training, but of most importance is the development of the skill. Fitness improves as the bi-product of training.
posted by Louis Brothnias @ 5:17 AM
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