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?

I Want More! ….OK:

Mastering The Head-To-Toe Assessment

Five Big Trauma Scene Mistakes You Can Avoid

5 Assessment Findings That Should Concern You

The Art of The Pulse Check

Remembering The Glasgow Coma Score


  1. Brittany says:

    My personal preference is, unless it’s helping me in any sort of way, the helmet has to go. The other thing I was always taught was TAKE IT WITH YOU. The doctor’s want to be able to look at the helmet, because it’s an amazing tool for assessing where the patient may potentially be injured.

    Another wonderful post, Steve! Your scenario was perfectly described and fit distinctly with my memory of taking off a motorcycle helmet for the first time. Kudos!

  2. GrahamBoone says:

    Yeah in our class it was leave it unless the airway is compromised, but I like the precaution of at least clearing the airway. And they never told us about pads, I wish we had some specific sports injury dummies with sporting gear to visualize how it all worked.

    As for helmet removal I would never want to do that one-person. The diagram in our textbook just looked like a how-to-get-sued manual.

    I’m currently waiting for my state license, passed my NREMT-B exam. While I’m really excited, I’m worried that a lot of stuff we should have learned in class was pretty much omitted. But with a combination of an open mind, personal research, and great blogs like this, maybe I can fill in some of those blank spots. Please keep up this awesome blog. And compile it into a book someday!

  3. Since I work at football games every fall, as well as mountain bike races where racers use full face helmets (Especially downhill mountain bike races), I feel the need to chime in on this one…

    First PRACTICE REMOVING HELMETS! This technique of holding c-spine from the front is odd, and takes practice to get down pat. Go to a local football practice and ask the coach/trainer if you can practice on some players. Or borrow some helmets and guinea pig each other. Get to know how you need to place your hands depending on the player’s build. No-neck players vs tall skinny ones… tighter helmets vs looser. Like any other skill, practice, practice, practice.

    When removing the helmet, be aware that some helmets fit so tight, you may need the person with the longest thinnest fingers to hold the head from the front while the other removes the helmet. Gloves that are loose on our hands make it harder to hold c-spine on these patients.

    Do not “open” the helmet by pulling the rounded area surrounding the player’s ears. This actually causes a flex to the helmet and changes the shape enough that makes it harder to remove the helmet, and increases risk of further c-spine injury to the player.

    For a time, we left the helmets and pads on football players on, but getting the faceplates off has been problematic, as sometimes the screws are rusted and impossible to unscrew, or stripped outright. And honestly, it takes a LOT of time. If I am stabilizing a patient, and feel the need to leave the helmet on, I have the trainer work on removing the screws.

    Many schools are not purchasing new equipment due to budgetary constraints, and not all helmets have the “snap-away” faceplates that can be removed with shears. Local FD policy is to remove helmets, but sometimes they forget about the pads. If we leave helmet and pads on, we ALWAYS use foam Head Blocks and copious tape to secure them to the board.

    Downhill MTB helmets with the Leatt brace system are becoming popular, especially among younger racers. We did have a racer volunteer to lay down on a board to visual alignment one day. There is no benefit to leaving the helmet and brace on. It does not keep the neck in alignment. It actually takes them out of alignment. We will remove these, especially since most downhill MTB helmets are full face, and cover the mouth. And the tight helmet issue is a problem with this group as well.

  4. Steve Whitehead says:

    @Brittany Doh! The take it with you advice is so good, I;m a little frustrated I missed it. Thanks for that addition. I’m considering going back and adding it to the original piece (With all credit do)

    I’d add one thing to it. Don’t just bring it for the doctor…examine it for yourself. Check it out good. And then, when you get to the hospital, hand it to the doctor and tell him what you think. Subtle but important difference. Thanks for the addition.

  5. Steve Whitehead says:

    @Renee Thanks for your additions. It’s hard to get folks to practice these moves but it really does help. When someone shows up at the station riding a motorcycle, just ask. “Hey, let’s see if we can take that off you without pulling on your neck.”

  6. I would have to agree on all of this. Our textbook says to remove the helmet if it doesn’t fit properly or could compromise airyway interventions. I guess I’m just not sure why there would be any questions on when or if to remove a helmet. I am new to this so perhaps I’m benefitting from years of trial and error that I don’t have to endure. If that’s the case, then thank you everyone who came before me. It makes it much easier on us new guys.

  7. I have worked at a car/motorcycle race track for the last 4 summers and this is always a topic of discussion. We are trained and tested frequently throughout each season. I personally prefer taking the helmets off, it kind of wards off the evil spirits of bad or non existent airways, the emesis gods, and the trouble breathing spirits too. I’d rather be prepared and nothing happen than not prepare and and face the consequences. I have to agree that you have to know how to properly remove one, and the best way to ensure you are doing it properly is practice it properly.
    Steve, this was a great article with good an daccurate info. I appreciate what your doing and love getting the newsletters, and I even follow you on Twitter. Thanks again and keep up the good work!

  8. Here is an interesting product that I have seen used and it is quite amazing!

  9. As an emt/motorcycle rider, I leave the helmet unless it is obstructing the ABCs. There really is too much that could go wrong that would open you up for a lawsuit otherwise. There are even attorneys now that is specializing in this issue here in CA and NV.

  10. Consideration after the decision to leaving an open face helmet on a Pt without shoulderpads, like a skier or motorcyclist, is the need to place a length of folded towel or pad under the shoulders and behind the scapulas.
    Reason; The head to body proportion of helmeted adult heads are similar to that of nonhelmeted children.
    Effect; Head and neck are put into a neutral position and the airway is put into a more patent position.