title: What is the optimal position of an intubator wearing CBRN-PPE when intubating on the floor: a manikin study.
abstract: BACKGROUND
  Prompt airway management following a CBRN incident is linked to improved patient survival. However, responding rescuers will have to wear CBRN-PPE and treat patients positioned on the floor which will adversely impact on intubation skill performance.
  
  
  METHODS
  48 final year paramedic students intubated manikin's positions in 4 different positions; on an ambulance trolley (60 cm of the floor), lying prone, kneeling and sitting. Each skill was performed twice once wearing CBRN-PPE and once in normal clothes. Intubating order was randomised.
  
  
  RESULTS
  Intubation performance when wearing standard clothing was similar in all four positions but this was not the case when intubation was performed while wearing CBRN-PPE. CBRN-PPE had a negative impact on intubation performance regardless of the position of the intubator. Intubation on the trolley while wearing CBRN-PPE was completed in 100% of attempts within 60s compared with 79.2% for kneeling, 75% for sitting and 43.8% for laying. After 120 s nearly 20% of intubation attempts using the kneeling and sitting position and nearly 40% of attempts with the intubator lying on the floor were still not completed. Intubation on an ambulance trolley, while wearing CBRN-PPE, was always successful compared with sitting (88.8%), kneeling (81.2%) and laying (62.5%).
  
  
  CONCLUSIONS
  This manikin-based study serves to reaffirm that CBRN-PPE has an adverse impact on intubation performance as well as identifying the negative impact of patient position on the performance of intubation within a CBRN environment. Elevating the patient off the floor, prior to intubation, could improve intubation success when wearing CBRN-PPE as well as potentially improving safety of the intubator. In the immediate phase of a CBRN incident, intubation attempts should be delayed until optimal intubating conditions are available or at least until the patient is removed from the floor. Use of and intermediate airway devices should be considered as a 'stop gap'.
authors.affiliation: Emergency Department Frimley Park Hospital, UK. Castle.nicholas@googlemail.com
authors.forename: Nick
authors.initials: N
authors.lastname: Castle
authors.forename: Yugan
authors.initials: Y
authors.lastname: Pillay
authors.forename: Neil
authors.initials: N
authors.lastname: Spencer
mesh_terms: D000059:Accidents; D000402:Airway Obstruction / Q000150:complications / Q000628:therapy; D018592:Cross-Over Studies; D006323:Heart Arrest / Q000209:etiology / Q000517:prevention & control*; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods*; D008348:Manikins; D056888:Patient Positioning / Q000379:methods*; D011482:Protective Devices / Q000592:standards*; D012131:Respiratory Insufficiency / Q000150:complications / Q000628:therapy