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Caring for a football player with an acute neurologic injury: When do the pads come off?
By Charles S. Krin, DO FAAFP
Dec 8, 2006, 15:33

Courtesy the EMS House of DeFrance http://www.defrance.org

Caring for a football player with an acute neurologic injury: When do the pads come off?

by Charles S. Krin, DO FAAFP

Field removal of an injured football player’s pads or helmet is a point that is not well covered in any of the standard Trauma Life Support Courses, or for that matter in most EMS courses. However, these techniques can be very important for physicians and field medical personnel who work with this breed of athlete. The publication by the National Association of Athletic Trainers (NATA) of The Report of the Inter-Association Task Force for the Appropriate Care of the Spine Injured Athlete, in 2001 covers this material in some detail. These guidelines are in the process of being updated, with the release date of the new version expected “early in 2007.”

Twenty-six different organizations are participating in the new version, ranging from NATA to the American College of Sports Medicine, the American College of Surgeons’ Committee on Trauma, the American Academy of Family Physicians, and representatives of the medical branches and athletic trainers of all levels of organized sports from the High School Athletic Association to the Olympic Committee and Professional Sports.

Introduction

For practically any other emergency situation, expeditious removal of a helmet in the field is the general rule, as the helmet generally forces the head into significant flexion, causing problems with both the airway and the cervical spine. The relatively light helmets of bicycling, lacrosse and various hockey players are quite straight forward to remove, while the heavier helmets of motorcyclists, especially the full face variety, can pose significant challenges to the field medical team. It is when we get into the now sophisticated protective systems involved in American and Canadian style football where the patients actually are easier to stabilize with the helmet and pad system intact in the field   Significant injuries are rare in the ‘Pee Wee’ and early Junior High/Middle School leagues, mostly because the players are not large and fast enough to cause injury around the helmet/pad systems. Starting with the High School athletes, players are nearing their full growth and are big enough and fast enough to suffer significant injuries despite the pads. This is even truer as a player advances to the College, and Professional levels of Football.

The NATA guidelines for Prehospital Care of the Spinal Injured Athlete  are perhaps the most well accepted ones currently in use, being referenced in Tintinalli’s  Emergency Medicine among other places. There have been a number of articles in the last 5 years in the Athletic literature, much of which is probably unfamiliar to Emergency and Family Medicine physicians and the EMS community.  A recent article by JW Whiteside in The American Family Physician, Management of Head and Neck Injuries by the Sideline Physician , covers field assessment of injured players, including methods to evaluate players who may not need full packaging.
 
I found it significant when Dr. Whiteside noted:

Cervical spine instability and the accompanying potential for neurologic loss may be commonly underdiagnosed. When 108 freshmen recruits to the University of
Iowa football team underwent radiographic assessment of the neck, 35 were found to have evidence of previous cervical spine injury.  These injuries included old compression fractures, posterior element fractures, and disk narrowing with resultant instability.

This is a good indication to me that the ‘pressure to play’ extends well below the level of high profile college athletics, and results in many young players not seeking or receiving appropriate medical follow up. Interestingly enough, a review of both the Trauma.org  and Eastern Association for Surgical Trauma  (two of the major references for trauma care) websites, shows no guidelines comparable to the NATA publication available to the interested clinician. Even The Cochrane Database of Systematic Reviews  shows nothing beyond a review of bicycle helmet removals in 1999.

Equipment:

Most of the time when we are treating football players who need cervical spine precautions, we are working with players who are still in full gear and who are on the ground. At this point, cervical spine precautions are fairly straight forward, as the combination of the helmet and intact shoulder pads together provide a good basis for packaging the patient on a long spine board. This player can be log rolled to the supine position (if needed), the face mask removed, then the player is packaged and transported to the appropriate facility with the helmet and pads otherwise intact.

Fortunately for field medics, team physicians, and athletic trainers, helmets and pads are fairly uniform in design by now. Helmets approved by the National Operating Committee on Standards for Athletic Equipment (NOCSAE) have polycarbonate shells, with the face masks attached by plastic or Nylon™ loop straps, and some combination of firm foam and adjustable air pads to insure a snug, custom fit for the player. They are held in place by a combination of that snug fit around the ring from the occiput to the forehead and a firm chin strap that cups the point of the chin. The chin strap is held to the helmet by one or two flexible/ elastic straps on either side of the helmet, which attach to the helmet by ‘pull the dot’ heavy duty snaps. The padding inside the helmet is generally removable to allow for differing levels of thickness and firmness for a custom fit to the player. In particular, the padding of the cheek and ear areas can often be removed while the helmet is still on the player. I will discuss the trick of doing this later in the article.

