FASTx Trainers Manual(1)

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Trainers ManualApril 2010 www.pyng.com

2010 Pyng Medical Corp.


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Pyng Medical Corp. www.pyng.com

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This Trainers Manual is an essental component of the

FASTxTMSternal Intraosseous Device educaton program. It

contains the guidelines and informaton needed to

effectvely and efficiently teach emergency personnel how to

perform sternal intraosseous (IO) infusion using the FASTx.

Although the FASTx can be quickly and easily mastered, this

is a SPECIALIZED MEDICAL PROCEDURE WHICH SHOULD NOT

BE ATTEMPTED BY UNTRAINED PERSONNEL.

Quality educaton is paramount to ensure users achieve

the highest levels of competence and confidence with this

lifesaving device.

Upon completon of training students will be able to:

Discuss the principles of intraosseous infusion

List indicatons and precautons for use of the FASTx

Demonstrate safe and effectve use of the FASTx on a

manikin and on training devices

Explain and demonstrate the removal procedure for

the FASTx

Pyng Medical Corp. is commied to saving lives in seconds.

Comments and suggestons for improvement of training and

use of the FASTx are greatly appreciated.

Pyng Medical Corp.

7-13511 Crestwood Place

Richmond BC V6V 2E9 Canada

Phone:

604-303-7964

1-800-349-7964

TRAINERS MANUAL


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TABLE OF CONTENTS

INTRODUCTION .................................................................................1

INTRAOSSEOUS INFUSION AND FASTx...............................................2

INDICATIONS AND PRECAUTIONS.......................................................5

DEMONSTRATION .............................................................................. 6

STEP-BY-STEP INSTRUCTIONS ............................................................7

SKILL PRACTICE TO MASTERY ............................................................9

REMOVAL ........................................................................................10

FASTx TRAINING DEVICE INSTRUCTIONS..........................................11

TROUBLESHOOTING ........................................................................16

FASTx SKILLS EVALUATION .............................................................. 18

FASTx WRITTEN EVALUATION ......................................................... 19

REFERENCES.....................................................................................23

FASTx LESSON PLAN


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INTRODUCTION(5 minutes)

1. Introduce yourself and welcome students

2. Display course objectves:

By the end of this session you will be able to:

Discuss the principles of intraosseous infusion

List indicatons and precautons for use of the FASTx

Demonstrate safe and effectve use of the FASTx

on a manikin and training device

Explain and demonstrate the procedure for removal

of the FASTx

3. Provide overview of training:

Brief discussion of intraosseous infusion and

FASTx device

Demonstraton of FASTx (done in real-tme)

Step-by-step instructon

Skill pract

ce to mastery Troubleshootng

Evaluaton

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1. Have students recall their most recent cardiac arrest

patents (codes) or most recent aempt to secure

vascular access on a trauma casualty, and then ask

these questons:

Were you able to establish a patent IV?

How many aempts were required?

How long did this process take?

Were chest compressions interrupted to start

the IV?

Would your patents benefit from a faster, morereliable procedure?

Studies show it takes an average of 3-12 minutes to

establish an IV with failure rates of 10-40% in the

pre-hospital seng. Transport is ofen delayed due

to the difficulty of insertng an IV in a moving

vehicle.

2. Ask:

Who is familiar with IO?

Who has done IO before?

How does IO work?

Fluids and medicatons infused into the bone

marrow are drained into the vascular/circulatory

system

Who has performed this Sternal IO procedure on

a patent?

Ask the student to share briefly about the

experience.

INTRAOSSEOUS INFUSION AND FASTx(10-15 minutes)

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3. FASTx:

Provides vascular access comparable to a central

line

The manubrium is the most effectve IO site

(research shows fluids and medicatons reach the

heart in 20-30 seconds) due to its close proximity

to the heart and immediate absorpton via internal

mammary and azygos veins which empty directly

into vena cava.

Takes about 10 seconds to insert, less than

60 seconds for entre procedure

Does not interfere with other procedures and

can be used concurrently (compressions,

cricothyroidotomy, etc.)

