First Response For Kiteboarders To Bodily Trauma

[ricki]

NOTE: The identities of the victims and locations of the accidents are not included in these summaries. Given the nature of reported observations and difficulty of fact checking, these accounts would be best considered as plausible, hypothetical scenarios as opposed to actual incidents for purposes of discussion.

Case #2 involves poor victim response to severe trauma after the accident. It happens to also have some similar circumstances to another accident, Case #3, that happened in another location now that I think about it. Case #2 involved a cerebral concussion from a board leash driven board impact in excessively gusty conditions for a first time kiter. He felt "sore" and decided to sit out the rest of the day. I believe he may have suffered an epidural hematoma and was in a lucid state (thanks for setting me straight SAB), upon returning to the beach. I went through something similar myself about five years ago without the board impact. I think I hit a guardrail of a house and tree instead. Anyway, about two hours later he passed out momentarily but revived within seconds. He then entered a coma shortly thereafter. He was transported to a clinic and then on to a hospital. He reportedly died from "a fractured skull and cerebral bleeding" several days later. The person that relayed this information to my source was a physician. He felt that had the victim responded in a more timely fashion shortly after his accident he might not have died.

Case #3 involved cervical trauma and paralysis bellow the knees in a rider following dragging and lofting. By one report after the impact the victim was seen to get up and walk around for a short time. It is felt that if this happened, it may have heavily contributed to the later condition of paralysis.

In these later two cases, I would like to try to build better awareness in the kiteboarder community, aside from the normal focus (e.g. weather, launch selection criteria, non-board leash use and safety gear, etc.), to appropriate first response to bodily trauma. Such trauma seems to be a fairly common risk with dragging and lofting. If the victim remembers the cautions great, but I would like other kiteboarders to be sensitive to what they can and should do in terms of keeping the victim immobilized, symptoms of some of the more obvious nervous system disorders, seeking proper medical care rapidly and other measures as indicated. This later set of precautions is totally out of my ballpark. Also, I am not trying to replace paramedics or an advanced first aid course either. I really just want to try to build better awareness and sensitivity to what can go wrong and how to try to avoid it from happening.

I was thinking of cutting and pasting quotes from online TBI and related references with links. From what I have seen however, it would simply be too long. Our audience sad to say has quite a limited attention span at times. So, I was thinking something shorter and to the point on the basics of first response that could be conveyed in online forums with links to more detailed references might work. If you can help in this latter case that would be outstanding. There would be no need to mention your identity in this unless you wouldn't mind attribution for your help.

[ricki]

NOTE: The identities of the victims and locations of the accidents are not included in these summaries. Given the nature of reported observations and difficulty of fact checking, these accounts would be best considered as plausible, hypothetical scenarios as opposed to actual incidents for purposes of discussion.

Case #2 involves poor victim response to severe trauma after the accident. It happens to also have some similar circumstances to another accident, Case #3, that happened in another location now that I think about it. Case #2 involved a cerebral concussion from a board leash driven board impact in excessively gusty conditions for a first time kiter. He felt "sore" and decided to sit out the rest of the day. I believe he may have suffered an epidural hematoma and was in a lucid state (thanks for setting me straight SAB), upon returning to the beach. I went through something similar myself about five years ago without the board impact. I think I hit a guardrail of a house and tree instead. Anyway, about two hours later he passed out momentarily but revived within seconds. He then entered a coma shortly thereafter. He was transported to a clinic and then on to a hospital. He reportedly died from "a fractured skull and cerebral bleeding" several days later. The person that relayed this information to my source was a physician. He felt that had the victim responded in a more timely fashion shortly after his accident he might not have died.

Case #3 involved cervical trauma and paralysis bellow the knees in a rider following dragging and lofting. By one report after the impact the victim was seen to get up and walk around for a short time. It is felt that if this happened, it may have heavily contributed to the later condition of paralysis.

In these later two cases, I would like to try to build better awareness in the kiteboarder community, aside from the normal focus (e.g. weather, launch selection criteria, non-board leash use and safety gear, etc.), to appropriate first response to bodily trauma. Such trauma seems to be a fairly common risk with dragging and lofting. If the victim remembers the cautions great, but I would like other kiteboarders to be sensitive to what they can and should do in terms of keeping the victim immobilized, symptoms of some of the more obvious nervous system disorders, seeking proper medical care rapidly and other measures as indicated. This later set of precautions is totally out of my ballpark. Also, I am not trying to replace paramedics or an advanced first aid course either. I really just want to try to build better awareness and sensitivity to what can go wrong and how to try to avoid it from happening.