Athletic trainers, team physicians and medics assigned in support of football games should be aware of the construction and limitations of the helmets and pads worn by the class of athlete in their areas of operation!

The majority of the shoulder pads lace up along the sternal line, and are held in place under the arms by elastic straps attaching from the scapular pads to the pectoral pads. Other elastic or flexible plastic straps connect the paldrons (true shoulder pads) to the scapular and pectoral pads and the pectoral/scapular pads to each other. There may be other associated pads, including posterior neck rolls (often attached to the back of a lineman’s jersey), and ‘flack jackets’ (rib protectors on back field players) among others.

Because of variations of equipment in a locale, and the need for close coordination and team work, it is strongly recommended by NATA that preseason cross training between the coaches, athletic trainers, team physicians and responsible EMS and Emergency Department professionals occur both on the field and in the Emergency Department and that refresher drills occur during the season. 

Initial Assessment:

First and foremost, the classic “ABCDEs” of trauma care must be observed: Open the Airway while maintaining cervical spine control, rapidly assess Breathing and Circulation, and treat any life threatening conditions found. Only then, evaluate the player’s level of Disability (immediate Neurologic status including Glasgow Coma Scale, neck or back pain, limb sensation and motor strength, and rectal tone as appropriate), and proceed with Exposure and Environmental control as most of these incidents will occur outside in inclement weather. While it would be ideal to roll the prone patient directly onto the long spine board, critical airway and breathing problems should not wait for the board to be brought out! An additional point would be the need for crowd control, especially at High School games. This requires some of the coaches to keep the other players, concerned family and fans away from the injured player to allow the trainers, medics and team physician room to properly assess the player.

Any time a player suffers a loss of consciousness of more than a few seconds OR complains of neck or back pain OR has significant face or jaw injuries, cervical spine precautions should be maintained in the field by manual stabilization from the time problems are noted until the player is fully immobilized on the long spine board. 

In all cases, it is now recommended that the face mask be removed from the helmet to insure that airway management is not delayed if the patient becomes unresponsive. It should be noted that the chin strap should be left in place to help immobilize the head inside the helmet, unless the player’s injuries are such that the chin strap is interfering with the airway or other aspects of emergent care.

A number of tools and techniques have been recommended for removal of the face masks, which are generally held on the helmet by four plastic clip straps attached to the helmet by screws and T bolts . There are some types of face masks, in particular, the Riddell Cra-Light solid plastic face mask, which require other methods of removal. My favorite is the use of a pair of 15 to 20 cm (6 to 8 inch) long diagonal wire cutters. Two cuts on each strap, one next to the screw head (outside strap), and the other on the back side of the bar (inside strap) allow the mask to be easily removed without compromising movement.
 
The mouth guard should also be removed at this time if the player has not already spit it out. Otherwise, removal of the protective gear should be left until arrival at the Emergency Department, to allow for better control of the cervical spine in these situations.

Packaging:

If the patient is supine, and the helmet/pad system is intact, the next problem is getting the player on the long spine board. The NATA report points out:

To transfer a supine athlete [to a long spine board], the Inter-Association Task Force recommends using a six-plus--person lift along with a scoop stretcher to lift the athlete onto a rigid long spine board rather than a log roll technique.   A six-plus--person lift is recommended due to the size of many athletes and the interference by protective equipment.

The player’s body should be secured to the back board with at least three straps (preferably more), with padding along the sides of the body and in the voids of the neck, lumbar curve, and popliteal space to help prevent the player from moving on the board in case the board needs to be tipped up on the side to prevent aspiration from vomiting. Lastly, the helmet needs to be secured to the spine board with tape or straps along with the head blocks. It should be noted that there is often no room for a traditional cervical collar between the helmet and the shoulder pads, and a combination of head blocks around the helmet and a towel or blanket roll around and behind the neck must be considered. A vacuum splint, if available, would be very effective in this role as well as it can be molded to fill the void between the helmet, the shoulder pads, and the long spine board before the vacuum is drawn. Manual stabilization should not be released until first the body and then the helmet have been secured to the board.

