We have all experienced or know of someone who has been in this situation

Stanley Havea - Epworth Hospital - photo courtesy of Stanley

While riding with my regular bunch, Stanley Havea, President of the group called Gruppetto Melbourne came off his bike at over 50km/h. With no visible damage apart from grazing and with reassurances from Stanley that he was ok,  we proceeded to ride back home.

For Stanley this was an over 40km ride home and fortunately upon his arrival, his wife Rita immediately thought it was best to go to the local hospital in Richmond. On admission, the doctors (precautionary measures, given speed), immediately put him into a cervical and neck brace.  But after a CT of the neck and brain was given the all clear; sutures of the elbow, rib tenderness and an MRI confirmed evidence of a Grade 2 AC shoulder joint sprain, he left the hospital with a sling and required 3 months of intense physiotherapy.

Unfortunately it's becoming more frequent

The Head of Emergency at the Epworth Hospital Richmond, Associate Professor Ron Sultana says that with cycling gaining more popularity as a recreational pastime activity, there has seen an increase in frequency of people presenting to the Emergency Department  with cycling-related injuries.

There are nuances with injuries, some injuries such as hits to the head are obviously more felt and can be seen by the person who was impacted. The person may still be conscious and able enough to get back on the bike without realising their impairment is more significant than what they think. This may also be affected by the fact that their senses may be dulled and not working as well as usual,  the brain neurones having been stunned by the trauma.

This kind of injury is common when there has been significant damage to the helmet, impaired consciousness and alertness, significant bruisingg around the head and associated tenderness and headaches.

Similar to sleepwalking

It's a similar feeling to waking up after receiving general anaesthetic. You may have no recollection of speaking to people when you regain consciousness or leaving the hospital — it's similar to sleepwalking. 

You may be able to get onto a bike and ride but your level of alertness is nowhere near where it should be. This presents an ongoing risk to you as you may not be taking into account all of the stimuli to make appropriate decisions when dealing with traffic, other cyclists, changes in the road variables or navigating your way home.

If you've fallen and suffered a significant hit to the head,  you may look normal but  you may be in fact be impaired so it's better to get some other form of transport home and get medical attention as soon as possible.

Subtle brain injury 

A subtle brain injury is quite difficult to quantify. If you were to look microscopically you would notice that the neurones were affected, but scans do not pick up this level of damage. This is a concussion and it would only be picked up with detailed neuropsychiatric tests similar to what footballers have to do when injured in the field. The patient is asked to remember things, tested on their recall of basic facts or mathematic problems. Usually, the medical professional is looking for subtleties where the patient is not performing to their usual standard.

These are some indicators after a significant hit to the head where serious brain trauma can develop quickly:

• a broken helmet
• trauma to the head
• impaired or loss of consciousness
• impairment of alertness, movement or speech
• headache
• nausea or vomiting

It can be a very serious injury

A/Prof Sultana recalls looking after a a cyclist knocked over by a car, who landed on his head. came into the emergency department talking, and within half an hour had deteriorated and required urgent neurosurgery.

You may be unlucky and hit the wrong part of your head. One vulnerable area are your temples, where the bones are a bit softer and just below the temple area, where there is quite a significant artery that if torn, can create significant bleeding in the brain and skull.

A closed space

The problem with the head is that it is a closed space, so there is no space for other substances. If you have bleeding into a closed space then the brain will get smaller and once the brain starts getting squashed the more critical structures of the brain that control breathing and the cardio-vascular system are also squashed. This is how people can die from brain injuries.

What to do next

When you see professional footballers get struck and fall to the ground but are okay within a few minutes, what you don't see is that they have the benefit of having an onsite doctor to assess them as well as an experienced sports physician who can determine whether or not they may have concussion.

There are very strict rules about re-current head trauma as repetitive injury to the head has the potential for long term medical issues to develop for the athlete as well as the possibility of sustaining another injury while playing with a concussion.

Cyclists do not have a doctor nearby so if you witness someone falling and showing the symptoms then there is also a possibility of other injuries that will require an ambulance such as upper limb, wrist, elbow injuries and abrasions. It's impossible to know where things may go, so it's always best to get checked by a medical professional.

For example it may just look like a skin breech to the elbow but if you rode where there is a lot of gravel and dirt and as a result of the  bike's velocity at the time of your injury the gravel gets injected quite deep into the tissues and may be difficult to clean out. What may seem like a relatively minor injury may result in some structures like the bursa (the sack like structure around the joints that allow the skin to glide over the joints) to be affected by the gravel particles and the person may end up with infected wounds a few days later.

Neck injuries

Fortunately Stanley was all clear - photo courtesy of Stanley Havea

When there is head trauma there is also a chance of neck injuries. If there is neck pain related to fall or injury from a bike then you must treat it seriously as it may potentially be an unstable neck fracture, so it would be wise to call an ambulance. Especially with a head and neck injury while experiencing numbness in the limbs or deformed limbs then the person needs to be kept still and call an ambulance (as long as they are not in any immediate danger).

Trauma to the chest and abdomen 

This can happen from impact to the handle bars and you can get rib fractures, bruising, collapsed or punctured lungs. Splenic injuries are also a serious and delayed injury that can result from the impact.

The spleen — I got hit in the stomach but I'm ok

When someone has been injured on the left upper quadrant of their abdomen, left shoulder tip, upper stomach or lower left chest and they experience pain in that region, then in some cases the spleen has been injured.