I was thinking of cutting and pasting quotes from online TBI and related references with links. From what I have seen however, it would simply be too long. Our audience sad to say has quite a limited attention span at times. So, I was thinking something shorter and to the point on the basics of first response that could be conveyed in online forums with links to more detailed references might work. If you can help in this latter case that would be outstanding. There would be no need to mention your identity in this unless you wouldn't mind attribution for your help.

[ricki]

Some comments and ideas from an Emergency Physician follow. It would be good to receive the comments and opinions of other members and from various areas of practice. Even with the relatively small membership at this point, the broad diversity of training, experience and perspective from various parts of the medical profession is impressive.

"This is a typical story of an epidural hematoma (or subdural) involving blunt head injury, possible loss of consciousness, a lucid interval and subsequent loss of consciousness and death. These are avoidable deaths with timely intervention. Brain damage is not always avoidable. That being said, my professional life is spent searching for the proverbial needle in the haystack of brain bleeding after concussion. I probably cat scan 100 heads to find one. The vast majority of those I do find do not need surgery. On the flip side, you can’t get everyone who has had a concussion to go the the ER. Sometimes people get their bell rung and see stars and don’t know the severity of their injury. Some people just want to be tough. Also, the mortality from these I’m sure is significantly greater in underdeveloped countries as opposed to in the states a short ambulance ride away from a waiting neurosurgeon."

"To state the obvious, board leashes are dangerous. Board leashes without helmets are fatal.

The bottom line is always launch toward the water, keep the kite low, and try to stay out of the chicken loop when launching. Convincing people to do that will save more skin.

An ounce of prevention…"

[ricki]

Some comments and ideas from an Emergency Physician follow. It would be good to receive the comments and opinions of other members and from various areas of practice. Even with the relatively small membership at this point, the broad diversity of training, experience and perspective from various parts of the medical profession is impressive.

"This is a typical story of an epidural hematoma (or subdural) involving blunt head injury, possible loss of consciousness, a lucid interval and subsequent loss of consciousness and death. These are avoidable deaths with timely intervention. Brain damage is not always avoidable. That being said, my professional life is spent searching for the proverbial needle in the haystack of brain bleeding after concussion. I probably cat scan 100 heads to find one. The vast majority of those I do find do not need surgery. On the flip side, you can’t get everyone who has had a concussion to go the the ER. Sometimes people get their bell rung and see stars and don’t know the severity of their injury. Some people just want to be tough. Also, the mortality from these I’m sure is significantly greater in underdeveloped countries as opposed to in the states a short ambulance ride away from a waiting neurosurgeon."

"To state the obvious, board leashes are dangerous. Board leashes without helmets are fatal.

The bottom line is always launch toward the water, keep the kite low, and try to stay out of the chicken loop when launching. Convincing people to do that will save more skin.

An ounce of prevention…"

[ricki]

Eagle provided the following comments regarding first response to a kiteboarder injury accident from a paramedic's perspective:

"I would like to see one of the publications address what should be done in the event of kiter injury.
What to do ?
a.Notify EMS
b. check the ABC's (airway,breathing,circulation)
c. ensure no further injury occurs to kiter/bystander (secure kite)
d. consider removal from the water
e. neck/spine stabilization until EMS arrival
f. direct pressure applied to any external bleeding
g. identify resources (lifeguards, off duty docs or other healthcare providers) "

and the following general comments regarding head trauma and response:

"The difference between the epidural hematoma and subdural is the onset of symptoms, and origin of the bleed. Subdurals can take days to weeks to manifest into textbook symptoms, although close friends and relatives do report the victim often acts "slightly odd". The bleed is often of venous origin involving smaller vessels. The epidural has a rapid onset, LOC followed by lucid interval then coma. Most always involves the Meningeal artery and usually results from blunt trauma to the temporal/parietal region of the skull.

A loss of consciousness for less than 5 minutes is typical of a cerebral concussion, which a full recovery is likely. Loss of consciousness for more than 5 minutes is typical of a cerebral contusion (brain bruise) and this carries a high risk of neuro impairment and should be investigated through CT studies. Head injuries in older people are more serious, and warrant a thorough exam.

