Helmet removal (sports)

Last updated
Spine board being positioned under injured hockey player in a practice drill Spine board 2.jpg
Spine board being positioned under injured hockey player in a practice drill

In sports medicine, helmet removal is the practice of removing the helmet of someone who has just experienced a sports injury in order to better facilitate first aid. Obvious causes include head and neck injury, or both, with no immediate means of excluding neck injury in the athlete who may be unable to give a history.

Contents

Compounding the problem is the potential for the athlete's airway being compromised. Such a situation requires effective triage with the possibility of the athlete's injury being worsened or its effects being made permanent, if the initial steps taken are not appropriate. [1]

Paradoxically, the equipment designed to prevent or mitigate injury, such as helmets, face masks, neck rolls, and shoulder pads, contributes to the complexity of the steps needed to be taken.

Finally, environmental challenges, such as the difficulty of first responders moving on an ice arena, or maneuvering an ambulance through inadequate access routes, will add to the problem if not previously addressed by inspection of facilities and, in the best circumstances, rehearsal.

Potential for inadvertent injury

The consequence of injury to the nerve cord is, in the worst of circumstances, quadriplegia. This is an inappropriate time for practice conflicts to arise and the potential is real, although the less so the more organized the situation. For example, Emergency Medical Technicians (EMTs) and Paramedics are trained to remove helmets while athletic training staff and the NCAA believe that the helmet should be left in place, unless the athlete's airway is compromised and cannot be managed otherwise.

This potential conflict relates to the design of the helmet used in the situation to which each of the parties most frequently responds. With EMTs and paramedics, it is most often motor vehicle accidents. With athletic training staff, it is exclusively athletic events unless acting in the role of 'Good Samaritan'. Helmets worn by motorcyclists and four-wheel operators are usually of an integral design making removal of the face mask either impossible or extremely difficult. Consequently, management of a compromised airway demands removal of the helmet.

Removal tools Helmet removal tools.jpg
Removal tools

On the other hand, helmets worn in football and ice hockey, are designed specifically so that the face mask may be quickly removed, although the technique for its removal will vary by helmet design. Accordingly, potential and serious difference in practice should be avoided by good communication between athletic training staff and first responders prior to the start of the event. Certified athletic training staff are familiar with the helmet model currently in use by their athletes, are expert in its removal, and carry the equipment needed to do so, and there is no substitute for familiarity and practice. At the same time, investigation and development of improved, face mask release systems is ongoing. [2]

The National Collegiate Athletic Association in its advice to athletic trainers and team physicians, contained in the NCAA Sports Medicine Handbook, advises that the helmet should never be removed from an injured athlete, conscious or unconscious, with a suspected or potential head or neck injury during pre-hospital management. In this advice, certain assumptions are made. The first is that the facemask can be removed so that airway care, if needed, can be carried out. The second is that the helmet fits securely so that supporting the helmet will support the athlete's head and neck. The advice accepts that helmet removal may be necessary if an ill-fitting helmet prevents the head and neck from being secured safely for emergency transport. It is also accepted that helmet removal may be necessary if, for some reason or another, the facemask cannot be removed in a reasonable time. There is general agreement that should helmet removal be required, it should only be carried out by trained personnel. The NCAA also asserts that the injured athlete should be maneuvered to a spine board for transport as a 'single unit' using a lift/slide maneuver or log-roll technique. [3]

Face mask removal

With agreement on the importance in maintaining cervical spine alignment, and by implication, the most common strategy of leaving the helmet and shoulder pads in place, the immediate task falls into two parts:

Face mask being unscrewed Face mask fastener.jpg
Face mask being unscrewed
  1. the coordinated, synchronized log roll of an injured athlete who happens to be lying in the face down or prone position;
  2. removal of the face mask to allow care and protection of the airway.

Currently, face masks fall into two broad categories, the 'traditional', secured by screws and plastic loops or thin wire ties and a combination of screws and T-nuts, and the 'innovative' using some additional type of proprietary 'quick release' hardware. However, it should be recognized that helmet and face mask design is an area of active development and change.

