Trainer’s Manual - Pyng Medical FASTx... · This Trainer’s Manual is an essenti al component of the ... Connect the IV line, ... achieves mastery of psychomotor skills at a diﬀ

Trainer’s ManualOctober 2010 • www.pyng.com

© 2010 Pyng Medical Corp.

Pyng Medical Corp. www.pyng.com

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This Trainer’s Manual is an essenti al component of the FASTxTM Sternal Intraosseous Device educati on program. It contains the guidelines and informati on needed to eff ecti vely and effi ciently 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 educati on is paramount to ensure users achieve the highest levels of competence and confi dence with this lifesaving device.

Upon completi on of training students will be able to:

• Discuss the principles of intraosseous infusion

• List indicati ons and precauti ons for use of the FASTx

• Demonstrate safe and eff ecti ve use of the FASTx on a manikin and on training devices

• Explain and demonstrate the removal procedure for the FASTx

Pyng Medical Corp. is committ ed to “saving lives in seconds.” Comments and suggesti ons 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

TRAINER’S 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 objecti ves:

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

• Discuss the principles of intraosseous infusion

• List indicati ons and precauti ons for use of the FASTx

• Demonstrate safe and eff ecti ve 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

• Demonstrati on of FASTx (done in real-ti me)

• Step-by-step instructi on

• Skill practi ce to mastery

• Troubleshooti ng

• Evaluati on

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1. Have students recall their most recent cardiac arrest pati ents (codes) or most recent att empt to secure vascular access on a trauma casualty, and then ask these questi ons:

• Were you able to establish a patent IV?

• How many att empts were required?

• How long did this process take?

• Were chest compressions interrupted to start the IV?

• Would your pati ents benefi t from a faster, more reliable 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 setti ng. Transport is oft en delayed due to the diffi culty of inserti ng an IV in a moving vehicle.

2. Ask:

• Who is familiar with IO?

• Who has done IO before?

• How does IO work?

• Fluids and medicati ons infused into the bone marrow are drained into the vascular/circulatory system

• Who has performed this Sternal IO procedure on a pati ent?

Ask the student to share briefl y 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 eff ecti ve IO site (research shows fl uids and medicati ons reach the heart in 20-30 seconds) due to its close proximity to the heart and immediate absorpti on via internal mammary and azygos veins which empty directly into vena cava.

• Takes about 10 seconds to insert, less than 60 seconds for enti re procedure

• Does not interfere with other procedures and can be used concurrently (compressions, cricothyroidotomy, etc.)

• The locati on of the manubrium inserti on site high on the torso is oft en protected in trauma and military situati ons, and allows for emergency care from a single area near the pati ent’s head

• Can be inserted while transporti ng the pati ent in moving vehicles

• Fluids and medicati ons can be administered as you would for IV such as slow drip, boluses or pressure infuser

• Fluids and medicati ons 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 pati ent (penetrates 6mm into the manubrium) and staff

• Is quick to learn and easy to retain

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4. Pass around sample Infusion Tubes

• Note its fl exibility – this allows it to move with pati ent’s 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 batt ery-dependent, spring-loaded or pneumati c)

- Typically approximately 30 pounds into Simstern block

- Compare to typical CPR at approximately 90 pounds

- Actual force will vary depending on pati ent anatomy

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• Establish a sternal Intraosseous access route for fl uids or drugs

• For pati ents 12 years of age and older (adolescent to adult)

• Use whenever vascular access is required to facilitate emergency resuscitati on

• Can be left in place up to 24 hours

PRECAUTIONS/WARNINGS

• Trauma, infecti on or burns at inserti on site may preclude use

• Safety with very severe osteoporosis has not been proven

• Use in pati ents with recent sternotomy may prove less eff ecti ve

• The functi on of the device may be aff ected by fracture of the sternum or vascular injury which may compromise the integrity of the manubrium or its vascularizati on

• Inserti on in sites other than the manubrium may result in ineff ecti ve infusion and/or serious injury to the pati ent and are not approved

• Reuse of FASTx is not recommended due to the potenti al of cross-contaminati on, which may lead to serious injury or death. The FASTx is unlikely to functi on aft er use.

INDICATIONS

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1. Be sure the trainer, manikin and other equipment are ready for a speedy, fl awless procedure. Practi ce, practi ce, practi ce!

2. Invite someone to ti me it. Ask students to hold their questi ons unti l aft erward.

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

(ex1: “Here’s a 68 year-old male in cardiac arrest – we need to give drugs– I’m going to use the FASTx.”)

(ex2: “A 19 year-old male with bilateral lower extremity amputati on is in severe pain following tourniquet appli-cati on, hemorrhage and breathing have been controlled and the airway is secure. There are no visible or pal-pable peripheral veins because of signifi cant blood loss. I’m going to use the FASTx to secure vascular access.”)

4. Perform procedure.

5. Ask if this appears to be superior to numerous IV att empts, interrupti ng CPR and/or delaying transport.

DEMONSTRATION (Should be less than 1 minute)

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Pyng Medical Corp. www.pyng.com 7

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1. Expose sternum and locate sternal notch.

Tell students to place � nger in the sternal notch.

Have them pair up and do the same with their partner.

“This is the landmark – it’s easy to � nd on any pa ent. That’s where you place the Target Foot.”

2. Clean inser on site.

3. Remove the Adhesive Liner with the Locking Pin.

By pulling the Locking Pin off , the Adhesive Liner comes off too.