For the layperson, if the victim is unconscious the first priority should be removal from the water to the beach and immobilizing the neck by holding the lateral part of the head. Airway is opened by pushing the mandible up and away from the maxilla (aka modified jaw thrust) An obstucted airway (tongue) is common in those unconscious, simply opening the airway utilizing the above mentioned technique may save a life. It is rather non invasive and can be performed by many laypersons with CPR training.

In someone who is conscious, I would advise they lay still while manually holding c-spine with the hands until medics arrive. Reassurance and a calm demeanor goes along way in this situation. Sometimes head injury patients can be unpredictable, bizzare and violent. If the person is acting in this manner the best thing to do is not place yourself in danger and allow EMS to handle the situation- all it takes is one call.

With an isolated head injury the main concerns are Level of Consciousness, whether the airway is open or not, and cervical/spinal immobilization. The airway and unstable cervical fractures are the immediate life threats.

Penetrating head trauma is treated in the same manner, only the onset of neurological symtoms occur more rapidly, i.e Cushings Reflex, seizures, abnormal ventilatory patterns. "


Thanks for your input, Kitezilla and Eagle.

What other opinions does the membership have on first response to kiteboarding injury accidents? The eventual goal following discussion is the preparation of a concise, effectively worded guidance document for circulation among kiteboarders at large dealing with this subject.

[ricki]

Eagle provided the following comments regarding first response to a kiteboarder injury accident from a paramedic's perspective:

"I would like to see one of the publications address what should be done in the event of kiter injury.
What to do ?
a.Notify EMS
b. check the ABC's (airway,breathing,circulation)
c. ensure no further injury occurs to kiter/bystander (secure kite)
d. consider removal from the water
e. neck/spine stabilization until EMS arrival
f. direct pressure applied to any external bleeding
g. identify resources (lifeguards, off duty docs or other healthcare providers) "

and the following general comments regarding head trauma and response:

"The difference between the epidural hematoma and subdural is the onset of symptoms, and origin of the bleed. Subdurals can take days to weeks to manifest into textbook symptoms, although close friends and relatives do report the victim often acts "slightly odd". The bleed is often of venous origin involving smaller vessels. The epidural has a rapid onset, LOC followed by lucid interval then coma. Most always involves the Meningeal artery and usually results from blunt trauma to the temporal/parietal region of the skull.

A loss of consciousness for less than 5 minutes is typical of a cerebral concussion, which a full recovery is likely. Loss of consciousness for more than 5 minutes is typical of a cerebral contusion (brain bruise) and this carries a high risk of neuro impairment and should be investigated through CT studies. Head injuries in older people are more serious, and warrant a thorough exam.

For the layperson, if the victim is unconscious the first priority should be removal from the water to the beach and immobilizing the neck by holding the lateral part of the head. Airway is opened by pushing the mandible up and away from the maxilla (aka modified jaw thrust) An obstucted airway (tongue) is common in those unconscious, simply opening the airway utilizing the above mentioned technique may save a life. It is rather non invasive and can be performed by many laypersons with CPR training.

In someone who is conscious, I would advise they lay still while manually holding c-spine with the hands until medics arrive. Reassurance and a calm demeanor goes along way in this situation. Sometimes head injury patients can be unpredictable, bizzare and violent. If the person is acting in this manner the best thing to do is not place yourself in danger and allow EMS to handle the situation- all it takes is one call.

With an isolated head injury the main concerns are Level of Consciousness, whether the airway is open or not, and cervical/spinal immobilization. The airway and unstable cervical fractures are the immediate life threats.

Penetrating head trauma is treated in the same manner, only the onset of neurological symtoms occur more rapidly, i.e Cushings Reflex, seizures, abnormal ventilatory patterns. "


Thanks for your input, Kitezilla and Eagle.

What other opinions does the membership have on first response to kiteboarding injury accidents? The eventual goal following discussion is the preparation of a concise, effectively worded guidance document for circulation among kiteboarders at large dealing with this subject.

[ricki]

Here are some comments from an orthopaedic surgeon with some experience with neurological injuries. It provides clarifying information regarding the probability of a Epidural Hemotoma having occurred in this case as opposed to a Subdural Hemotoma as originally proposed in the email.

"Case 2: This patient had a closed head injury from the board. The dura is the layer of tough tissue surrounding the brain and lies directly beneath the skull. Subdural (below dura) hematomas are usually associated with significant underlying brain injury and the patient is usually unconscious from the time of injury. Epidural (outside the dura) hematomas is when the blood collection occurs between the skull and the dura, usually in association with a skull fracture which expand and push on the brain, These patients usually have a lucid interval and before they loose consciousness. These patients if treated early enough often make a near complete recovery. I suspect this patient had an epidural hematoma with an associated skull fracture which accounts for his lucid interval. "

Thanks for your input!

