A severe head trauma, such as from a motorcycle crash or sports injury, often forces a rescuer to make a complex decision: Should the protective helmet be removed? This choice must be made quickly, balancing the risk of worsening a hidden injury against the need for immediate life-saving care. Removing the helmet can have catastrophic consequences if not performed correctly or if the circumstances do not warrant it. Understanding specific trauma protocols is the only way to navigate this situation safely.
The Overarching Principle: Stabilize and Wait
The primary safety concern following severe trauma to the head or neck is potential injury to the cervical spine (C-spine). The neck’s seven vertebrae protect the spinal cord, and movement of an unstable fracture can cause irreversible secondary damage. Therefore, the overarching principle is to maintain manual inline stabilization of the head and neck and avoid helmet removal unless absolutely necessary.
Leaving the helmet in place acts as a natural splint, minimizing movement of the head relative to the torso, especially with full-face designs. Untrained or solo removal attempts almost guarantee movement, which is the most dangerous factor for an unstable C-spine injury. The rescuer’s focus should be on keeping the victim still and activating emergency medical services immediately. Professional medical personnel are trained to maintain stabilization until the patient is fully assessed and medically cleared.
Some helmets, particularly those worn by motorcyclists, are bulky and can push the patient’s head into a flexed (chin-to-chest) position when they lie flat. This flexion can compromise the spinal cord or airway. Even in this situation, the preferred action for an untrained rescuer is to support the neck in a neutral alignment rather than attempting removal. This support is often achieved by placing padding under the shoulders to raise the torso, helping achieve neutral spinal alignment while the helmet remains on. Only trained responders should proceed with removal, and only if the risks of leaving the helmet on outweigh the risks of moving the spine.
Critical Exceptions Requiring Immediate Removal
Despite the danger of movement, rare circumstances exist where the risk of leaving the helmet on is greater than the risk of removing it. These exceptions focus on maintaining the victim’s ability to breathe and circulate blood (the ABCs of trauma care). The first exception is when the helmet physically obstructs the airway, preventing breathing or making it impossible to clear vomit or blood from the mouth. A full-face helmet may impede access needed for suctioning or for performing jaw-thrust maneuvers to open the airway.
The second exception occurs when the victim is unconscious and has stopped breathing, requiring immediate cardiopulmonary resuscitation (CPR). It is often impossible to perform adequate ventilations or access the mouth for rescue breathing or intubation with a full-face helmet in place. In these life-threatening situations, the helmet must be removed immediately by a minimum of two people. The decision to remove the helmet in the field is based on whether the helmet significantly delays or prevents these life-saving measures.
Performing the Two-Person Removal Technique
If the decision to remove the helmet is made due to a life-threatening airway compromise, the procedure must involve two people to minimize C-spine movement. The first rescuer kneels at the victim’s head and applies manual inline stabilization by placing hands on the sides of the helmet, securing the head and neck. This rescuer controls the stabilization and must not allow the head to move during the entire process.
The second rescuer stands to the side and takes over stabilization by placing one hand under the neck, gripping the occiput, and the other hand on the victim’s jaw and chin. Once stabilization is transferred, the first rescuer carefully unbuckles or cuts the chin strap and removes any glasses, visors, or face cages. The helmet is then gently pulled off using a slow, rocking motion. It should be tilted slightly backward to clear the nose, and then forward to clear the base of the skull and ears.
The person removing the helmet should expand it laterally to help clear the ears and avoid catching on the jaw. As the helmet slides off, the first rescuer’s hands must immediately move to replace the helmet’s bulk. They secure the head directly with palms over the victim’s ears and fingers spread along the jaw and occiput. This technique ensures that continuous, secure manual stabilization of the head and neck is never lost during the transition.
Post-Removal Care and Monitoring
Once the helmet is safely removed, the person holding the head must maintain continuous manual inline stabilization without interruption. This ongoing support prevents secondary spinal cord injury until professional medical personnel can apply a rigid cervical collar and secure the victim to a backboard. The rescuer should then immediately assess the victim’s airway, breathing, and circulation, focusing on the life-saving measures that necessitated the removal.
If the victim is not breathing, rescue breaths or chest compressions should be initiated immediately. The rescuer should also quickly check for external bleeding and apply direct pressure to any major wounds. Since trauma victims are susceptible to hypothermia, which can worsen outcomes, the rescuer should cover the victim with a blanket or clothing to maintain body temperature while monitoring their level of consciousness until the ambulance arrives.