Face Mask Removal Technique

In accordance with current practice standards, the  medical staff employs the Combo-Tool Approach to face mask removal when face mask removal is required to provide emergent or non-emergent access to an injured patient’s airway.

Key Points:

Small, low voltage hand held power screwdrivers (PSD) are used to reduce the risk of stripping face mask hardware screws.  The directional buttons of all PSDs are locked and taped in the reverse direction to avoid accidentally tightening helmet hardware to reduce the risk of accidentally tightening or stripping hardware.  A phillips style screw driver bit is glued into the end-effector of all PSDs to avoid having them fall out and lost while being stored in emergency kits.  PSDs are taken out of all emergency kits following each and every event, and are plugged in to ensure they are fully charged.  Each PSD is tested for proper function prior to being packed for event use.  FMx3 functionality is checked prior to each event and the blade lubricated with a silicone based lubricant before each event.

If face mask removal is delayed or complicated to the point of disrupting completion of other primary objective critical care tasks, the A-Man or designated code runner will direct the team to initiate the helmet removal protocol.  Generally, the criteria to abort the face mask removal procedures and initiate the helmet removal protocol is met if face mask removal cannot be completed prior to the start of the second cycle of CPR, or approximately 2 min.  The A-Man or designated code runner will ultimately determine the appropriateness of helmet vs. face mask removal on a case by case basis.

A-Man

B- and C-Man

Helmet Removal

Conditions which may warrant removal of the football helmet from an athlete may include, but are not limited to:

  1. Inability to gain access to the injured athlete’s airway with face mask removal;
  2. Inability to perform sufficient injury assessment;
  3. Desire to have access to stable or unstable athlete during transport.

When it is determined that the football helmet should be removed from an athlete, the following removal procedure shall be followed:

  1. The A-Man shall maintain in-line stabilization of the head and neck;
  2. The B- and/or C-Man shall prepare the helmet for removal by cutting the chin-strap and removing the mouth guard. In some helmet models removal of cheek pads, and deflation of air bladders may facilitate helmet removal.  In the event that the B- and C-Man are occupied with completion of other critical care tasks, extended members of the Critical Care Triangle™(CCT) shall be directed to prepare the helmet for removal.
  3. The B- or C-Man shall take control of and maintain in-line stabilization of the athlete’s head and neck by reaching in from the side to wrap hands around the neck such that the thumbs run along the mandible, coming to rest at the temporal-mandibular joint, while the fingers interlock to support the cervical spine posteriorly. Extended members of the CCT may be assigned this task in the event that B- and C-Man are completing other necessary critical care tasks.
  4. Upon securing in-line stabilization B- or C-Man shall iterate to the A-Man that they have sufficient control of in-line stabilization, upon which the B- or C-Man shall count “1-2-3, Release” to officially take control of the in-line stabilization from the A-Man.
  5. The A-Man will begin the helmet removal process by first removing all pack-n-fill towels used to maintain cervical neutral position;
  6. The A-Man will the begin helmet removal by slightly spreading the helmet at the earholes, then will carefully begin pulling the helmet from the athlete until the athlete’s ears are just about to clear the helmet cheek pads, at which point the A-Man shall pause helmet removal;
  7. The A-Man shall next iterate to the team member providing stabilization that the athlete’s ear are about to clear the helmet cheek pads and that helmet removal will resume on the count of “1-2-3, Remove”. This allows the team member providing in-line stabilization ample time to prepare to mediate a rebound force often observed to cause significant movement of the cervical spine when the helmet cheek pads slide over the athlete’s ears during football helmet removal.  Upon the “1-2-3, Remove” command, the A-Man shall resume extraction of the helmet by pulling the helmet while tipping the helmet slightly forward to clear the occiput posteriorly, but being careful to not hit the athlete’s nose when the face mask is still in place.
  8. Once the football helmet has been removed the A-Man shall pack-n-fill the athlete in cervical neutral position and then retake control of in-line stabilization by placing arms along the lateral aspect of the athlete’s head and placing the web space of hands on the athlete’s traps bilaterally with the thumbs on the collar bone, thus securing the head and neck to the torso.
  9. The A-Man shall iterate to the team member presently maintaining in-line stabilization that they properly positioned and are ready to re-take control of in-line stabilization, at which time the A-Man shall count “1-2-3, Release”. The A-Man shall now have control of in-line stabilization.
  10. The CCT will then resume prudent on-going assessment, care, and support of the athlete’s vital signs.