Whichever, removal customarily involves cutting/releasing the loop straps and various tools have been advocated including cutting tools and cordless screwdrivers. [4] [5] In some studies, the cordless screwdriver has been shown to be the most efficient and quickest. [2]

Face mask loops being cut Face mask loops.jpg
Face mask loops being cut

However, concern has been raised concerning the use of a single technique when helmet fittings have been degraded by poor maintenance. In those circumstances, a screw seized with rust, or in which the threads have been stripped, may be encountered. Accordingly, there has been advocacy for a reliable, combined, tool technique such as a cordless screwdriver with backup cutting tool. [6] Moreover, in some innovative designs, a cutting tool is essential.

In general, 'quick release' face-mask attachments appear to make face-mask removal quicker and cause less unwanted movement of the athlete's head or neck. The opposite is the case in cutting loop straps. [2]

Helmet removal

At some stage, the helmet and protective equipment will need to be removed. How this may be done with minimum risk remains a question of importance.

First, there are three possible athlete/equipment configurations:

Of the three options, the least desirable appears to be helmet removal with shoulder pads retained (third choice), that combination potentially allowing the head to drop back in relation to the shoulders inducing the greatest amount of movement (extension) of the cervical spine. [7]

It was also previously held that X-ray of the neck should be carried out before movement of the neck was permitted. Since retention of helmet and shoulder pads would be the least disruptive to the neck as previously observed, the second question to arise became the reliability of what is referred to as cross-table lateral X-ray of the neck, the routine radiologic procedure in such cases. Although previously regarded as standard procedure, at least one study has found that football equipment is an impediment to accurate X-ray interpretation. [8] In those with significant trauma X-ray computed tomography is a more accurate test. [9]

Current opinion now suggests that X-ray of the cervical spine adds little to what can be obtained by clinical examination and two clinical assessment strategies have been validated, the first being the National Emergency X-Radiography Utilization Study (NEXUS) and the second, the Canadian C-Spine Rule (CCR). The first has a reported sensitivity for detecting cervical spine injury of 99% and the second, if anything, higher. [10]

Fracture dislocation of cervical spine. Cervical fracture dislocation C6-C7.jpeg
Fracture dislocation of cervical spine.

Accordingly, a practice has arisen that "clears" the patient from cervical spinal injury if the following criteria are met:

  1. the subject is alert and oriented;
  2. has a normal neurological examination;
  3. has no concurrent injury that would distract him/her from full cooperation;
  4. is free from pain when the cervical spine is carefully palpated;
  5. is free from pain on flexing and extension of the cervical spine. [11]

Since the last part of the exam requires removal of cervical restraints such as collars and attachments to spinal boards etc., the implication is that it is 'safe' to remove such restraints if the first four criteria are satisfied.

In the event that application of the above criteria fails to indicate a 'normal cervical spine', the next step currently is CT examination, which has a reported 98-99% sensitivity for cervical spinal injury. [12] A separate imaging technique, magnetic resonance imaging, has been found to be too prone to artifacts from parts of the protective equipment to be clinically useful. [13]

It should be understood that, apart from the clinical examination rules and CT, the majority of sports or athletic information has been derived from studies involving football, ice hockey, and motorcycle accidents. This induces an age (late adolescence and young adult) and sex (mainly male) bias. Consequently, caution should be used in applying the conclusions to injuries involving the use of helmets of other design such as those used in lacrosse, horseback riding, baseball/softball, or cycling. They also cannot necessarily be applied to a younger or female population without caution.

Related Research Articles

<span class="mw-page-title-main">Sports injury</span> Physical and emotional trauma

Sports injuries are injuries that occur during sport, athletic activities, or exercising. In the United States, there are approximately 30 million teenagers and children who participate in some form of organized sport. Of those, about three million athletes age 14 years and under experience a sports injury annually. According to a study performed at Stanford University, 21 percent of the injuries observed in elite college athletes caused the athlete to miss at least one day of sport, and approximately 77 percent of these injuries involved the knee, lower leg, ankle, or foot. In addition to those sport injuries, the leading cause of death related to sports injuries is traumatic head or neck occurrences.

<span class="mw-page-title-main">Tracheal intubation</span> Placement of a tube into the trachea

Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill, or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway obstruction.

