The French team first-aid guidelines define that the torso straps of a KED should be fastened and secured in the following order: middle, low, top.

(This order seems to be the same in other countries, like Ireland, where the straps are placed in a slightly different order but secured in exact same order.)

Is this a result driven difference, or is there another rationale?


Kendrick Extrication Devices (KED) are used during extrications (Such as in automobiles) where space is limited, and a backboard can't be used safely.

Generally the mnemonic for securing the straps is My Baby Looks Hot Tonight.

  • Middle
  • Body (Torso)
  • Legs
  • Head
  • Top

It is to be noted, that recently in the US, the recommended order is My Baby Looks Totally Hot, recommending securing the Top before the Head.

Some of the reasons behind the order are that if the top is secured first, it creates uneven pressures (Think of a teeter totter, securing one end pushes the other away), and that securing one end does not prevent the other from sliding around. This is why torso and body are secured first.

According to the wiki entry, there is no peer reviewed support for preferred strap order:

An exhaustive search of the literature for peer reviewed scientific data regarding the positive or negative effects of application of the K.E.D. straps in any specific order found no results. It is likely such data does not exist, and that there are valid arguments on both sides of the issue. However, best practices indicate that the manufacturer's directions should be followed whenever using any piece of medical equipment. That being said, whenever the EMS professional is in doubt about a medical procedure it is advisable to contact your local medical director.

The most recent user manual that I could find is dated 2001, and it recommends the MBLHT order of strap securing. I did find a clarification memo from the State of Connecticut dated 2009, which states that they will be following the manufacturers recommendation:

Teaching and testing standards for long backboard and short spine board fixation sequences have always been clear. Criteria identified by the National Registry and observed by OEMS for several years have identified that the sequence for both long and short spinal immobilization devices should be in the following order:

 1. Torso fixation
 2. Leg fixation
 3. Head fixation

Many of the commonly used EMT-Basic and Paramedic texts have also identified this sequence as the standard. However, the Kendrick Extrication Device (KED) product manual suggests that the top torso strap be secured last, and after the head is secured. This apparent “exception to the rule” may have contributed to student, instructor and examiner confusion.

The Office contacted the Ferno –Washington, Inc., the manufacturers of the KED for clarification. Based on responses from Ferno spokespeople and effective immediately, the expected sequence of strap application in the Spinal Immobilization - Seated (if the KED is used) will be: Middle Strap, Lower Strap, Leg Straps, Head Immobilization and lastly the Top Strap, as described in the Ferno KED user manual.

However, these are all dating from up to 2009, and several forum postings from 2011 and later suggest that the order changed, and this is supported by the testing sheet currently in use by the National Registry for EMT's (NREMT) in the United States.

Secures the device to the patient’s torso
Evaluates torso fixation and adjusts as necessary
Evaluates and pads behind the patient’s head as necessary
Secures the patient’s head to the device

Further supporting this is Mosby's Paramedic Manual which also specifies the head being last (Step 4).

In the absence of evidence to the contrary (Such as a current user manual), I would state that the current recommendation in the United States is the MBLTH order, with the head being last. (It is to note that this is different than when I was certified EMS, in that the Top was the last strap, not the Head).

As far as the differences between different countries/districts, I would posit that they are following whatever protocol exists, and it either was not updated, or there was a feeling that no update needed to be made in this case. Hardly definitive, but this is the most that I could find that is in any way current enough to be relative.

  • 1
    "1. Torso fixation [mid-lo-hi], 2. Leg fixation; 3. Head fixation": this is exactly what we do here.
    – Shlublu
    Apr 20 '15 at 21:09
  • @Shlublu - I suspect that the user manual changed, or that there is some research that I didn't come across that indicates why it was changed. It's too universal for there not to be a reason, but I couldn't find a specific instance.
    – JohnP
    Apr 20 '15 at 21:11
  • I completely agree, there must be a reason. This is what made me ask
    – Shlublu
    Apr 20 '15 at 21:18

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