Emergency Department Care:

When a fully packaged player is transported to the Emergency Department for evaluation, it would be helpful for at least one Athletic Trainer and the EMS team to remain in the department until the helmet and pads have been removed, and the patient re secured to the long spine board. This is to provide both the personnel and specialized knowledge needed to quickly and safely remove the equipment. The boarded player should be transferred to the ED gurney as a package, and then further exposure and assessment can be undertaken.

Manual stabilization of the head and cervical spine must be maintained from the time the helmet is released from the restraints until the head is again secured to the long spine board or the spine is cleared clinically by using the EAST Spinal Clearing Protocol.

In the Emergency Department, the ABCDs must be reassessed. If the patient is stable, then Exposure is started by deflating any air cells of the helmet either with an athletic inflation needle, or a large bore IV needle, inserted into the inflation port, and then cutting the chin strap of the helmet on both sides. Next, any cheek or ear pads, which are held in place by either Velcro™ or snaps are removed with the use of a tongue blade (or other thin, rigid implement that can be slid between the pad and the helmet) ‘popping’ the pads loose. These actions will create enough space that the helmet may then be removed from the player’s head by rotating it slightly forward and pulling gently along the axis of the spine.

Manual support and stabilization of the head continues, as the pectoral lacings and under arm straps are cut. After this is accomplished, multiple (the team leader at the head to maintain airway and cervical spine control and six to ten other) rescuers can do a coordinated vertical lift while maintaining cervical spine control, and the remaining clothing and pads can be extracted while the player is suspended. This lift is much easier in the ED than on the field, as the gurney can be brought to waist height, and the lift is easier to synchronize. The main disadvantages of this approach is that it is labor and time intensive and that it does not allow for direct examination of the dorsal portion of the body. While the patient is being lifted, the long spine board should be padded by at least the addition of a folded blanket before the patient is gently lowered to the surface again.

After the protective equipment has been removed and the player has been returned to (now padded) the long spine board, clinical clearance may be considered prior to repackaging the player. The EAST protocol requires that the player has had no significant loss of consciousness, has no distracting injuries, and has not received any mind altering medications. In-line stabilization is maintained by one rescuer while the appropriate clinician (usually the ED or Team Physician) first palpates the scalp, neck and shoulders. If no pain or tenderness is found, then the player is allowed to gently flex and extend his neck, followed by side bending and rotational movements. If there is no pain on active range of motion, then gentle axial pressure is applied. If no pain is noted on any of these maneuvers, the player is allowed to sit up so that Spurling’s maneuver can be used to assess the lateral foramina for cervical nerve root problems  and the thoracic and lumbar spine can be more closely evaluated. If there is no neurologic deficit, no point tenderness and no significant spasm noted, then the player does not need to be re-secured to the long spine board and radiographs of the cervical spine are not needed.

Special Situations:

Removal of the face mask and packaging the injured player with helmet and pads intact is fairly straight forward, and is the most common situation. However, we must consider several other cases that do occur from time to time. What about the player who has suffered from an otherwise minor loss of consciousness which is not recognized at the time? Or if the chin strap comes loose and the helmet is knocked off during play? Or if the player has a helmet on, is unconscious, and the shoulder pads have become badly disarrayed?

With the helmet off, trying to package the patient with the shoulder pads on becomes more of a challenge. Just as bad would be leaving the helmet on if the pads are not providing proper support.  I have seen several cases over the years where an attempt was made to place the patient on a long spine board and just pad under the occiput. Even with a good cervical collar in place, the restriction of head/neck motion was less than adequate.

As the NATA guide points out:

Spinal immobilization must be maintained while the helmet is removed; therefore, during helmet removal, the shoulder pads must be removed simultaneously. 2 The helmet/shoulder pad unit should be thought of as an all-or-none scenario with regard to spinal immobilization. Studies have shown excess movement in the cervical spine when helmet or shoulder pads are removed alone. 

And:

Research with fluoroscopy and kinetic magnetic resonance imaging shows that unless [the helmet and] the shoulder pads are removed simultaneously, it is not possible to maintain in-line neutral stabilization.