<span class="mw-page-title-main">Whiplash (medicine)</span> Informal term for injuries to the neck

Whiplash is a non-clinical term describing a range of injuries to the neck caused by or related to a sudden distortion of the neck associated with extension, although the exact injury mechanisms remain unknown. The term "whiplash" is a colloquialism. "Cervical acceleration–deceleration" (CAD) describes the mechanism of the injury, while the term "whiplash associated disorders" (WAD) describes the subsequent injuries and symptoms.

<span class="mw-page-title-main">Airway management</span> Medical procedure ensuring an unobstructed airway

Airway management includes a set of maneuvers and medical procedures performed to prevent and relieve airway obstruction. This ensures an open pathway for gas exchange between a patient's lungs and the atmosphere. This is accomplished by either clearing a previously obstructed airway; or by preventing airway obstruction in cases such as anaphylaxis, the obtunded patient, or medical sedation. Airway obstruction can be caused by the tongue, foreign objects, the tissues of the airway itself, and bodily fluids such as blood and gastric contents (aspiration).

<span class="mw-page-title-main">Respiratory arrest</span> Medical condition

Respiratory arrest is a serious medical condition caused by apnea or respiratory dysfunction severe enough that it will not sustain the body. Prolonged apnea refers to a patient who has stopped breathing for a long period of time. If the heart muscle contraction is intact, the condition is known as respiratory arrest. An abrupt stop of pulmonary gas exchange lasting for more than five minutes may permanently damage vital organs, especially the brain. Lack of oxygen to the brain causes loss of consciousness. Brain injury is likely if respiratory arrest goes untreated for more than three minutes, and death is almost certain if more than five minutes.

<span class="mw-page-title-main">Spinal cord injury</span> Injury to the main nerve bundle in the back of humans

A spinal cord injury (SCI) is damage to the spinal cord that causes temporary or permanent changes in its function. Symptoms may include loss of muscle function, sensation, or autonomic function in the parts of the body served by the spinal cord below the level of the injury. Injury can occur at any level of the spinal cord and can be complete, with a total loss of sensation and muscle function at lower sacral segments, or incomplete, meaning some nervous signals are able to travel past the injured area of the cord up to the Sacral S4-5 spinal cord segments. Depending on the location and severity of damage, the symptoms vary, from numbness to paralysis, including bowel or bladder incontinence. Long term outcomes also range widely, from full recovery to permanent tetraplegia or paraplegia. Complications can include muscle atrophy, loss of voluntary motor control, spasticity, pressure sores, infections, and breathing problems.

<span class="mw-page-title-main">Cervical collar</span> Medical device used to support a neck

A cervical collar, also known as a neck brace, is a medical device used to support and immobilize a person's neck. It is also applied by emergency personnel to those who have had traumatic head or neck injuries, and can be used to treat chronic medical conditions.

<span class="mw-page-title-main">Cervical fracture</span> Medical condition

A cervical fracture, commonly called a broken neck, is a fracture of any of the seven cervical vertebrae in the neck. Examples of common causes in humans are traffic collisions and diving into shallow water. Abnormal movement of neck bones or pieces of bone can cause a spinal cord injury, resulting in loss of sensation, paralysis, or usually death soon thereafter, primarily via compromising neurological supply to the respiratory muscles as well as innervation to the heart.

In medicine, a stinger, also called a burner or nerve pinch injury, is a neurological injury suffered by athletes, mostly in high-contact sports such as ice hockey, rugby, American football, and wrestling. The spine injury is characterized by a shooting or stinging pain that travels down one arm, followed by numbness and weakness in the parts of the arms, including the biceps, deltoid, and spinati muscles. Many athletes in contact sports have suffered stingers, but they are often unreported to medical professionals.

<span class="mw-page-title-main">Health issues in American football</span> Dangers to the health of athletes participating in American football

Health issues in American football comprise a large number of health risks associated with participating in the sport. Injuries are relatively common in American football, due to its nature as a full-contact game. Injuries occur during both practice and games. Several factors can affect the frequency of injuries: epidemiological studies have shown older players can be at a greater risk, while equipment and experienced coaches can reduce the risk of injury. Common injuries include strains, sprains, fractures, dislocations, and concussions. Concussions have become a concern, as they increase the risk of mental illnesses like dementia and chronic traumatic encephalopathy (CTE). In individual leagues like the National Football League (NFL) and National Collegiate Athletic Association (NCAA), a public injury report is published containing all injured players on a team, their injury and the game-day status of each player.

