Comparison of techniques for securing the endotracheal tube while wearing chemical, biological, radiological, or nuclear protection: a manikin study

The Impact of Personal Protection Equipment on Intubation Times

INTRODUCTION

Hazardous material (HAZMAT) protocols require health care providers to wear personal protective equipment (PPE) when caring for contaminated patients. Multiple levels of PPE exist (level D - level A), providing progressively more protection. Emergent endotracheal intubation (ETI) of victims can become complicated by the cumbersome nature of PPE.

STUDY OBJECTIVE

The null hypothesis was tested that there would be no difference in time to successful ETI between providers in different types of PPE.

METHODS

This randomized controlled trial assessed time to ETI with differing levels of PPE. Participants included 18 senior US Emergency Medicine (EM) residents and attendings, and nine US senior Anesthesiology residents. Each individual performed ETI on a mannequin (Laerdal SimMan Essential; Stavanger, Sweden) wearing the following levels of PPE: universal precautions (UP) controls (nitrile gloves and facemask with shield); partial level C (PC; rubber gloves and a passive air-purifying respirator [APR]); and complete level C (CC; passive APR with an anti-chemical suit). Primary outcome measures were the time in seconds (s) to successful intubation: Time 1 (T1) = inflation of the endotracheal tube (ETT) balloon; Time 2 (T2) = first ventilation. Data were reported as medians with Interquartile Ranges (IQR, 25%-75%) or percentages with 95% Confidence Intervals (95%, CI). Group comparisons were analyzed by Fisher's Exact Test or Kruskal-Wallis, as appropriate (alpha = 0.017 [three groups], two-tails). Sample size analysis was based upon the power of 80% to detect a difference of 10 seconds between groups at a P = .017; 27 subjects per group would be needed.

RESULTS

All 27 participants completed the study. At T1, there was no statistically significant difference (P = .27) among UP 18.0s (11.5s-19.0s), PC 21.0s (14.0s-23.5s), or CC 17.0s (13.5s-27.5s). For T2, there was also no significant (P = .25) differences among UP 24.0s (17.5s-27.0s), PC 26.0s (21.0s-32.0s), or CC 24.0s (19.5s-33.5s).

CONCLUSION

There were no statistically significant differences in time to balloon inflation or ventilation. Higher levels of PPE do not appear to increase time to ETI.

Impact of Clinician Personal Protective Equipment on Medical Device Use During Public Health Emergency: A Review

The aim of this systematic review is to evaluate the impact of personal protective equipment (PPE) on medical device use during public health emergency responses. We conducted a systematic literature search of peer-reviewed journals in PubMed, Web of Science, and EBSCO databases. Twenty-nine of 92 articles published between 1984 and 2015 met the inclusion criteria for the review. Although many medical device use impacts were reported, they predominantly fell into 3 categories: airway management, drug administration, and diagnostics and monitoring. Chemical, biological, radiological, and nuclear (CBRN)-PPE increased completion times for emergency clinical procedures by as much as 130% and first attempt failure rates by 35% (anesthetist) versus 55% (non-anesthetist). Effects of CBRN-PPE use depend on device, CBRN-PPE level, and clinician experience and training. Continuous clinical training of responders in CBRN-PPE and device modifications can improve safety and effectiveness of medical device use during public health emergency response.

Using the skin protective lotion IB1 as a substitute for chemical protective gloves