The spleen as an organ can bleed and the bleeding can progress over time and rupture. Once this occurs you have abdominal haemorrhaging and it is life-threatening.

If the person has trauma to the stomach but they feel okay but experience these symptoms and have difficulty breathing, they really should get themselves checked out.

Obvious fractures

These are the one that everyone can tell that something is not right. An obvious fracture could be a big lump on the collar bone protruding through the top of the jersey, a deformity, or an open wound with a fracture. Of course it is probably best to call an ambulance.

Less obvious fractures

These are the injuries where you think you're okay and it's just an ankle/knee sprain but it tends to be more painful than what you've experienced before. It's a pain that persists and you can't put your weight on it, use the limb or feel localised tender points when you place your thumb on the pain.

The wrists are complex joints, with many bones, in particular a bone called the scaphoid bone, which if broken may not heal without medical intervention. If you experience local pain, impaired function or can't push against the hand without there being significant pain, consider that there may be a fracture. . The hips can experience complex trauma that impacts the pelvis with an inability to move the hip or have any weight bearing movements. Usually if it's that bad, it's probably a bone fracture.

Fingers can be deceiving as well 

The fingers may seem sprained but fingers can be broken and look like a soft tissue injury. If there is persistent pain, swelling and impairment of function then you should be seen by a Doctor as it may be a fracture.

DRSABCD — Basic First Aid 

Danger: Ensure the area is safe for the person injured, yourself and the people around you. 
Response: Are they responding? Are they alert and talking or impaired? Ask them for their name.
Send for Help: Call an ambulance or get someone nearby to call for you while you check on the injured person and listen to the emergency instructions. 
Airway: Check that the person's airways are clear. If conscious and not in danger keep the patient still, keeping in mind they may have a neck injury. If unconscious, place  the person in the recovery position, but support the head and neck and avoid any twist or bend to the neck. Their tongue, spit or other object could be blocking their airways so clear it with your hands.
Breathing: Are they breathing? Place your hands or ears over their nose and mouth and try and feel and listen for their breath.
CPR: If they are not breathing, begin CPR. 30 chest compressions followed by 2 breaths into the person's mouth. Continue CPR until help arrives.
Defibrillator: Apply defibrillator if available and follow the prompts.

Stay a little longer

In the instance where a person is determined to ride on when there are symptoms, impairment and behavioural changes, suggest to the person to wait a little longer and see what they are like after a few minutes before getting back on the bike.

Being remote — planning

If you are going somewhere remote always have a plan B if something happens. What means of communication do we have? Is there mobile reception? Are the batteries fully charged? Do you have tracking device or an emergency beacon?

A good idea is to carry a basic first aid kit and let people know of your itinerary and where you expect to be at a certain time.

In the situation of an accident if you can get up and put sustained pressure on a leg or arm then there is probably no significant break or bleeding, but go and get yourself checked out by a medical professional. It's better to be safe than sorry.

For First Aid courses

HLTAID001 | Provide cardiopulmonary resuscitation

HLTAID002  Provide basic emergency life support

HLTAID003 | Provide first aid - minimum requirement

First Aid Providers

Red Cross Courses
https://www.redcross.org.au/get-involved/learn/first-aid/first-aid-training

St Johns Ambulance Courses
https://shop.stjohn.org.au/e-learning-courses

Australia Wide First Aid
https://www.australiawidefirstaid.com.au/

First Aid Training Melbourne
https://www.firstaidtrainingmelbournecbd.com.au/?First-Aid;Info;1685

CPR first aid
https://www.cprfirstaid.com.au/courses.aspx

Emergency First Aid
https://emergency.com.au

Vic First Aid
https://vicfirstaid.com/courses

Accredited First Aid Courses
https://accreditedfirstaidcourses.com.au/location/melbourne/

Australian First Aid: 
https://www.australianfirstaid.com.au/course/provide-first-aid-2

Disclaimer

This article seeks to provide a broad overview of possible injuries sustained during a bicycle accident and what the next steps may be. It in no way forms or purports to form an exhaustive list of what to do in the event of an accident or in any way should not be relied upon to form a particular view or action based on the information provided.

Furthermore, the aforementioned treatments and remedies outlined will vary from individual to individual and depending on the individual’s level of injuries and other factors (known/unknown) will vary the level of support required and the next steps/actions may vary.

If in doubt always call 000 for an ambulance and police if a vehicle is involved.

This information is was kindly provided by Associate Professor Ron Sultana, a senior Emergency Physician and the Director of Emergency Medicine at Epworth HealthCare.

A happy ending - Stan riding again with his local Gruppetto bunch

Riding again up the Mountain Pleasant Climb - Eltham, Victoria

A special thank you to Stanley Havea for his support of our article and allowing us to use his images.

If a car is involved and you are in Victoria, Australia

If the unthinkable happens, depending on whichg state the acident happens, there are some things you will need to consider.

Bunchrides.com/the-spin/cycling-tips/what-to-do-in-a-car-accident

Reporting what happended

To help create a safer environment and provide information for future cycling infrastructure projects there are online resources where you can document your accident,crash, incident or unsafe riding areas;

Upride.cc is an iniative from bicycle video lights supplier Cyclic where you can upload video footage with a map pin based on whether the incident was a crash, close call, punishment, danger or an animal ecounter

Bikespot offered a simialr crowd mapping platform in 2016 that highlighted areas that were deemed unsafe by the cyling community with a new release in the coming months.