Equipment

Providers: At least 2 providers (3-4 is ideal) should be present.

Facemask removal: Studies have been performed to determine the ideal tool to remove the facemask in prehospital and hospital settings.^[11]The findings suggest that a cordless screwdriver is the superior tool to remove the screws securing the facemask.^[12]However, a manual screwdriver can also be used.

Screwdrivers have been shown to minimize neck motion more than pipe cutters, anvil pruners, facemask extractors, or Trainer’s Angels. These 4 tools do reduce the time needed to remove a facemask; unfortunately, they also increase the amount of motion of the cervical spine.

Helmet removal: A pair of scissors is also necessary for helmet removal.^[13]Scissors should be used to cut clothing and the laces holding the shoulder pads together, if present.^{[14, 15]}Exposure is one of the basic tenets of trauma resuscitation.

Anesthesia

No anesthesia is needed for helmet removal.

If airway instability occurs, rapid sequence intubation should be employed to secure the airway. For more information, see Tracheal Intubation, Rapid Sequence Intubation and Tracheal Intubation, Medications.

Positioning

The patient should be placed supine on a long cervical immobilization board if he or she is not already on one.

Minimization of cervical spine motion should be maintained prior to the initiation of helmet removal.^[16]

Monitoring & Follow-up

Helmet removal, when performed properly, does not carry inherent risks.

The major complication of helmet removal is worsening an extant cervical spine injury.

Technique

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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].
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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.