We aimed to evaluate the performance of medical personnel in using the IB1 topical protective lotion on their hands and wrists together with standard disposable medical gloves, compared to standard-issued medical chemical protective gloves. This randomized cross-over study included 144 medical personnel. Primary endpoints were time-to-completion of autoinjection; success rate, number of attempts, and time-to-achieve successful endotracheal intubation; time-to-achieve satisfactory tube fixation; time-to-draw and inject the content of an ampoule; and the total time-to-perform all medical procedures. Secondary endpoints included the subjective assessment of convenience to perform these four procedures with each protective measure. Mean time was significantly shorter using IB1 compared to chemical protective gloves for tube fixation, ampoule drawing, and the total time-to-perform all procedures (58.6±22.7 seconds vs. 71.7±29.7; 31.5±21.8 vs. 38.2±19.4; 137.4±56.1 vs. 162.5±63.6, respectively; P<.001 for all). For all medical procedures, the use of IB1 was reported as significantly more convenient than the use of chemical protective gloves (P<.001 for all comparisons). IB1 with standard medical gloves significantly shorten the time-to-perform medical procedures requiring fine motor dexterities and is subjectively more convenient than chemical protective gloves. IB1 should be considered as an appropriate alternative for medical teams in a chemical event.

Airway control in case of a mass toxicological event: superiority of second-generation supraglottic airway devices

INTRODUCTION

Early respiratory support and airway (AW) control with endotracheal intubation (ETI) are crucial in mass toxicology events and must be performed while wearing chemical personal protective equipment (C-PPE).

AIM

The aim of this study is to evaluate the efficiency of AW control by using second-generation supraglottic AW devices (SADs) as compared with ETI and first-generation SAD while wearing C-PPE.

METHODS

This is a randomized crossover trial involving 117 medical practitioners. Four AW management devices were examined: endotracheal tube, the first-generation SAD, laryngeal mask AW unique and 2 second-generation SAD, the laryngeal tube suction disposable, and supreme laryngeal mask AW (SLMA). Primary end point measured were success or failure, number of attempts, and time needed to achieve successful device insertion. Secondary end point was a subjective appraisal of the AW devices by study population.

RESULTS

More attempts were required to achieve AW control with endotracheal tube, with and without C-PPE (P<.001). Time to achieve AW control with ETI was, on average, 88% longer than required with other devices and improved with practice. The mean times to achieve an AW were longer when operators were equipped with C-PPE as compared with standard clothing. Subjectively, difficulty levels were significantly higher for ETI than for all other devices (P<.0001).

CONCLUSIONS

When compared with ETI, the use of SADs significantly shortened the time for AW control while wearing C-PPE. Second-generation SAD were superior to laryngeal mask AW unique. These finding suggest that SADs may be used in a mass toxicology event as a bridge, until definite AW control is achieved.

Mapping the use of simulation in prehospital care - a literature review

Background

High energy trauma is rare and, as a result, training of prehospital care providers often takes place during the real situation, with the patient as the object for the learning process. Such training could instead be carried out in the context of simulation, out of danger for both patients and personnel. The aim of this study was to provide an overview of the development and foci of research on simulation in prehospital care practice.

Methods

An integrative literature review were used. Articles based on quantitative as well as qualitative research methods were included, resulting in a comprehensive overview of existing published research. For published articles to be included in the review, the focus of the article had to be prehospital care providers, in prehospital settings. Furthermore, included articles must target interventions that were carried out in a simulation context.

Results

The volume of published research is distributed between 1984- 2012 and across the regions North America, Europe, Oceania, Asia and Middle East. The simulation methods used were manikins, films, images or paper, live actors, animals and virtual reality. The staff categories focused upon were paramedics, emergency medical technicians (EMTs), medical doctors (MDs), nurse and fire fighters. The main topics of published research on simulation with prehospital care providers included: Intubation, Trauma care, Cardiac Pulmonary Resuscitation (CPR), Ventilation and Triage.

Conclusion

Simulation were described as a positive training and education method for prehospital medical staff. It provides opportunities to train assessment, treatment and implementation of procedures and devices under realistic conditions. It is crucial that the staff are familiar with and trained on the identified topics, i.e., intubation, trauma care, CPR, ventilation and triage, which all, to a very large degree, constitute prehospital care. Simulation plays an integral role in this. The current state of prehospital care, which this review reveals, includes inadequate skills of prehospital staff regarding ventilation and CPR, on both children and adults, the lack of skills in paediatric resuscitation and the lack of knowledge in assessing and managing burns victims. These circumstances suggest critical areas for further training and research, at both local and global levels.