Background

With each passing year, more individuals are playing contact sports and riding motorcycles. Therefore, healthcare workers involved in emergency care should be proficient in the procedure of helmet removal.^{[1, 2]}Helmet removal, which requires minimal training, is a safe and quick procedure that gives providers access to a patient's airway and allows them to stabilize the patient's head and neck.^{[3, 4, 5, 6, 7]}

Indications

The indications for hospital helmet removal are as follows:

Suspected cervical spine injury
Suspected head injury
Inability to securely immobilize the neck prior to transport to another healthcare facility^[8]

The following prehospital recommendations for helmet removal are based on the Inter-Association Task Force's Prehospital Care of the Spine-Injured Athlete:^[9]

If the helmet and chin strap fail to hold the head securely^[10]
If the helmet and chin strap design prevent adequate airway control, even after facemask removal
If the facemask cannot be removed
If the helmet prevents adequate proper immobilization for transport

Contraindications

The major contraindications to helmet removal are paresthesia or neck pain during the removal procedure. Paresthesia suggests worsening stretch or pressure on nerve endings as they exit the spinal column.

Healthcare providers with minimal knowledge of helmet removal should use caution if attempting to remove a helmet.

Best Practices

A cordless screwdriver is the most efficient tool for removing the screws attaching the facemask to the helmet because it can reduce the time needed for screw removal and help reduce spinal motion.

If the airway is unstable, facemask removal is all that is necessary to intubate the patient; the entire football helmet does not need to be removed for intubation. According to one study, face mask removal for the potential spine-injured American football player is safer than helmet removal for emergent airway access.^[24]Face mask removal results in less motion in all three planes (sagittal, frontal, transverse), requires less completion time, and is easier to perform.

Fullface motorcycle helmets should be removed in the prehospital setting for the following reasons:

They can increase forward flexion of the neck when the patient is placed on a backboard.
The airway cannot be observed with a full helmet in place.

