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A 29-year-old male motorcyclist presents to the emergency department (ED) after being involved in a high-speed motor vehicle crash (MVC). The motorcyclist was traveling at approximately 65 km·h−1 (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 m (160 ft) 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 nonmodular 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.

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

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The general principles of trauma care and resuscitation apply to this patient. An initial, rapid survey of the patient's vital functions including his airway, breathing, and circulation (the A-B-Cs) is undertaken.1 Large-bore intravenous access, oxygen, and basic monitoring (pulse oximetry, ECG, and serial blood pressure readings) are instituted quickly. If the helmet cannot be easily or safely removed for the primary survey, supplemental oxygen may be provided by placing an inverted simple face mask through the opening in the helmet. His airway assessment shows that he is wearing a full-face, nonmodular 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 this patient is protecting his airway, is breathing, and has an adequate blood pressure, he may require intervention to control his airway and breathing urgently after completion of the primary survey.

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17.2.2 Are There Recommendations in the Advanced Trauma Life Support® Guidelines for the Removal of Helmets Prior to Transport?

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There is currently no consensus regarding whether prehospital personnel should routinely remove a patient's helmet prior to transport to hospital. Individual patient factors and coexisting injuries will guide the decision to remove the patient's helmet. If possible, the helmet should remain in place unless emergency airway 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 Prehospital personnel should be encouraged ...

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