A 29-year-old male motorcyclist presents to the emergency department (ED) accompanied by a paramedic rescue team after being involved in a high-speed motor vehicle crash (MVC). The motorcyclist was traveling at approximately 65 kilometers per hour (40 miles per hour) when he drove through an intersection and collided with a car. Although damage to the car was minimal, the motorcycle was severely damaged and the patient was found approximately 50 meters (160 feet) from the point of impact. The patient’s vital signs at the scene were: HR 110 beats per minute (bpm), BP 120/70 mm Hg, RR 24 breaths per minute, and SpO₂ 93% on room air. Paramedics placed the patient on a spine board and transferred him to the ED. In the ED, he complains of pain in his chest, difficulty breathing, and pain in his legs. He is wearing a non-modular full-face helmet. His vital signs are found to be HR 120 bpm, BP 110/50 mm Hg, RR 32 breaths per minute, SpO₂ 89% and he is becoming confused. There is clinical evidence of a compound fracture of his right femur.

What Are the Initial Steps in the Management of This Patient?

The general principles of trauma care and resuscitation apply to this patient. An initial, rapid survey of the patient’s vital functions is undertaken including his airway, breathing, and circulation (the ABCs).¹ Large-bore intravenous access, oxygen, and basic monitoring (pulse oximetry, ECG, and serial blood pressure readings) are instituted quickly. Supplemental oxygen had been provided in the field by placing an inverted simple face mask through the opening of the helmet, an acceptable maneuver if the helmet cannot be easily or safely removed for a primary survey. He is non-obese. His airway assessment shows that he is wearing a full-face, non-modular type motorcycle helmet, obscuring his mouth from view. His nose and nares are visible above the line of the face shield portion of the helmet, and his anterior neck is visible and displays normal anatomy. Rapid examination of his chest demonstrates equal air entry bilaterally and his pulses are equal. Although the patient is protecting his airway, he is breathing and has an adequate blood pressure. After completion of the primary survey he may require intervention to control his airway and breathing.

Are There Recommendations in the Advanced Trauma Life Support^® (ATLS^®) Guidelines for the Removal of Helmets Prior to Transport?

There is currently no consensus regarding whether pre-hospital personnel should routinely remove a patient’s helmet prior to transport to hospital. Individual patient factors and coexisting injuries will guide this decision. If possible, the helmet should remain in place unless emergency airway intervention or respiratory support is needed, in which case the helmet should be carefully removed in a manner that minimizes cervical spine motion. Most helmet removal techniques endorse a two-person approach: one person stabilizes the patient’s head from below while another person carefully removes the helmet from above.² New safety innovations in motor sports helmets include specialized helmet removal systems that facilitate the safe, careful removal of a helmet from a patient (e.g., EQRS™, Shock Doctor Eject Helmet Removal System™). Pre-hospital personnel should be encouraged to consult with a hospital-based EMS physician if questions regarding patient care exist. Airway practitioners who provide first responder care to motor sports athletes wearing helmets should familiarize themselves with these specialized helmet release systems.

Are There Recommendations in the ATLS^® Guidelines for the Removal of Helmets Once the Patient Has Arrived in Hospital?

There is also no consensus on when or how a patient’s helmet should be removed once the patient arrives in hospital. If the patient’s condition is stable, the helmet can remain in place during the trauma assessment to minimize the potential for cervical spine movement. After a careful neurological assessment, and if the patient is in stable condition, removal of the helmet under fluoroscopy may be considered. If the patient’s condition necessitates emergency airway or breathing support, the risks of providing airway management with the helmet in place should be carefully weighed against the risks of emergency removal of the helmet. These issues will be discussed later in this chapter.

Following a High-Speed Motorcycle Crash, What Other Injuries Might You Anticipate for This Patient?

