Spinal Motion Restriction:
There is an ongoing debate of opinions, that constantly changes, regarding when it is appropriate to apply SMR to a patient. Do we rely on neck/back pain, mechanism of injury, or age as guiding factors? Do existing health conditions play a role in making the decision to collar a patient? Several standards have been developed to address the issue, but none has truly hit the mark as of yet. The Canadian C-Spine clearance rule is overcomplicated, the NEXUS spine rule is not widely used, and the Provincial SMR protocol is reviewed often. There is a degree of discretion on the part of the paramedic, and the patient in applying SMR, but aim to clarify current Ontario protocols for the reader. The regional SMR rule may be different for you, and this is in no way medical advice. Adhere to local protocols.
When do we need to consider SMR application?
The Provincial standard in Ontario identifies the need for spinal motion restriction in several circumstances including:
-Sports accidents
-Trauma associated with neck or back pain
-Diving accidents
-Falls from height
-Pedestrians struck
-Lightening strikes
-Penetrating trauma to the head neck or torso
To simplify, any time a patient “could” have a spinal injury, we need t consider SMR.
How to we assess for SMR:
We need to apply a rigid cervical collar to any patient with a mechanism of injury suggestive of spinal injury, who meets the following criteria:
-Neck or back pain
-Spine tenderness
-Neurological signs or symptoms
-Altered LOA
-Suspected Drug/ETOH use
-Anatomical deformity of the spine
-Age >65 years of age including falls from standing
-High risk auto crash
-Axial load to the head
-Fall from height greater than 3 feet (5 stairs)
-Pedestrians struck
-Motorized ATV collisions
-Cyclist struck
Regarding penetrating trauma, we DON’T have to a apply SMR if the patient meets the following:
-No neck or back pain
-No spine tenderness
-No neurological signs or symptoms
-No altered LOA
-No suspected drug/ETOH use
-No anatomic deformity of the spine
So what counts as SMR?
Heres where it gets interesting. We know we can apply a collar in MOST cases, however we may not be able to in some. For example a patient with a clavicle fracture, or a pediatric patient with a small neck may not appropriately fit a collar in any comfortable or practical manner. Additionally, a TRAUMATIC VSA should technically have SMR in place, however this may not be practical in the context of resuscitation. SMR does not simply refer to the use of a collar. Manual maneuvers, towel rolls, head blocks, and knee stabilization during ventilation all count as SMR. That being said there are some NO-NO’s regarding SMR. DO NOT walk the patient, or elevate the head of the stretcher beyond 30 degrees. Do not sit the patient unless there is no other viable means of extrication (ie:stair chair). Scoop stretchers, and backboards are the most appropriate means of moving these patients, although some situations may require pole canvas, manta tarps, or sheet lifts. Whatever you do, simply ensure that you are minimizing spinal movement and documenting your thought process and the circumstances of the lift. There are situations where life comes before limb, and deviation from protocols may be justified. Ensure you have followed your protocol to the fullest extent before considering improvisation.
So, thats SMR, in the simplest explanation I can come up with today. Cheers.
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