Helmet and Shoulder Pad Removal

Conditions which may warrant removal of both the football helmet and shoulder pads from an athlete may include, but are not limited to:

  1. The need to assess status of respiration;
  2. The need to assess effectiveness of ventilation;
  3. The need to perform CPR;
  4. Proper placement of defibrillator pads;
  5. Inability to perform necessary injury assessment;
  6. The need to perform critical care tasks associated with internal injury
  7. Desire to have access to stable or unstable athlete during transport.

When it is determined that the football helmet and shoulder pads should be removed should be removed from an athlete, the following removal procedures shall be considered:

Flat-Torso Technique

  1. The A-Man shall maintain in-line stabilization of the head and neck;
  2. The B- and/or C-Man shall prepare the helmet for removal by cutting the chin-strap and removing the mouth guard. In some helmet models removal of cheek pads, and deflation of air bladders may facilitate helmet removal.  In the event that the B- and C-Man are occupied with completion of other critical care tasks, extended members of the Critical Care Triangle™(CCT) shall be directed to prepare the helmet and shoulder pads for removal.
  3. The B- and/or C-Man shall prepare the shoulder pads for removal by first cutting the athlete’s jersey with heavy-duty bandage shears, beginning at the neckline and cutting down away from the athlete at the midline, and cutting laterally across each shoulder all the way through the arm sleeve cuffs.
  4. Next, in order to reduce the potential onset of a rebound force caused by the release of elastic tension in the shoulder pads straps upon cutting the breast plate strings, the B- and/or C-Man shall cut the shoulder pad elastic straps BEFORE cutting the laces and/or breast plates. In some instances, shoulder pads secured anteriorly with thick plastic plates may be removed without first cutting the plastic breast plate.  This option is more likely in smaller athletes and less likely with larger athletes.  The medical team will be able to assess this option upon observation of shoulder pad fit once the jersey, straps, and strings have been cut.
  5. Next, the B- or C-Man shall cut the athlete’s undergarments with heavy-duty bandage shears by beginning at the neckline and cutting down away from the athlete at the midline, and cutting laterally across each shoulder all the way through the arm sleeve cuffs to expose the chest.
  6. The B- or C-Man shall take control of and maintain in-line stabilization of the athlete’s head and neck by reaching in from the side to wrap hands around the neck such that the thumbs run along the mandible, coming to rest at the temporal-mandibular joint, while the fingers interlock to support the cervical spine posteriorly. Extended members of the CCT may be assigned this task in the event that B- and C-Man are completing other necessary critical care tasks.
  7. Upon securing in-line stabilization B- or C-Man shall iterate to the A-Man that they have sufficient control of in-line stabilization, upon which the B- or C-Man shall count “1-2-3, Release” to officially take control of the in-line stabilization from the A-Man.
  8. The A-Man will begin the helmet removal process by first removing all pack-n-fill towels used to maintain cervical neutral position;
  9. The A-Man will the begin helmet removal by slightly spreading the helmet at the ear holes, then will carefully begin pulling the helmet from the athlete until the athlete’s ears are just about to clear the helmet cheek pads, at which point the A-Man shall pause helmet removal;
  10. The A-Man shall next iterate to the team member providing stabilization that the athlete’s ear are about to clear the helmet cheek pads and that helmet removal will resume on the count of “1-2-3, Remove”. This allows the team member providing in-line stabilization ample time to prepare to mediate a rebound force often observed to cause significant movement of the cervical spine when the helmet cheek pads slide over the athlete’s ears during football helmet removal.  Upon the “1-2-3, Remove” command, the A-Man shall resume extraction of the helmet by pulling the helmet while tipping the helmet slightly forward to clear the occiput posteriorly, but being careful to not hit the athlete’s nose when the face mask is still in place.
  11. Once the football helmet has been removed the A-Man shall grasp the shoulder pads and gently pull them from under the athlete. The medical team may elect to perform a torso-lift or flat-lift technique to ease shoulder pad removal.  The medical team may elect to have extended members of the CCT aid in shoulder pad removal by grasping the shoulder pads on either side of the athlete.
  12. Once the football helmet and shoulder pads have been removed the A-Man shall pack-n-fill the athlete in cervical neutral position and then retake control of in-line stabilization by placing arms along the lateral aspect of the athlete’s head and placing the web space of hands on the athlete’s traps bilaterally with the thumbs on the collar bone, thus securing the head and neck to the torso.
  13. The A-Man shall iterate to the team member presently maintaining in-line stabilization that they properly positioned and are ready to re-take control of in-line stabilization, at which time the A-Man shall count “1-2-3, Release”. The A-Man shall now have control of in-line stabilization.
  14. The CCT will then resume prudent on-going assessment, care, and support of the athlete’s vital signs.

