Impact of Chemical, Biological, Radiation, and Nuclear Personal Protective Equipment on the performance of low- and high-dexterity airway and vascular access skills

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. Analysis: 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. Conclusion: 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.