Spinal motion restriction.
The old mantra was "immobilize everyone." The modern approach is selective: protect the spine when the risk is real, but avoid the harm that rigid boards cause to low-risk patients.
When to apply SMR
Apply SMR when there is a significant mechanism of injury plus one or more of the following risk factors:
- Altered mental status or GCS < 15
- Intoxication (alcohol, drugs, or medications)
- Midline spinal pain or tenderness
- Distracting injury (e.g., femur fracture, severe chest trauma)
- Neurologic deficit, numbness, or weakness
- Communication barrier that prevents reliable assessment
When NOT to apply SMR
A patient with a minor mechanism, normal mental status, no intoxication, no distracting injury, no midline tenderness, and no neurologic complaint generally does not need SMR. These patients are better transported on a stretcher without a rigid board.
Seated patient SMR steps
- Take BSI and ensure scene safety.
- Manually stabilize the head in a neutral, in-line position.
- Assess pulse, movement, and sensation.
- Apply a properly sized cervical collar.
- Position the vest/short board behind the patient.
- Secure the torso straps first, then the head straps.
- Rotate the patient as a unit onto the stretcher or long board.
- Reassess PMS and comfort.
Supine patient SMR steps
- Manual in-line stabilization of the head.
- Apply a cervical collar.
- Secure the torso to the device or stretcher.
- Secure the head with foam blocks and straps.
- Maintain neutral alignment throughout.
NREMT tip
On the NREMT, always apply a cervical collar before moving the patient. The most common critical fail is moving the patient without first stabilizing and collaring the head.
FAQ
What is selective spinal motion restriction?
Selective SMR means applying spinal precautions only to patients who actually meet clinical and mechanism criteria for spinal injury risk, rather than immobilizing every trauma patient on a long board.
What are the NREMT indications for spinal motion restriction?
Mechanism of injury plus any of the following: altered mental status, intoxication, midline spinal pain or tenderness, distracting injury, or neurologic deficit. The patient must also have a significant mechanism of injury.
Is the long backboard still used?
Yes, but as an extrication device and not a routine transport device. Most patients who need SMR are transported on a stretcher with a cervical collar and minimal movement, not strapped to a rigid board.
What are the steps of SMR for a seated patient?
Manual stabilization, apply a cervical collar, position a vest-type immobilization device or short board behind the patient, secure the torso first, then the head, and carefully rotate the patient to the stretcher.
What are the critical fails on the NREMT SMR skill?
Failure to take BSI, failure to manually stabilize the head before moving the patient, moving the patient without first securing the torso, and failing to reassess the patient after immobilization.