Full Faced Automotive Helmets and the Suspected Cervical Spine Injury

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In the world of motorsports, the safety of the driver or rider is only assured by the gear they have on when out on the track. Regardless of the driving capacity, skill, or experience of the man or woman at the seat of their chosen racing vehicle, variables beyond the control of the driver will ultimately lead to accidental crashes and the potential for injury. Though the world of motorsport safety has advanced lightyears in the past few decades, it is impossible to overcome the potential danger high speeds place on the human body with space age helmets, firesuits, and armor. As such, a well rounded and keen EM physician should be wary of any motorsport accident which ends up in the ER. It would be wise to see the motorsport patient as lying a thin but never budging line: your safety equipment will always save you…until it doesn’t.

As such, a patient who arrives in the ED from the track should immediately put up red flags: LOC, non responsive, and extremely high speed MOI should point you to c-spine injury, head injury, and above all else the compromise of your ABCDEs. Even if a patient is responsive, few track incidents which require the extrication of a driver to the ED immediately from the track are from MOIs that can safely be handled by PPE, no matter what the rating. However, the equipment used by motorsports enthusiasts and professionals is of stark contrast to that used by professional athletes.

First of all, consider this article by the American Journal of Sports Medicine: in it, they outline the relationship between an athlete’s PPE and the injuries incurred on the field, particularly in regard to the management of the patient with a compromised c-spine or airway. Of note, most classes of PPE in sports outside of motorsports require little management or removal in the ED, and most studies preach caution to ED physicians attempting to remove helmets from affected individuals, as they indicate the potential danger from manipulation for removal outweighs the benefit of removal.

However, they add a particularly poignant caveat: motorsport PPE is particularly difficult to work around in the ED: first of all, the size and use of the helmet does not permit a neutral position of the C spine with a patient supine on a trauma bed or backboard, leaving the neck flexed due to occipital helmet protection. Furthermore, full faced helmets leave little room for airway management, neither by DL, VL, or even BVM. Furthermore, the high speed MOIs common to motorsport ED mean head and C spine injuries may be present even in patients with intact PPE off the track. With these two points in mind, the strongest indication for PPE removal is provided to full faced automotive/motorcycle helmets, indicating the incapacity to manage airway and assess for injury with it on is nearly impossible.

So, we need to remove the helmet with the patient rolling in. However, though we are better off removing it, the danger of manipulating the helmet is still present. How, then, should we remove the helmet?

This is where the meet the American College of Surgeons Committee on Trauma, who put out this manual on the removal of full faced helmets. It is important that we as ED physicians familiarize ourselves with this subset of injuries and patient population, specially when it comes to managing these sensitive situations. In summary, the procedure requires two providers, one maintaining cervical immobilization and one working to remove the helmet by providing lateral expansion of the helmet and clearing the nose through posterior tilting of the helmet along the curve of the helmet.

As a motorsport enthusiast myself, I am hopeful EM physicians and residents will slowly become more aware of the caveats motorsport PPE bring to the management of patients.