The solution is simple for the player who is in need of transport for further evaluation:

If the helmet is off, the pads come off, and vice versa.

This is something that is quite simple to do if the patient is still standing or sitting up, but a bit more complex if the patient is on the ground.

 
Case Studies:

We shall consider four cases where the removal of the helmet and pads on the field should be undertaken:

Case One:  Player suffered a minor concussion, but was up and walking on his own after the incident. Player has removed his own helmet, but is now noted to be only semi coherent and missing parts of his memory. He is sitting upright and is cooperative. He may or may not complain of neck pain.

Case Two: Player was involved in a major collision, hard enough that his helmet came off. He is supine, and may be unconscious or conscious and complaining of neck pain.

Case Three: Player was involved in a major collision, hard enough that his helmet came off. He is prone, and may be unconscious or conscious and complaining of neck pain.

Case Four: Player was involved in a major collision, hard enough that his shoulder pads are disarrayed. He is not responding and it is impossible to position him to maintain a neutral spine and an open airway because of the pads.

Other situations requiring the removal of the helmet and shoulder pads on the field would include those, fortunately rare, situations involving multiple injuries to the upper body where the pads or helmet interfere with appropriate access for evaluation or stabilization. The rescue team should be able to handle these situations through pad and helmet removal as described in case 4 above.

Techniques and Decisions:

While there are some significant differences in the approach to each of these patients, there are more similarities in the practical treatment.

If the injured player is still upright and has taken his own helmet off, then a lateral stabilizing approach may be used, allowing easier access to the jersey and pads. The first rescuer supports the chin and occiput while standing next to the player and resting his elbows on his own thorax.
 
Dr Whiteside’s article offers a reasonable approach, consistent with the EAST protocols, for clearing the upright, conscious patient with no airway problems, as shown in the following chart:

 
 Figure 1. The Spurling test, a foraminal compression test,
is used to evaluate cervical nerve root injury. The examiner
actively compresses the right and left foramina as shown.
Cervical radiculopathy is indicated if this position elicits
radicular symptoms in the upper limb. 

If the player fails the clearance testing at any point, then simply cutting the jersey and all other shirts from neck to waist and down both shoulders to the sleeve hems will allow easy removal of the clothing.

Once the clothing is removed and the pads exposed, cut the laces and elastic bands holding the pads in place, spread the pectoral pads and ease the pads off the shoulders in a posterior direction. A cervical collar is then applied, and a second rescuer takes over cervical spine control from behind for the standing or seated ‘take down’ maneuver. The player is then secured to the long spine board with a minimum of three body straps, side padding, head blocks and tape to secure the head to the blocks and board before manual spine control is released.

Securing a supine patient without a helmet is more difficult, but, with practice, may be quickly accomplished. Cervical spine control is achieved from above the patient’s head, grasping either both mastoids or using the chin/occiput method, depending on how the patient is lying. The airway is opened by the jaw thrust or chin lift methods, if needed, to help keep the neck in the neutral position. The jersey and t shirts are again cut down both shoulders and from the neck line to the lower hem along the path of easiest access.

If the patient is supine, then the lacing is cut between the pectoral pads, the elastic straps are cut, and then additional cuts are made on each side where the flexible straps join the paldrons to the scapular pads and the scapular pads to the pectoral pads. The anterior portions of the pads are then lifted off, leaving the player ‘on the half shell’ of the scapular pads.

If possible, a semi rigid cervical collar is applied at this point to ease cervical spine control. The anterior neck and chest are then examined, and the patient is log rolled with continued cervical spine control, so that the posterior segment of the pads and clothing can be removed, the back examined, and the patient log rolled back onto a padded long spine board. If the cervical collar has not been previously applied, it is applied at this time, and the remainder of the packaging is applied, again maintaining manual control until first the body and then the head is secured.

The prone patient without a helmet presents a more challenging problem simply because of the increased difficulty maintaining proper cervical spine alignment during the initial maneuvers, but the principles remain the same. Cervical spine and air way control are managed by the rescuer at the player’s head, usually by grasping both sides of the head at the mastoids. A second rescuer may be needed to provide a jaw thrust maneuver to open the air way and to help stabilize the head and neck as the player is rolled onto his back.

