KEY WORDS: Cerebral trauma, computerised tomography, mild head injury, prevention.

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.

• Head injuries are common in full contact sports.
• GCS is the examination of choice to determine neurological status in the field.
• Detailed neurological examination cannot detect intra-cerebral haemorrhage.
• 38% of mild brain injuries result in intra-cerebral haemorrhage.
• Discussion between clinicians in the field and hospital clinicians is necessary to provide full details of the clinical picture to avoid premature discharge.