Pediatric trauma patients who are injured while involved in sports or recreational activities may present to the emergency department (ED) wearing various types of helmets. In these patients, it is important that the helmet be removed by trained personnel in order to prevent injury to the cervical spine. In most cases, this will not be necessary before radiographic evaluation. When the airway is compromised or has the potential to become compromised, the helmet should be removed promptly by using the techniques described in this chapter.

Helmets are being used more frequently by the general population because people have been made more aware of injury prevention. This is a positive move toward preventing the devastating effects of traumatic brain injury. As the demand for helmets has increased, so has the sophistication of their design, and they increasingly encompass more of the head and neck. Medical personnel who deal with trauma victims must be aware of the types of helmets and successful means for removing them without causing spinal cord injury.

The incidence of spinal cord injury is fortunately low in children, occurring in 1% to 2% of multiple trauma victims (1) (see also Chapter 24). Injury occurs most commonly in the upper cervical spine in infants and young children. Older children (over age 8) show a pattern of injury similar to that of adults, with the C5-6 area being most frequently injured. Children engaged in activities that require protective head gear are at increased risk for trauma and spinal cord injury. The helmeted young trauma victim always should be treated as having a possible cervical spine injury.

Helmets and their use in the pediatric population have changed over the years. Previously most helmeted patients were teenage motorcyclists or football players. Now children wear helmets from the toddler age on for bicycles, mopeds, rollerblades, and all-terrain vehicles. Most states now require helmet use for all motorcyclists and their passengers, and some jurisdictions have mandatory bicycle helmet laws. This means more helmets on more children and, as mentioned, a necessary awareness of safe helmet removal.

Most injured pediatric patients who are helmeted at the time of injury will arrive immobilized on a spine board with the helmet still in place. Paramedics as well as athletic trainers often are trained in safe helmet removal to facilitate airway management. The physician assumes responsibility for assessing the patient and directing removal of the helmet once the patient has entered the ED and must therefore also be aware of safe helmet removal techniques.

Helmets have been shown to cause cervical flexion in adults when the patient is supine and the helmet is unsupported (2). In-line stabilization of the helmet, however, eliminates this flexion and provides easy control of the cervical spine. Small children have an exaggerated degree of flexion as a result of their prominent occiputs. Some elevation beneath the shoulders should help eliminate this problem and aid in maintaining neutral cervical immobilization. It is particularly important not to apply traction while stabilizing the neck of a child, because the spinal cord is vulnerable to further injury by these types of forces.

As noted above, cervical spine injury sites vary with age in the pediatric population. Infants and young children injure the upper cervical spine (C2-3) most frequently because of their larger relative head size, weaker neck muscles and cartilage, and shorter necks. These anatomic differences cause the forces of extension and flexion to pivot about a higher point in the neck. As children approach 8 years of age, the site of cervical spine injury resembles the adult injury site (C5-6) (1) (see also Chapter 24).

The pediatric spine contains more cartilage than the adult spine. Although this can enable it to be more forgiving to injuries, it may also mean that serious injuries will go undetected by radiographic evaluation. It is for this reason that the appearance of the soft tissues is so important in detecting spinal injury in children.

The pediatric spine has more inherent anterior and posterior movement than the adult spine. It can sustain a significant subluxing injury without any change of alignment on the lateral radiograph. The soft tissue changes and neurologic findings are the only suggestion of injury.

The shorter necks of younger children demand that the clinician be careful not to obstruct the airway with his or her hands while maintaining cervical immobilization. In addition, a larger helmet may compromise central venous access if it covers most of the child’s neck and clavicular areas.

As children mature, the nose becomes more prominent and the ear cartilage stiffens. Older children require a technique to remove the helmet that spreads the helmet laterally away from the ears while tilting it backward to clear the nasal prominence.

The typical pediatric patient wearing a helmet is brought by emergency medical services (EMS) on a spine board with neck and helmet immobilized by sandbags and tape. The patient often comes from the scene of a sporting event or may have sustained a fall while engaged in a low-speed recreational activity. Occasionally the pediatric patient is a passenger on a motorcycle involved in a high-speed injury, often with devastating consequences.

Children may be wearing the full-faced helmets that are used by motorcyclists, the open-faced helmets that are used in football or hockey, or the simple helmets only enclosing part of the skull that are worn by bicyclists, skateboarders, and rollerbladers. In the case of the latter type of helmets, these are frequently removed before patients arrive in the ED.

Immediate helmet removal is indicated in the pediatric patient with airway compromise who is wearing a helmet that obstructs airway access. All other patients should be transported with the helmet in place and immobilized with tape, collar, spine board, and sandbags or soft spacers, as detailed in Chapter 24. Some support beneath the shoulders, such as a small towel roll, should be used to maintain a neutral position of the neck.

In most cases, on arrival at the hospital the patient requires a lateral cervical spine radiograph and a thorough neurologic examination before the clinician attempts to remove the helmet. In some instances, the helmet can be removed without radiograph, but it is only advised if the child is alert and over 5 years of age, denies neck pain, has a history of minor trauma without loss of consciousness, and on examination has no neurologic deficits or midline cervical tenderness (1). All children under 5 years of age require spinal radiographs before helmet removal.