Backing away from backboards

In 2013, the National Association of EMS Physicians (NAEMSP) and American College of Surgeons (ACS) issued a position statement on spinal precautions and the use of long backboards by Emergency Medical Services providers. The guidelines change the way suspected spinal injuries have been managed in trauma patients for the last 50 years. Instead of routinely using a rigid backboard and cervical collar during extrication and transport to help protect the spinal column, the position paper suggests using immobilization judiciously, and in many cases not at all.

Incremental changes in the guidelines have occurred since the 1990s, when a growing number of studies questioned the wisdom of spinal immobilization for all but the very small subset of patients at risk of unstable spine injuries. Eventually, it became clear that keeping most people on a backboard after they had been extricated not only didn't provide much benefit, but also could cause significant harm, including pain, compromised respiration and unnecessary radiological testing.

Rigid backboards are also a leading cause of pressure ulcers, especially among older adults with fragile skin. One study found early signs of pressure sores in healthy volunteers who spent just 30 minutes on a backboard.

Other studies have challenged the shaky science underlying spine immobilization, including the idea that prehospital emergency care can inadvertently damage the spinal cord or that patients who are immobilized are less likely to experience neurological damage than those who aren't. Neither, it turns out, is true.

The mounting evidence against routine use of backboards led to the new, evidence-based recommendations, which try to clarify previous guidelines and describe current best practices for prehospital providers. That includes which patients should never be on a backboard, which should be removed from it as quickly as possible — preferably before being transported — and which may need to stay on it.

The new guidelines: Cliff's Notes version

According to the NAEMSP-ACS position paper, immobilization on a backboard may be appropriate for patients who have:

  • Blunt trauma and altered level of consciousness
  • Spinal pain or tenderness
  • Neurological complaints, such as numbness or motor weakness
  • Spinal deformity
  • A high-energy mechanism of injury and who are also intoxicated, are unable to communicate or have a distracting injury

Immobilization isn't necessary for patients who have all of the following:

  • Normal level of consciousness — a Glasgow Coma Score of 15
  • No spinal tenderness or anatomic abnormality
  • No neurological findings or complaints
  • No intoxication or distracting injury

The guidelines apply to both adults and children, although the incidence of cervical spine injuries is lower in younger patients and the mechanism of injury often isn't as severe. Spinal precautions — cervical collar, secure fastening to the stretcher, minimal movement and transfers — are crucial for at-risk trauma patients of all ages, whether a backboard is used or not.

"Everybody is going to be conservative," says Scott P. Zietlow, M.D., a trauma surgeon at Mayo Clinic's campus in Minnesota. "We don't want to cause harm, so we will always err on the side of safety if there is any question about patients who don't seem to fit the criteria. These guidelines reflect the best current thinking, but there are always going to be exceptions — nothing is ever 100 percent. Still, the point is that most people don't need to be on a backboard."

Making it work

Dr. Zietlow says Mayo's ground and air medical transport services implemented the new recommendations in 2014, as did most hospital and prehospital providers in the south central and southeastern Minnesota trauma regions.

"We've been able to implement these changes in a timely fashion because we have such motivated people and a lot of experience," he says. "We've shared our experiences at the state trauma advisory council meetings, but participation in the guidelines is voluntary and not always easy for everyone to adopt. It takes a long time to change practices that have been around for decades. You can incorporate new practices into paramedic training programs, so you reach the new folks, but how do you bring everyone else up to speed?"

Dr. Zietlow answers his own question, saying making the changes stick requires an active medical director, high-quality educational programs, buy-in from providers and some way to measure whether guidelines are being adhered to.

"Change takes time in most aspects of medicine, not just the prehospital setting," he says. "But this is a team sport, and you have to get everyone to participate."

For more information

White C, et al. EMS spinal precautions and the use of the long backboard-Resource document to the Position Statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. Prehospital Emergency Care. 2014;18:306.