<span class="mw-page-title-main">Blunt trauma</span> Physical trauma caused to a body part, either by impact, injury or physical attack

Blunt trauma, also known as blunt force trauma or non-penetrating trauma, describes a physical trauma due to a forceful impact without penetration of the body's surface. Blunt trauma stands in contrast with penetrating trauma, which occurs when an object pierces the skin, enters body tissue, and creates an open wound. Blunt trauma occurs due to direct physical trauma or impactful force to a body part. Such incidents often occur with road traffic collisions, assaults, sports-related injuries, and are notably common among the elderly who experience falls.

<span class="mw-page-title-main">Ice hockey equipment</span>

In ice hockey, players use specialized equipment both to facilitate the play of the game and for protection as this is a sport where injuries are common, therefore, all players are encouraged to protect their bodies from bruises and severe fractures.

<span class="mw-page-title-main">Protective equipment in gridiron football</span>

Protective equipment in gridiron football consists of equipment worn by football players for the protection of the body during the course of a football game. Basic equipment worn by most football players include helmet, shoulder pads, gloves, shoes, and thigh and knee pads, a mouthguard, and a jockstrap or compression shorts with or without a protective cup. Neck rolls, elbow pads, hip pads, tailbone pads, rib pads, and other equipment may be worn in addition to the aforementioned basics. Football protective equipment is made of synthetic materials: foam rubbers, elastics, and durable, shock-resistant, molded plastic. Football protective equipment has remained consistent in use for decades with some slight modifications made over the years in design and materials. The assignment and maintenance of football gear belongs to the team equipment manager.

<span class="mw-page-title-main">Tracheobronchial injury</span> Damage to the tracheobronchial tree

Tracheobronchial injury is damage to the tracheobronchial tree. It can result from blunt or penetrating trauma to the neck or chest, inhalation of harmful fumes or smoke, or aspiration of liquids or objects.

<span class="mw-page-title-main">Facial trauma</span> Medical condition

Facial trauma, also called maxillofacial trauma, is any physical trauma to the face. Facial trauma can involve soft tissue injuries such as burns, lacerations and bruises, or fractures of the facial bones such as nasal fractures and fractures of the jaw, as well as trauma such as eye injuries. Symptoms are specific to the type of injury; for example, fractures may involve pain, swelling, loss of function, or changes in the shape of facial structures.

<span class="mw-page-title-main">Protective gear in sports</span>

Personal protective equipment serves an integral role in maintaining the safety of an athlete participating in a sport. The usage and development of protective gear in sports has evolved through time, and continues to advance over time. Many sports league or professional sports mandate the provision and usage of protective gear for athletes in the sport. Usage of protective gear is also mandated in college athletics and occasionally in amateur sports.

A catastrophic injury is a severe injury to the spine, spinal cord, or brain. It may also include skull or spinal fractures. This is a subset of the definition for the legal term catastrophic injury, which is based on the definition used by the American Medical Association.

A sports-related traumatic brain injury is a serious accident which may lead to significant morbidity or mortality. Traumatic brain injury (TBI) in sports are usually a result of physical contact with another person or stationary object, These sports may include boxing, gridiron football, field/ice hockey, lacrosse, martial arts, rugby, soccer, wrestling, auto racing, cycling, equestrian, rollerblading, skateboarding, skiing or snowboarding.

<span class="mw-page-title-main">Spinal precautions</span> Efforts to prevent movement of the spine in those with a risk of a spine injury

Spinal precautions, also known as spinal immobilization and spinal motion restriction, are efforts to prevent movement of the spine in those with a risk of a spine injury. This is done as an effort to prevent injury to the spinal cord. It is estimated that 2% of people with blunt trauma will have a spine injury.