The locaton of the manubrium inserton site

high on the torso is ofen protected in trauma

and military situatons, and allows for

emergency care from a single area near the

patents head

Can be inserted while transportng the patent in

moving vehicles

Fluids and medicatons can be administered as

you would for IV such as slow drip, boluses or

pressure infuser

Fluids and medicatons have been infused

into sternums at 30ml/min by 1m gravity drip,

120ml/min by pressurized source and 250 ml/

min by syringe (infusion rates)

Safe for patent (penetrates 6mm into themanubrium) and staff

Is quick to learn and easy to retain

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4. Pass around sample Infusion Tubes

Note its flexibility this allows it to move with

patents skin which prevents it from dislodging

Look at steel bone portal it will be inserted just

inside marrow space

Approximately 14 gauge inner diameter tubing

Approximately 17 gauge inner diameter portal

See page 3 for system infusion rates

5. Hold up Introducer

Releases at a depth of 6 mm from the surface of

manubrium to place in the marrow space

Muscle-powered

(not baery-dependent, spring-loaded or

pneumatc)

- Typically approximately 30 pounds into

Simstern block

- Compare to typical CPR at approximately

90 pounds

- Actual force will vary depending on patent

anatomy

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Establish a sternal Intraosseous access route for

fluids or drugs

For patents 12 years of age and older (adolescent

to adult)

Use whenever vascular access is required to

facilitate emergency resuscitaton

Can be lefin place up to 24 hours

PRECAUTIONS/WARNINGS

Trauma, infecton or burns at inserton site may

preclude use

Safety with very severe osteoporosis has not been

proven

Use in patents with recent sternotomy may prove

less effectve

The functon of the device may be affected by

fracture of the sternum or vascular injury which may

compromise the integrity of the manubrium or its

vascularizaton

Inserton in sites other than the manubrium may

result in ineffectve infusion and/or serious injury to

the patent and are not approved

Reuse of FASTx is not recommended due to the

potental of cross-contaminaton, which may lead to

serious injury or death. The FASTx is unlikely tofuncton afer use.

INDICATIONS

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1. Be sure the trainer, manikin and other equipment are

ready for a speedy, flawless procedure. Practce,

practce, practce!

2. Invite someone to tme it. Ask students to hold their

questons untl aferward.

3. Describe a real-life scenario with the manikin as

your patent

(ex1: Heres a 68 year-old male in cardiac arrest we

need to give drugs Im going to use the FASTx.)

(ex2: A 19 year-old male with bilateral lower extremity

amputaton is in severe pain following tourniquet appli-

caton, hemorrhage and breathing have been controlled

and the airway is secure. There are no visible or pal-

pable peripheral veins because of significant blood loss.

Im going to use the FASTx to secure vascular access.)

4. Perform procedure.

5. Ask if this appears to be superior to numerous IV

aempts, interruptng CPR and/or delaying transport.

DEMONSTRATION(Should be less than 1 minute)

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1. Expose sternum and locate sternal notch.

Tell students to place finger in the

sternal notch.

Have them pair up and do the same with their

partner.

This is the landmark its easy tofind on any

patent. Thats where you place the Target Foot.

2. Clean inserton site.

3. Remove the Adhesive Liner with the Locking Pin.

By pulling the Locking Pin off, the Adhesive Liner

comes offtoo.

4. Stand at patents head or side, hold Introducer in

dominant hand (or as comfortable).

Align the Target Foot notch with the patents

sternal notch.

Point out that this is over the midline and

perpendicular to the manubrium. Hold Introducer perpendicular to manubrium and

PAUSE. Consider the angle of the manubrium.

This positon ensures the Infusion Tubetp will be

inserted correctly.

Give everyone an opportunity to see what

perpendicular to the manubrium looks like and

also model NOT perpendicular.

STEP-BY-STEP INSTRUCTIONS(5-10 minutes)

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5. Press down completely with increasing force

untl you hear and feel Infusion Tube separate

from Introducer.

Hold this positon while you ask a couple of

students to describe the pressure you just used.

Note:The force used will be less with the FASTx

than with the FAST1 (for those with experience with

the FAST1). Please see step 5 on page 4.

Reinforce that it was smooth and steady.

Dont stab, jab or twist just push untl it

releases.

6. Withdraw the FASTx Sternal straight back while

holding down the Target Foot.

Support comes out with the Infusion Tube.

Discard the FASTx Sternal following local

contaminated sharps protocols.

7. Connect the IV line, or source of fluid or

medicaton, directly to the luer.

Clip the Strain Relief Hook on the Infusion Tube luer,

to the Target Foot clip.

Opton: (refer to your protocol)

Flush with fluid to clear

Confirm placement by aspiraton

8. Remove the liner from the Protectve Dome and

apply the Dome over the Target Foot Infusion Site.

Use of the FASTx Dome is optonal as the Target

Foot also provides protecton.

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Most medical providers will only need one or two trials to

be totally competent and confident however, since everyone

achieves mastery of psychomotor skills at a different rate, be

sure to plan for and allow plenty of tme with this secton.

Remember, once a medical provider feels comfortable with

the FASTx, he/she is more likely to utlize it.

HANDY TEACHING HINT:

Put the students who finish first to work: they can quickly

be taught to reset the trainer, turn the manikins disk, etc.,

which frees you up to work more closely with anyone who

requires more instructon. Reassure those who are struggling

that, I needed to practce that a few tmes too.

