If the player is unconscious or not breathing, it may be necessary to remove his or her helmet to access the airway. Helmet removal requires a careful, methodical approach to avoid compounding a suspected injury to the spinal cord. Hence, the first rule of management on the field is to stabilize the neck and keep the helmet on if possible. For football and ice hockey players in the supine position, shoulder pads elevate the trunk, so that when the helmet is removed, the head drops and the neck hyperextends. Leaving the helmet in place keeps the neck from hyperextending.
Helmets also fit snugly and cradle the head, minimizing head and neck motion.
Thus, if an injured athlete is breathing and does not require airway management, the helmet should be left on to help support the head and neck. An athlete who requires airway intervention requires immediate removal of the face mask for access to the airway while leaving the helmet on. Ideally, the helmet is left in place until the cervical spine can be imaged with radiography. The only reason to remove the helmet in most situations is inability to establish an airway and effective breathing or failure of the helmet to stabilize the head adequately. The practice of leaving the helmet on unless removal is absolutely necessary differs from the advanced trauma life-support protocol for helmet removal in motorcycle accidents.