[ricki]

Here are some comments from an orthopaedic surgeon with some experience with neurological injuries. It provides clarifying information regarding the probability of a Epidural Hemotoma having occurred in this case as opposed to a Subdural Hemotoma as originally proposed in the email.

"Case 2: This patient had a closed head injury from the board. The dura is the layer of tough tissue surrounding the brain and lies directly beneath the skull. Subdural (below dura) hematomas are usually associated with significant underlying brain injury and the patient is usually unconscious from the time of injury. Epidural (outside the dura) hematomas is when the blood collection occurs between the skull and the dura, usually in association with a skull fracture which expand and push on the brain, These patients usually have a lucid interval and before they loose consciousness. These patients if treated early enough often make a near complete recovery. I suspect this patient had an epidural hematoma with an associated skull fracture which accounts for his lucid interval. "

Thanks for your input!

[ricki]

Some comments from a plastic surgeon with interests in peripheral nerve injuries and frequent involvement with Neurosurgeons follow:

" Further to our email 10 days ago I have researched the issue of spinal/neurological injuries in kiting. I talked to some neurosurgeons and trauma surgeons. Interestingly boogie boarding was a more common theme to them as it seems that boogie boarders have a habit of face planting into sand and sufferring neck fractures.

Recently, as I alluded to, a top kiter from ---- fractured his neck hitting the sand in shallow water and waves. A kiting buddy of mine who is an anaesthesiologist and another GP who kites were there and strapped him to the floor of their 4wd with gaffer tape to drive him to hospital. He was fine after 6 weeks in a collar, but if he had been mismanaged he could have been in dire trouble. This is a lesson in how to manage an injury properly.

Anyway the take home message is:
If you witness a kiting accident where the kiter could have a suspected neck or spinal injury and is on land DO NOT MOVE HIM. Keep warm with a blanket and wait for a paramedic with a stretcher and proper skills to move him. If he is in the water of course he must be moved to prevent drowning but avoid excessive spinal movements to get to shore, then do as above. If it is you that is injured or the person is walking wounded and has pain in the spine or neck then seek proper medical examination in the first instance (at an ER).

Rick there are guidelines for management of spinal trauma in the paramedical and Trauma surgical literature and this stuff is taught all the time to medics. The question is whether it can be readily passed on to kiters in a digestible form. I guess it seems appropriate to warn people not to move a suspected spinally injured patient, and to seek medical help if injured but personally I think it unrealistic to expect much more from the general kiting public. It probably boils down to personal responsibility-how many people do a first aid course etc?? "

[ricki]

Some comments from a plastic surgeon with interests in peripheral nerve injuries and frequent involvement with Neurosurgeons follow:

" Further to our email 10 days ago I have researched the issue of spinal/neurological injuries in kiting. I talked to some neurosurgeons and trauma surgeons. Interestingly boogie boarding was a more common theme to them as it seems that boogie boarders have a habit of face planting into sand and sufferring neck fractures.

Recently, as I alluded to, a top kiter from ---- fractured his neck hitting the sand in shallow water and waves. A kiting buddy of mine who is an anaesthesiologist and another GP who kites were there and strapped him to the floor of their 4wd with gaffer tape to drive him to hospital. He was fine after 6 weeks in a collar, but if he had been mismanaged he could have been in dire trouble. This is a lesson in how to manage an injury properly.

Anyway the take home message is:
If you witness a kiting accident where the kiter could have a suspected neck or spinal injury and is on land DO NOT MOVE HIM. Keep warm with a blanket and wait for a paramedic with a stretcher and proper skills to move him. If he is in the water of course he must be moved to prevent drowning but avoid excessive spinal movements to get to shore, then do as above. If it is you that is injured or the person is walking wounded and has pain in the spine or neck then seek proper medical examination in the first instance (at an ER).

Rick there are guidelines for management of spinal trauma in the paramedical and Trauma surgical literature and this stuff is taught all the time to medics. The question is whether it can be readily passed on to kiters in a digestible form. I guess it seems appropriate to warn people not to move a suspected spinally injured patient, and to seek medical help if injured but personally I think it unrealistic to expect much more from the general kiting public. It probably boils down to personal responsibility-how many people do a first aid course etc?? "