The C-Spine / Helmet Issue

The good news in the world of head trauma and brain injury is that we’re seeing a lot more folks putting on helmets before they go out and do potentially dangerous, head crushing stuff. The good/bad news is that we’re encountering more patients who are wearing helmets and need to be placed in full spinal immobilization. This brings up a controversial decision. Should we remove the helmet or leave it in place?

The leave it or remove it controversy has been around for as long as I’ve been in EMS and, like most controversies that remain unresolved for years, there are merits to both options. In these instances, it’s easy to create blanket rules and then follow them mindlessly.

“Always leave the helmet in place, unless it obstructs the airway.”

“Always remove the helmet before you put them on a backboard.”

You’re going to hear some folks spout these rules off like they’ve been long established treatment guidelines, written in stone and backed by The American Board of Something Technical Sounding. They’re not. Whether you decide to remove a helmet is, and should be, a matter of clinical judgment. You’re going to need to decide for yourself, using your own good judgment and assessment findings.

Let’s help you sharpen your decision making scalpel so the next time you encounter a helmeted patient, you can proceed with confidence.

1) Helmets protect the head. They do not protect the neck.

If anything, that big helmet may have increased your patients risk for a neck injury. Don’t fall into a false sense of security when you see a helmeted patient walking around on scene. They’re still going to need a thorough evaluation of their neck and neurological status.

2) Athletic pads may need to remain in place or be removed in conjunction with the helmet.

This goes primarily for football players or anyone wearing shoulder pads or padding across their upper back. The back padding will often be equal to the added occipital padding that a helmet creates.

So if you decide to remove the helmet, take the pads off with them. If the helmet stays in place, leave the pads behind. This is going to help you find that neutral position for the neck when the patient lays down supine.

3) If you leave the helmet in place, everything covering the airway needs to go.

On some motorcycle helmets, this may be as easy as flipping up the face piece. Other helmets have the face guard integrated into the helmet. If the helmet permanently covers the mouth, it needs to go. Not, “If there’s a problem,” before there’s a problem.

You don’t want to have to figure out how to get a helmet off after the patient starts puking or becomes apnic. You want to get that airway uncovered beforehand.

3) Trainers may have a bunch of useful tools for removing face-plates and helmet garb.

So if you’re responding at a sporting arena, try to get the trainer to stay around and help out. If you’re going to want to leave the helmet on, ask them early if they have tools to remove the face-piece. They usually will.

They also know how all the pads lace and unlace so if you want to remove patient protective gear, get their advice. “Is there any way to remove these while he’s lying down? Where does that thingy tie?” The trainer can be a really useful person to have helping out. And they usually appreciate not being ignored.

4) Evaluate how well the helmet fits.

There’s no sense in securing the patients helmet to a board for c-spine if their head is rattling around inside the helmet like a pinball between two bumpers. If the helmet doesn’t fit sung, it’s no good for c-spine. However, it will probably be a cinch to take off.

5) You need two people to take a helmet off.

It’s not a one man job. You can do it on your own, but you can’t do it right. Here’s the technique.

I find it easier to do with the patient lying down. Have one rescuer hold the helmet from above while a second rescuer positions themselves at the patient’s side, facing the head. The second rescuer places their hands on either side of the patients neck and slides their fingers up inside the helmet toward the patient’s ears. When the second rescuer feels like they have a good grip on the patients head they can let the first rescuer know it’s OK to remove the helmet.

With the head secured by the second rescuer, the first rescuer pulls out on the helmet at the ears and slides it up and off the patients head, then returns to help secure the head to the board. Most open faced motorcycle helmets will need to tip slightly back during removal. Football and full-face helmets tilt slightly forward.

Olay! Your helmet worries are over.

Hopefully, the next time you encounter a c-spine/helmet dilemma, you’ll feel a little more at easy evaluating the situation and making a decision to leave the helmet on or take it off.

Now it’s your turn: Do you have a hard and fast rule about helmet removal? What things do you consider when faced with the c-spine/helmet dilemma?