SKILL PRACTICE TO MASTERY(Time variable)

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Students are taught how to remove the FASTx because

theres a strong possibility the hospital staffmay

request assistance (or just reassurance) with the

procedure.

1. Remove Protectve Dome from Target Foot.

2. Turn offthe source of fluid and medicaton and

disconnect IV tubing.

3. Grasp Infusion Tube with fingers or clamp and pull

perpendicular to the manubrium untl entre

Infusion Tube (including metal tp) emerges from

the patents chest.

Note: pull in one contnuous moton (do not start/stop) untl removed. Use the tube to pull, not

the luer connecton. It is normal for the tubing to

stretch.

4. Peel offthe Target Foot and dress the site as per

standard protocol.

5. Discard Infusion Tube and Target Foot following

local contaminated sharps protocol.

REMOVAL of FASTx

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DEPLOYMENT

1. Remove the red Locking Pin from the Handle of

the FASTx Training Device.

Note: The FASTx Training Device does not have the

Adhesive Liner on the Target Foot.

2. Place the FASTx Training Device on a Simstern

block (yellow foam with plastc over white foam).

3. Ensure to push down completely to deploy the

FASTx Training Device into the Simstern block.

FASTx TRAINING DEVICE INSTRUCTIONS

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4. Pull the FASTx Training Device straight back while

holding down the Target Foot to separate the

Handle from the Infusion tube, which is now

inserted into the Simstern bone.

5. Connect the luer to the IV line or source offluid

or medicaton. Connect the Infusion Tube Strain

Relief Hook to the Target Foot.

6. Place the Dome over the Target Foot.

Note: Use of the FASTx Dome is optonal as the

Target Foot also provides protecton.

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7. To remove, grip as close to the lower end of the

Infusion Tube as possible.

Pull the Infusion Tube out from the Simstern

bone.

Note: Pull in one contnuous moton (do not start/

stop) untl removed. Use the tube to pull, not

the luer connecton. It is normal for the tubing to

stretch.

RESETTING THE FASTx TRAINING DEVICE

1. Reset the FASTx Training Device using the Reset

Tool.

Push the Reset Tool into the hole in the back of the

FASTx Handle. Push gently untl you hear and feel

a click.

Note: You do not need to push hard to reset the

FASTx Training Device.

2. Carefully push down on the Needle Cover, and

hold it down with your thumb and/or fingers to

prepare for the next step.

REMOVAL

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3. While holding down the Needle Cover, load the

Infusion Tube over the Stylet.

Note: Load the Infusion Tube with the Strain Relief

Hook towards the side of the Handle (90 degrees

from the FASTx logo).

4. Load the blue Ant-Buckle into the slot next to the

Stylet with Infusion Tube.

Ensure to snap the Ant-Buckle into place.

5. Snap the Target Foot back on the Needle Cover.

Ensure that the Target Foot notch is aligned with

the Handle notch.

6. Check alignment of the Target Foot on the Needle

Cover. Ensure each needle is in its respectve

separate hole. (If not, repeat step 5.) Pull Needle

Cover back out in place.

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7. Snap the red Locking Pin back in the Handle.

8. The FASTx Training Device is now ready for re-use.

Note: The FASTx Training Device needles will get

worn with re-use and the device may need to be

replaced.

The Infusion Tube will stretch afer multple uses

and may need to be replaced.

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1. Fluid or medicaton does not flow through IV line to site.

Flush to clear. If fluid or medicaton does not flow even

afer flushing, infusion should be discontnued and an

alternatve method of vascular access should be used.

2. Leakage at Inserton Site (Extravasaton).

If excessive, use alternatve method of vascular access.

3. First aempt to place FASTx fails.

Double check inserton site, patent positon, medic

positon, and try again with a new device. Be sure to re-

mind students to save a device if the procedure/aempt

with the FASTx was not successful (afer protectng the

sharps) for shipment back to Pyng for examinaton.

4. Removing entre Infusion Tube

Pull perpendicular to the manubrium untl the entreInfusion Tube (including metal tp) emerges from the

patents chest.

Ensure to pull in one smooth contnuous moton (do not

start/stop) untl removed. Use the tube to pull, not the

leur connecton. It is normal for the tubing to stretch.

5. Introducer does not release.

Pull Introducer back, if Infusion Tube remains in pat

ent,verify placement by aspiratng marrow, proceed with

use.

If marrow cannot be withdrawn, remove tube and insert

second FASTx.

TROUBLESHOOTING

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6. Introducer releases but Infusion Tube is not secured in

patent.

Use new FASTx.

7. Force is applied but Introducer does not release.

Without pulling back, ensure Introducer is perpendicular

to manubrium and force is being applied directly along

this line.

