title: Impact of chemical, biological, radiation, and nuclear personal protective equipment on the performance of low- and high-dexterity airway and vascular access skills.
abstract: BACKGROUND
  Following CBRN incidents health care professionals will be required to care for critically ill patients within the warm zone, prior to decontamination, whilst wearing CBRN-PPE. The loss of fine-motor skills may adversely affect delivery of medical care.
  
  
  METHODS
  64 clinicians were recruited to perform, intubation, LMA placement, insertion of an IV cannula and IO needle whilst wearing CBRN-PPE. A fractional factorial design was employed, in which each of the 64 clinicians had two attempts at performing each skill whilst wearing CBRN-PPE and once unsuited according to a pre-specified sequence.
  
  
  METHODS
  The unsuited and suit data were analysed independently with the primary outcome being time taken to complete each skill whilst suited. Analysis was undertaken using STATA (V9.2).
  
  
  RESULTS
  Mean times differ considerably by skill (p<0.001). Overall, times to completion on attempt 2 were shorter than attempt 1 (p=0.045), though the reduction in time differed significantly by skill (p=0.004). LMA placement was on average completed nearly 45 s faster than intubation, and IO cannulation was nearly 90 s faster than IV cannulation. Whilst suited, 8% of intubation and 12% of intra-venous cannulation attempts were unsuccessful. Previous familiarity with CBRN-PPE did not improve performance (p=0.23). Professional groups differed significantly (p=0.009) with anaesthetists performing all skills faster than the other clinicians.
  
  
  CONCLUSIONS
  This study supports the concept of instigating airway and vascular access skills whilst wearing CBRN-PPE but challenges the sole reliance on 'high-dexterity skills'. Intubation is feasible but must be considered within the context of the incident as the LMA may offer a viable alternative. Intra-venous access prior to casualty decontamination is arguably a pointless skill and should be replaced with IO access.
authors.affiliation: Emergency Department Frimley Park Hospital, Camberley, Surrey, UK. nicholas.castle@ntlworld.com
authors.forename: Nicholas
authors.initials: N
authors.lastname: Castle
authors.forename: Robert
authors.initials: R
authors.lastname: Owen
authors.forename: Mark
authors.initials: M
authors.lastname: Hann
authors.forename: Simon
authors.initials: S
authors.lastname: Clark
authors.forename: David
authors.initials: D
authors.lastname: Reeves
authors.forename: Ian
authors.initials: I
authors.lastname: Gurney
mesh_terms: D016887:Cardiopulmonary Resuscitation / Q000379:methods / Q000592:standards*; D002406:Catheterization, Peripheral / Q000592:standards*; D004636:Emergency Service, Hospital / Q000592:standards*; D004867:Equipment Design; D005720:Gamma Rays; D015386:Hazardous Substances; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D011481:Protective Clothing; D015203:Reproducibility of Results; D012121:Respiration, Artificial / Q000592:standards*; D013647:Task Performance and Analysis; D014965:X-Rays
chemical_list: D015386:Hazardous Substances