<span class="mw-page-title-main">Basic airway management</span>

Basic airway management are a set of medical procedures performed in order to prevent airway obstruction and thus ensuring an open pathway between a patient's lungs and the outside world. This is accomplished by clearing or preventing obstructions of airways, often referred to as choking, cause by the tongue, the airways themselves, foreign bodies or materials from the body itself, such as blood or aspiration. Contrary to advanced airway management, minimal-invasive techniques does not rely on the use of medical equipment and can be performed without or with little training. Airway management is a primary consideration in cardiopulmonary resuscitation, anaesthesia, emergency medicine, intensive care medicine and first aid.

References

  1. 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 (Phila Pa 1976). 2002 May 1;27(9):995-8; discussion 998-9. doi: 10.1097/00007632-200205010-00022. PMID 11979177.
  2. 1 2 3 Swartz EE, Belmore K, Decoster LC, Armstrong CW (Nov–Dec 2010). "Emergency face-mask removal effectiveness: a comparison of traditional and nontraditional football helmet face-mask attachment systems". J Athl Train. 45 (6): 560–9. doi:10.4085/1062-6050-45.6.560. PMC   2978007 . PMID   21062179.
  3. Klossner, David (Aug 2013). 2013-14 NCAA Sports Medicine Handbook (24 ed.). Indianapolis, Indiana: National Collegiate Athletics Association. p. 118.
  4. Knox KE, Kleiner DM (July 1997). "The efficiency of tools used to retract a football helmet face mask". J Athl Train. 32 (3): 211–5. PMC   1320239 . PMID   16558451.
  5. Swartz EE, Norkus SA, Cappaert T, Decoster LC (August 2005). "Football equipment design affects face mask removal efficiency". Am J Sports Med. 33 (8): 1210–9. doi:10.1177/0363546504271753. PMID   16000669. S2CID   2768429.
  6. Copeland AJ, Decoster LC, Swartz EE, Gattie ER, Gale SD (November 2007). "Combined tool approach is 100% successful for emergency football face mask removal". Clin J Sport Med. 17 (6): 452–7. doi:10.1097/JSM.0b013e31815b187d. PMID   17993787. S2CID   34014154.
  7. Laprade RF, Schnetzler KA, Broxterman RJ, Wentorf F, Gilbert TJ (Nov–Dec 2000). "Cervical spine alignment in the immobilized ice hockey player. A computed tomographic analysis of the effects of helmet removal". Am J Sports Med. 28 (6): 800–3. doi:10.1177/03635465000280060601. PMID   11101101. S2CID   5901650.
  8. Davidson RM, Burton JH, Snowise M, Owens WB (July 2001). "Football protective gear and cervical spine imaging". Ann Emerg Med. 38 (1): 26–30. doi:10.1067/mem.2001.116333. PMID   11423808.
  9. Gale SC, Gracias VH, Reilly PM, Schwab CW (November 2005). "The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma". J Trauma. 59 (5): 1121–5. doi:10.1097/01.ta.0000188632.79060.ba. PMID   16385289.
  10. Quann JT, Sidwell RA (February 2011). "Imaging of the cervical spine in injured patients". Surg Clin North Am. 91 (1): 209–16. doi:10.1016/j.suc.2010.10.016. PMID   21184910.
  11. Como JJ, Diaz JJ, Dunham CM, Chiu WC, Duane TM, Capella JM, Holevar MR, Khwaja KA, Mayglothling JA, Shapiro MB, Winston ES (September 2009). "Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee". J Trauma. 67 (3): 651–9. doi: 10.1097/TA.0b013e3181ae583b . PMID   19741415.
  12. Brown CV, Antevil JL, Sise MJ, Sack DI (May 2005). "Spiral computed tomography for the diagnosis of cervical, thoracic, and lumbar spine fractures: its time has come". J Trauma. 58 (5): 890–5. doi:10.1097/01.ta.0000162149.89139.ff. PMID   15920398.
  13. Waninger KN, Rothman M, Heller M (November 2003). "MRI is nondiagnostic in cervical spine imaging of the helmeted football player with shoulder pads". Clin J Sport Med. 13 (6): 353–7. doi:10.1097/00042752-200311000-00003. PMID   14627866. S2CID   36359111.