Helmet Removal in Head and Neck Trauma
William O. Roberts, MDDepartment Editor
THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 7 - JULY 2021
When an ice hockey player hits the boards head-first after a hard body check or a football defensive back doesn't get up after a head-on tackle, the initial response is critical. If the player is unconscious or not breathing, it may be necessary to remove his or her helmet to access the airway. Helmet removal requires a careful, methodical approach to avoid compounding a suspected injury to the spinal cord.
If You Can, Leave It On
Fluoroscopic studies have detected spinal motion even in the best of circumstances when removing hockey and football helmets (1). Hence, the first rule of management on the field is to stabilize the neck and keep the helmet on if possible.
For football and ice hockey players in the supine position, shoulder pads elevate the trunk, so that when the helmet is removed, the head drops and the neck hyperextends. Leaving the helmet in place keeps the neck from hyperextending. Helmets also fit snugly and cradle the head, minimizing head and neck motion.
Thus, if an injured athlete is breathing and does not require airway management, the helmet should be left on to help support the head and neck. But the face mask should be removed, since Emergency Medical Service (EMS) protocols require removal of the mask before transport. An athlete who requires airway intervention requires immediate removal of the face mask for access to the airway while leaving the helmet on. Ideally, the helmet is left in place until the cervical spine can be imaged with radiography.
The only reason to remove the helmet in most situations is inability to establish an airway and effective breathing or failure of the helmet to stabilize the head adequately.
The practice of leaving the helmet on unless removal is absolutely necessary differs from the advanced trauma life-support protocol for helmet removal in motorcycle accidents. This difference may cause some uncomfortable confrontations on the field if there has been no communication between the sideline medical personnel and the local EMS staff (see "C-Spine Management Guidelines Proposed," page 15).
If removing the face mask does not allow necessary airway access and management, the helmet will need to be removed. This procedure requires great care and a steady hand. To be done safely for an unconscious or neck-injured athlete, helmet removal requires at least two people. It may be helpful to have a third person standing by to stabilize the patient's trunk if necessary.
Tools that are necessary or useful for removing the face mask and helmet are shown in figure 1. Usually the face mask can be removed by unscrewing the plastic mounting clips, but if the bolts are rusted, a pliers or locking pliers can be used to break them free. If there is a true airway management emergency, the clips can be cut with a shears (figure 2) or similar heavy-duty cutting tool.
Some newer helmets have hard plastic clips that can't be cut with shears, and ice hockey helmets often have thin metal brackets, which also may resist cutting with shears. In these cases, rapid removal of the retaining screws will be required.
To remove the helmet, person 1 should be stationed near the top of the patient's head while person 2 kneels next to the patient (figure 3). The first step is for person 1 to stabilize the head and neck by grasping the helmet from above to prevent neck movement. Person 2 should cut the chin strap (unsnapping the strap may jerk the helmet) and gently remove the face mask and cheek pads (hockey helmets may not have cheek pads).
The cheek pads can be pried loose from their snap attachments with a screwdriver, bandage scissors, or reflex-hammer handle and gently slid out to open up the base of the helmet (figure 4). At this point it may become necessary for person 2 to begin to prop the head inside the helmet, as the lower portion of the head will lose some of its support.
If there is an inflated air pad inside the helmet (not the case with hockey helmets), it should be deflated by tapping it with an air pump needle (figure 5) or opening the valve. Again the head may need more support inside the helmet. Any additional removable padding should be detached at this point.
Person 2 then stabilizes the base of the skull and neck with one hand and the chin with the remaining hand. Person 1 then grasps the base of the helmet on each side, placing the thumbs in the ear holes for a football helmet (figure 6). With the hands in this position, person 1 can pull open the base of the helmet and slide it off with minimal resistance.
As soon as the helmet is removed, it is essential to place under the head a firm cushion or support thick enough to prevent neck hyperextension. Once the helmet is removed, a cervical collar can be applied and intubation or cricothyrotomy can be used to allow resuscitation or breathing.
Agree in Advance
Sideline physicians in football and ice hockey should be familiar with helmet and face mask removal and should meet with the regional EMS providers to establish a common policy on the removal of helmets before the issue arises on the field. An athlete with no airway has a very short and critical window of intervention. There will be little time to ponder the procedure or debate the proper technique.
Dr Roberts is a family physician at MinnHealth SportsCare in White Bear Lake, Minnesota, and medical director of the Twin Cities Marathon. He is a fellow of the American College of Sports Medicine, a charter member of the American Medical Society for Sports Medicine, and an editorial board member of The Physician and Sportsmedicine.
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