Anticipating and identifying coexisting medical conditions in patients are important for practitioners. Alcohol is often a factor in motorcycle crashes and should be suspected in all cases.³ A prospective study in 1996 involving 150 patients admitted to the emergency surgical service following an MVC showed that 37% were intoxicated with blood alcohol concentration (BAC) greater than or equal to 100 mg/dL⁴ or 0.1% (1% BAC by volume = 10 mg·mL⁻¹, and the BAC legal limit is between 0.08% and 0.1% depending on the Province or State). Other causes for the crash should also be considered, including cerebrovascular accident, cardiac event, seizure, or intoxication from substances other than alcohol. A focused survey of the patient as suggested by the ATLS^® guidelines will help to identify injuries that will significantly affect airway management decisions. Airway practitioners should presume that this group of patients will have a full stomach and are at high risk for a cervical spine injury. In addition, patients with open-face helmets are at higher risk of sustaining facial injuries, but these injuries are still possible in patients wearing full-face helmets. A rigorous assessment of the oropharynx, nasal passages, and ears is often difficult in patients wearing helmets and the benefits of a nasotracheal approach to endotracheal intubation should be weighed against the risks of this procedure in this patient population.

What Types of Helmets Worn by Motorcyclists Can Pose Problems for Airway Management?

Motorcycle helmets can be grouped into two categories in the context of airway management: open-face and full-face. Open-face helmets cover the cranium, sometimes cover the ears, but do not cover the neck, chin, mouth, or nose. These features make them less protective to the patient in the event of a crash. There is an increase in the likelihood of serious anterior neck and facial injuries affecting airway anatomy, but concurrently renders airway assessment and intervention more straightforward. Full-face helmets are more protective to patient’s face in the event of a crash, but are a major hindrance to airway assessment and intervention since access to the mouth is practically impossible (Figure 19–1). Moreover, removal of full-face helmets can be difficult, resulting in potentially significant cervical spine motion.^5,6 Laun et al. conducted a study to evaluate the cervical spinal movement during the removal of a full-face helmet in 10 fresh cadavers with an experimental unstable fractured odontoid. Under fluoroscopy, there was significant movement of C1-2 during helmet removal and dislocation of C1-2 in two cases.⁷ Although the clinical significance of these findings in live patients is unknown, this study suggests that there is a potential risk of spinal cord injury during the removal of a full-face helmet.

An important variation on the full-face helmet is the “modular” full-face helmet (Figure 19–2). The design of this helmet allows the movement of the face shield portion of the helmet away from the face. This helmet design allows the effective conversion of a full-face helmet into an open-face configuration, making airway management with the helmet in place more feasible.

Should Helmets Always be Removed in Order to Provide Airway Management?

Removal of helmets for airway management is case dependent. There is currently no consensus on whether helmets should be routinely removed prior to airway management in trauma patients. There are concerns that cervical spine movement during helmet removal may be significant. Although the evidence of cervical spine movement during helmet removal has been supported by radiographic studies in cadavers, its clinical importance remains unknown. In pre-hospital care, removal of helmets by paramedics is standard prior to airway management. However, in sports medicine it is sometimes recommended that emergency medical personnel have the tools to remove face shields in order to provide airway management with the helmet in place.⁸ Some sports helmets brands now have “quick release” features that allow medical personnel to quickly and easily remove face masks to allow access to the airway without removing the helmet (e.g., Riddell Speedflex Helmet, Riddell™). Hospital-based airway practitioners should expect situations in which pre-hospital personnel have deferred definitive airway management until arrival at the hospital and therefore should be prepared for any scenario.

Describe a Systematic Approach to Manage the Airway of a Patient Wearing a Motorcycle Helmet

Assessment of any patient wearing a motorcycle helmet should be completed in the standard fashion aiming to assess the feasibility of providing oxygenation and ventilation by: (1) bag-mask; (2) extraglottic device (EGD); (3) tracheal intubation by direct and indirect laryngoscopy; or (4) a surgical airway. The first part of the assessment of a patient wearing a motorcycle helmet is identifying whether the helmet is open-face or full-face configuration.