The jersey is cut down the back and the shoulders to the hems, and then laid open. This allows access to the under arm straps, and straps connecting the paldrons to the pectoral pads and the scapular pads to the pectoral pads, all of which are cut to allow removal of the pads as noted above, leaving the player on the pectoral pads. The back is then examined and the patient log rolled onto the padded long spine board, leaving the pectoral pads on the ground. The cervical collar is applied, and the chest examined. Packaging is completed in the usual fashion.

The most challenging situation is that of the unconscious player whose helmet is still on, but whose pads have become sadly disarrayed, leaving no good way to logroll the player to the supine position to start treatment. In this case, the player is stabilized in the position found, by supporting the head and helmet in a neutral position by grasping both the helmet and the mastoid area of the skull. A chin lift or jaw thrust maneuver is used to open the airway if needed.

Next, the jersey and the pads are removed from the anterior or posterior approach as described above to facilitate cervical spine protection and physical access to remove the helmet. The face mask is removed to facilitate airway access, and the chin straps are cut to begin the process of removing the helmet. If the mouth guard is still in place, it should be removed at this time.

Cheek and ear pads, held in the helmet by snap fittings or Velcro™ pads, can be removed by the use of a tongue blade or other thin, rigid device slid between the pad and the side of the helmet ‘popping’ them free as noted above. Any inflatable air cells are then deflated with the use of either the standard ball needle or a large bore IV needle inserted in the inflation hole. A second rescuer now assumes support of the airway and cervical spine from below the helmet, with manual stabilization at the occiput and mandible.

The helmet should now be loose enough that it can be removed from the player with a slight rotation forward to clear the occiput. It should be noted that trying to spread the helmet at the ear holes or cheek pieces at this time may actually increase the pressure needed to remove the helmet by increasing the squeeze the helmet has between the forehead and the occiput.

By the time all of this has been accomplished, the long spine board should be in position, and the player may be rolled or lifted by scoop stretcher onto that device and secured as appropriate. Again, manual cervical spine and airway control should not be relinquished until the player’s body and head have been secured to the long spine board.

Once the player is secured to the long spine board, the remaining treatment should follow ATLS protocols and local guidelines.

 
Summary:

Caring for the injured football patient on the field or in the Emergency Department has some unique problems involving control of the cervical spine and airway and access to the patient to provide evaluation and care. Generally, the player who is injured will be initially treated on the field with the helmet/pad system intact, and they may be packaged as a unit. In cases where the helmet has come off, or the pads seriously disarrayed, then the rest of that system needs to be removed before the player can be properly immobilized for transport. In any case, a well practiced team consisting of athletic trainers, physicians, EMS and ED personnel is needed to provide proper care for the injured player to prevent worsening of a critical spinal injury

It is also important for the Team, Emergency or Family Physician who cares for the injured player to be aware that significant neck injuries can be present, even if the player insists that they want to go back into the game. Our responsibility, especially in the case of younger, still growing players, is to error on the side of caution and SAFELY package for transport to the Emergency Department for further evaluation if there is any question of significant injury.
 
I have no financial interest in any product mentioned in this article.

Acknowledgements:

I want to thank Kat Rickey (of the various alpha bits) from New Hampshire for being a gracious First Reader and for giving much valuable feedback on formatting. In addition, the crew at Bates County (Missouri) Memorial Hospital, and Bates County (Missouri) EMS helped both as sounding boards and with some of the proofreading.

Bio:

Dr. Krin spent time as a Emergency Medical Technician-Ambulance in the late 1970s and early 1980s, including 3 years as an Flight Medic at Ft Sill, Oklahoma before attending the University of Health Sciences, College of Osteopathic Medicine (now the Kansas City University of Medicine and the Biosciences) in Kansas City, Missouri. Graduating in 1987, he did his post graduate training at the EA Conway Hospital, Louisiana State University Medical Center Family Practice Program in Monroe Louisiana. Starting a clinical practice in 1990, he became a Fellow of the American Academy of Family Physicians in 1995. Maintaining an active office practice while supporting his local High School and Junior High School athletic teams, he spent the nine years working part time in Emergency Departments near his office, until moving to full time Emergency Medicine in 1999. After practicing in Louisiana for almost 20 years, he is now practicing in Rural Missouri and living near St. Louis.

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