Torso-Lift Technique

  1. The A-Man shall maintain in-line stabilization of the head and neck;
  2. The B- and/or C-Man shall prepare the helmet for removal by cutting the chin-strap and removing the mouth guard. In some helmet models removal of cheek pads, and deflation of air bladders may facilitate helmet removal.  In the event that the B- and C-Man are occupied with completion of other critical care tasks, extended members of the Critical Care Triangle™(CCT) shall be directed to prepare the helmet and shoulder pads for removal.
  3. The B- and/or C-Man shall prepare the shoulder pads for removal by first cutting the athlete’s jersey with heavy-duty bandage shears, beginning at the neckline and cutting down away from the athlete at the midline, and cutting laterally across each shoulder all the way through the arm sleeve cuffs.
  4. Next, in order to reduce the potential onset of a rebound force caused by the release of elastic tension in the shoulder pads straps upon cutting the breast plate strings, the B- and/or C-Man shall cut the shoulder pad elastic straps BEFORE cutting the laces and/or breast plates. In some instances, shoulder pads secured anteriorly with thick plastic plates may be removed without first cutting the plastic breast plate.  This option is more likely in smaller athletes and less likely with larger athletes.  The medical team will be able to assess this option upon observation of shoulder pad fit once the jersey, straps, and strings have been cut.
  5. Next, the B- or C-Man shall cut the athlete’s undergarments with heavy-duty bandage shears by beginning at the neckline and cutting down away from the athlete at the midline, and cutting laterally across each shoulder all the way through the arm sleeve cuffs to expose the chest.
  6. The B- or C-Man shall take control of and maintain in-line stabilization of the athlete’s head and neck by reaching in from the side to wrap hands around the neck such that the thumbs run along the mandible, coming to rest at the temporal-mandibular joint, while the fingers interlock to support the cervical spine posteriorly. Extended members of the CCT may be assigned this task in the event that B- and C-Man are completing other necessary critical care tasks.
  7. Upon securing in-line stabilization B- or C-Man shall iterate to the A-Man that they have sufficient control of in-line stabilization, upon which the B- or C-Man shall count “1-2-3, Release” to officially take control of the in-line stabilization from the A-Man.
  8. The A-Man will begin the helmet removal process by first removing all pack-n-fill towels used to maintain cervical neutral position;
  9. The A-Man will the begin helmet removal by slightly spreading the helmet at the ear holes, then will carefully begin pulling the helmet from the athlete until the athlete’s ears are just about to clear the helmet cheek pads, at which point the A-Man shall pause helmet removal;
  10. The A-Man shall next iterate to the team member providing stabilization that the athlete’s ear are about to clear the helmet cheek pads and that helmet removal will resume on the count of “1-2-3, Remove”. This allows the team member providing in-line stabilization ample time to prepare to mediate a rebound force often observed to cause significant movement of the cervical spine when the helmet cheek pads slide over the athlete’s ears during football helmet removal.  Upon the “1-2-3, Remove” command, the A-Man shall resume extraction of the helmet by pulling the helmet while tipping the helmet slightly forward to clear the occiput posteriorly, but being careful to not hit the athlete’s nose when the face mask is still in place.
  11. Once the football helmet has been removed, an additional responder, or D-Man shall assume the position vacated by the team member who is presently responsible for stabilization.  The D-Man, together with the remaining B- or C-man shall position themselves at each shoulder of the athlete, and place their hands between the athlete’s shoulders and the shoulder pads.  Upon the A-Man command, the responders at the athlete’s shoulders gently lift the athlete to elevate the torso 30º to 40º by bending the athlete at the waist.  The pads are then removed by the A-Man.
  12. After the pads are removed, the A-Man directs the team to lower the athlete to the supine position where the A-Man re-assumes control of the head and neck.  Transfer of stabilization is again done by a “1-2-3 release” command given by the A-Man.  The A-Man then repositions the athlete to cervical neutral position.