Periprocedure

Offner PJ, Rivara FP, Maier RV. The impact of motorcycle helmet use. J Trauma. 1992 May. 32(5):636-41; discussion 641-2. [QxMD MEDLINE Link].
Krantz KP. Head and neck injuries to motorcycle and moped riders--with special regard to the effect of protective helmets. Injury. 1985 Jan. 16(4):253-8. [QxMD MEDLINE Link].
Roberts and Hedges. Prehospital Splinting. Chanmugam, Chudnofsky, Custalow, Dronen. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, Pa: Saunders; 2004. 913.
Roberts W. Helmet removal in head and neck trauma. The Physician and Sportsmedicine. 1998. 26:7.
Swartz EE, Mihalik JP, Decoster LC, Hernandez AE. A study of emergency American football helmet removal techniques. Am J Emerg Med. 2011 Oct 24. [QxMD MEDLINE Link].
Decoster LC, Burns MF, Swartz EE, Murthi DS, Hernandez AE, Vailas JC, et al. Maintaining Neutral Sagittal Cervical Alignment after Football Helmet Removal during Emergency Spine Injury Management. Spine (Phila Pa 1976). 2011 Aug 18. [QxMD MEDLINE Link].
Swartz EE, Hernandez AE, Decoster LC, Mihalik JP, Burns MF, Reynolds C. Prehospital emergency removal of football helmets using two techniques. Prehosp Emerg Care. 2011 Apr-Jun. 15(2):166-74. [QxMD MEDLINE Link].
Kleiner DM, Pollak AN, McAdam C. Helmet hazards. Do's & don'ts of football helmet removal. JEMS. 2001 Jul. 26(7):36-44, 46-8. [QxMD MEDLINE Link].
Inter-Association Task Force for the Appropriate Care of the Spine-Injured Athlete. Prehospital Care of the Spine-Injured Athlete. Inter-Association Task Force for the Appropriate Care of the Spine-Injured Athlete Web site. Available at http://www.nata.org/statements/consensus/NATAPreHospital.pdf. Accessed: June 10, 2009.
Swartz EE, Norkus SA, Cappaert T, Decoster LC. Football equipment design affects face mask removal efficiency. Am J Sports Med. 2005 Aug. 33(8):1210-9. [QxMD MEDLINE Link].
Swartz EE, Armstrong CW, Rankin JM, Rogers B. A 3-Dimensional Analysis of Face-Mask Removal Tools in Inducing Helmet Movement. J Athl Train. 2002 Jun. 37(2):178-184. [QxMD MEDLINE Link].
Waninger KN. Management of the helmeted athlete with suspected cervical spine injury. Am J Sports Med. 2004 Jul-Aug. 32(5):1331-50. [QxMD MEDLINE Link].
Sherbondy PS, Hertel JN, Sebastianelli WJ. The effect of protective equipment on cervical spine alignment in collegiate lacrosse players. Am J Sports Med. 2006 Oct. 34(10):1675-9. [QxMD MEDLINE Link].
Treme G, Diduch DR, Hart J, Romness MJ, Kwon MS, Hart JM. Cervical spine alignment in the youth football athlete: recommendations for emergency transportation. Am J Sports Med. 2008 Aug. 36(8):1582-6. [QxMD MEDLINE Link].
Peris MD, Donaldson WF WF 3rd, Towers J, Blanc R, Muzzonigro TS. Helmet and shoulder pad removal in suspected cervical spine injury: human control model. Spine. 2002 May 1. 27(9):995-8; discussion 998-9. [QxMD MEDLINE Link].
Davidson RM, Burton JH, Snowise M, Owens WB. Football protective gear and cervical spine imaging. Ann Emerg Med. 2001 Jul. 38(1):26-30. [QxMD MEDLINE Link].
Meyer RD, Daniel WW. The biomechanics of helmets and helmet removal. J Trauma. 1985 Apr. 25(4):329-32. [QxMD MEDLINE Link].
McSwain NE Jr. et al. Techniques of helmet removal from injured patients. Bull Am Coll Surg. 1980. 65:19.
Donaldson WF 3rd, Lauerman WC, Heil B, Blanc R, Swenson T. Helmet and shoulder pad removal from a player with suspected cervical spine injury. A cadaveric model. Spine. 1998 Aug 15. 23(16):1729-32; discussion 1732-3. [QxMD MEDLINE Link].
Gastel JA, Palumbo MA, Hulstyn MJ, Fadale PD, Lucas P. Emergency removal of football equipment: a cadaveric cervical spine injury model. Ann Emerg Med. 1998 Oct. 32(4):411-7. [QxMD MEDLINE Link].
Prinsen RK, Syrotuik DG, Reid DC. Position of the cervical vertebrae during helmet removal and cervical collar application in football and hockey. Clin J Sport Med. 1995 Jul. 5(3):155-61. [QxMD MEDLINE Link].
Horodyski M, DiPaola CP, DiPaola MJ, Conrad BP, Del Rossi G, Rechtine GR 2nd. Comparison of the flat torso versus the elevated torso shoulder pad removal techniques in a cadaveric cervical spine instability model. Spine (Phila Pa 1976). 2009 Apr 1. 34(7):687-91. [QxMD MEDLINE Link].
Dahl MC, Ananthakrishnan D, Nicandri G, Chapman JR, Ching RP. Helmet and shoulder pad removal in football players with unstable cervical spine injuries. J Appl Biomech. 2009 May. 25(2):119-32. [QxMD MEDLINE Link].
Swartz EE, Mihalik JP, Beltz NM, Day MA, Decoster LC. Face mask removal is safer than helmet removal for emergent airway access in American football. Spine J. 2014 Jun 1. 14(6):996-1004. [QxMD MEDLINE Link].

Media Gallery

Helmet removal.

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Author

James Cipolla, MD Attending Surgeon, Department of Traumatology and Critical Care, Program Director, Surgical Critical Care Fellowship, St Luke's University Hospital; Associate Professor of Surgery, Temple University School of Medicine; Assistant Clinical Professor of Surgery, University of Pennsylvania School of Medicine

James Cipolla, MD is a member of the following medical societies: American College of Surgeons, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Ankit Shah, MD Attending Physician, Department of Emergency Medicine, Reading Hospital and Medical Center

Ankit Shah, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Society of Critical Care Medicine, European Society of Intensive Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Jonathan P Miller, MD Director, Functional and Restorative Neurosurgery, Director of Epilepsy Surgery, Attending Neurosurgeon, University Hospitals Cleveland Medical Center; Director, Functional and Restorative Neurosurgery Center, UH Cleveland Medical Center Neurological Institute; Associate Professor of Neurosurgery, Fellowship Director, Functional and Stereotactic Neurosurgery, Associate Residency Program Director, Department of Neurosurgery, Surgical Director, Neuromodulation Center, Case Western Reserve University School of Medicine

Jonathan P Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Epilepsy Society, American Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons, International Neuromodulation Society, North American Neuromodulation Society, Ohio State Neurosurgical Society, Society of Neurological Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Andrew K Chang, MD, MS Vincent P Verdile, MD, Endowed Chair in Emergency Medicine, Professor of Emergency Medicine, Vice Chair of Research and Academic Affairs, Albany Medical College; Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Emergency Medicine, Montefiore Medical Center

Andrew K Chang, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American Academy of Pain Medicine, American College of Emergency Physicians, American Geriatrics Society, American Pain Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Helmet Removal

Background

Indications

Contraindications

Best Practices

References

Tables

Contributor Information and Disclosures

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