TROUBLESHOOTING

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1. Expose Sternum and locate Sternal Notch

2. Clean inserton site

3. Remove Adhesive Liner and Locking Pin

4. Stand at patents head or side, hold Introducer in

dominant hand (or as comfortable)

5. Align Target Foot with patents Sternal Notch

6. Press down completely with increasing force untl Infu-

sion Tube separates from Introducer

7. Withdraw FASTx straight back while holding down the

Target Foot

9. Discard the FASTx following local contaminated sharps

protocols

10. Connect the source of infusion to the luer

11. Clip the Strain Relief Hook on the Infusion Tube luer to

the Target Foot clip

12. Remove liner from Protectve Dome and apply Dome

over the Target Foot Infusion Site (use of the FASTx

Dome is optonal)

FASTx SKILLS EVALUATION

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1. Precautons/Warnings for the FASTx include:

a) previous sternotomy

b) compromised skin over site

c) severe osteoporosis

d) all of the above

2. The landmark for the Target Foot is the:

a) xiphoid process

b) sternal notch

c) subclavian ridge

d) Angle of Louis

3. Preparaton of the site should include:

a) sterile draping

b) wash with soap and water

c) maintain aseptc technique throughout the procedure

d) no preparaton is recommended

4. Approved sites for the FASTx include:

a) manubrium of sternum

b) medial tbia

c) proximal humerus

d) none of the above

FASTx WRITTEN EVALUATION

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5. Proper placement of the Infusion Tube can be ensured

by holding the Introducer:

a) at a 45-degree angle to the floor

b) perpendicular to the manubrium

c) vertcal to the body of the sternum

d) aimed toward the heart

6. The Introducer is powered by:

a) pneumatc force b) baeries

c) springs

d) muscles

7. How should force be applied to the Introducer?

a) with a quick thrust

b) smooth, increasing untl release

c) steady, decreasing for 5 seconds

d) any of the above is acceptable

8. The FASTx can be lefin place for:

a) 24 hours

b) 1 hour

c) only untl the patent is stabilized

d) 48 hours

9. Which of these can be delivered through the FASTx?

a) epinephrine

b) blood and blood products

c) normal saline or Ringers Lactate

d) all of the above

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1. Precautons for the FASTx include:

a) previous sternotomy

b) Compromised skin over site

c) severe osteoporosis

d) all of the above

2. The landmark for the Target Foot is the:

a) xiphoid process

b) sternal notch

c) subclavian ridge

d) Angle of Louis

3. Preparaton of the site should include:

a) sterile draping

b) wash with soap and water

c) maintain aseptc technique throughout the procedure

d) no preparaton is recommended

4. Approved sites for the FASTx include:

a) manubrium of sternum

b) medial tbia

c) proximal humerus

d) none of the above

ANSWER KEY

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5. Proper placement of the Infusion Tube can be ensured

by holding the Introducer:

a) at a 45-degree angle to the floor

b) perpendicular to the manubrium

c) vertcal to the body of the sternum

d) aimed toward the heart

6. The Introducer is powered by:

a) pneumatc force b) baeries

c) springs

d) muscles

7. How should force be applied to the Introducer?

a) with a quick thrust

b) smooth, increasing untl release

c) steady, decreasing for 5 seconds

d) any of the above is acceptable

8. The FASTx can be lefin place for:

a) 24 hours

b) 1 hour

c) only untl the patent is stabilized

d) 48 hours

9. Which of these can be delivered through the FASTx?

a) epinephrine

b) blood and blood products

c) normal saline or Ringers Lactate

d) all of the above

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Macnab, Andrew, Christenson, Jim, Findlay, Judy, Horwood,

Bruce, Johnson, David, Jones, Lanny, Phillips, Kelly, Pol-

lack, Charles, Robinson, David J., Rumball, Chris, Stair,

Tom, Tiffany, Brian and Whelan, Max : A new system for

sternal intraosseous infusion in adults. Prehospital

Emergency Care, 4:2, 173-177.

Findlay J, Johnson DL, Macnab AJ, MacDonald D, Shellborn

R, Susak L: Paramedic evaluaton of an adult

intraosseous infusion system. Prehospital and DisasterMedicine 2006; 21(5), 329335.

David L Johnson; Judy Findlay; Andrew J Macnab; Lark Susak:

Cadaver testng to validate design criteria of an adult

intraosseous infusion system. Military Medicine, March

2005; 170, 3; ProQuest Medical Library, 251-257.

Tsitlik JE et al: Elastc Propertes of the Human Chest During

Cardiopulmonary Resuscitaton. Critcal Care Medicine

1983; 11(9):685-692.

REFERENCES

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