4. Stand at pa ent’s head or side, hold Introducer in dominant hand (or as comfortable).

Align the Target Foot notch with the pa ent’s sternal notch.

Hold Introducer perpendicular to manubrium and PAUSE. Consider the angle of the manubrium.

“This posi on ensures the Infusion Tube p 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 unti l you hear and feel Infusion Tube separate from Introducer.

Hold this positi on 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.

“Don’t stab, jab or twist – just push unti l 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 fl uid or medicati on, directly to the luer.

Clip the Strain Relief Hook on the Infusion Tube luer, to the Target Foot clip.

Opti on: (refer to your protocol)• Flush with fl uid to clear • Confi rm placement by aspirati on

8. Remove the liner from the Protecti ve Dome and apply the Dome over the Target Foot Infusion Site.

Use of the FASTx Dome is opti onal as the Target Foot also provides protecti on.

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Most medical providers will only need one or two trials to be totally competent and confi dent however, since everyone achieves mastery of psychomotor skills at a diff erent rate, be sure to plan for and allow plenty of ti me with this secti on.

Remember, once a medical provider feels comfortable with the FASTx, he/she is more likely to uti lize it.

HANDY TEACHING HINT:

Put the students who fi nish fi rst to work: they can quickly be taught to reset the trainer, turn the manikin’s disk, etc., which frees you up to work more closely with anyone who requires more instructi on. Reassure those who are struggling that, “I needed to practi ce that a few ti mes too.”

SKILL PRACTICE TO MASTERY (Time variable)

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Students are taught how to remove the FASTx because there’s a strong possibility the hospital staff may request assistance (or just reassurance) with the procedure.

1. Remove Protecti ve Dome from Target Foot.

2. Turn off the source of fl uid and medicati on and disconnect IV tubing.

3. Grasp Infusion Tube with fi ngers or clamp and pull perpendicular to the manubrium unti l enti re Infusion Tube (including metal ti p) emerges from the pati ent’s chest.

Note: pull in one conti nuous moti on (do not start/stop) unti l removed. Use the tube to pull, not the luer connecti on. It is normal for the tubing to stretch.

4. Peel off the 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 plasti c 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 of fl uid or medicati on. 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 opti onal as the Target Foot also provides protecti on.

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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 conti nuous moti on (do not start/stop) unti l removed. Use the tube to pull, not the luer connecti on. 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 unti l you hear and feel a ‘click’.

Note: You do not need to push hard to reset the FASTx Training Device. Use the short FASTx™ reset

tool (with orange on handle).

2. Carefully push down on the Needle Cover, and hold it down with your thumb and/or fi ngers 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 Anti -Buckle into the slot next to the Stylet with Infusion Tube.

Ensure to snap the Anti -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 respecti ve 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 aft er multi ple uses and may need to be replaced.

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1. Fluid or medicati on does not fl ow through IV line to site.

Flush to clear. If fl uid or medicati on does not fl ow even aft er fl ushing, infusion should be disconti nued and an alternati ve method of vascular access should be used.

2. Leakage at Inserti on Site (Extravasati on).

If excessive, use alternati ve method of vascular access.

3. First att empt to place FASTx fails.

Double check inserti on site, pati ent positi on, medic positi on, and try again with a new device. Be sure to re-mind students to save a device if the procedure/att empt with the FASTx was not successful (aft er protecti ng the sharps) for shipment back to Pyng for examinati on.

4. Removing enti re Infusion Tube

Pull perpendicular to the manubrium unti l the enti re Infusion Tube (including metal ti p) emerges from the pati ent’s chest.

Ensure to pull in one smooth conti nuous moti on (do not start/stop) unti l removed. Use the tube to pull, not the leur connecti on. It is normal for the tubing to stretch.

5. Introducer does not release.

Pull Introducer back, if Infusion Tube remains in pati ent, verify placement by aspirati ng 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 pati ent.

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 inserti on site

3. Remove Adhesive Liner and Locking Pin

4. Stand at pati ent’s head or side, hold Introducer in dominant hand (or as comfortable)

5. Align Target Foot with pati ents Sternal Notch

6. Press down completely with increasing force unti l 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 Protecti ve Dome and apply Dome over the Target Foot Infusion Site (use of the FASTx Dome is opti onal)

FASTx SKILLS EVALUATION

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1. Precauti ons/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. Preparati on of the site should include:

a) sterile draping

b) wash with soap and water

c) maintain asepti c technique throughout the procedure

d) no preparati on is recommended

4. Approved sites for the FASTx include:

a) manubrium of sternum

b) medial ti bia

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 fl oor

b) perpendicular to the manubrium

c) verti cal to the body of the sternum

d) aimed toward the heart

6. The Introducer is powered by:

a) pneumati c force

b) batt eries

c) springs

d) muscles

7. How should force be applied to the Introducer?

a) with a quick thrust

b) smooth, increasing unti l release

c) steady, decreasing for 5 seconds

d) any of the above is acceptable

8. The FASTx can be left in place for:

a) 24 hours

b) 1 hour

c) only unti l the pati ent 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 Ringer’s Lactate

d) all of the above

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1. Precauti ons 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. Preparati on of the site should include:

a) sterile draping

b) wash with soap and water

c) maintain asepti c technique throughout the procedure

d) no preparati on is recommended

4. Approved sites for the FASTx include:

a) manubrium of sternum

b) medial ti bia

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 fl oor

b) perpendicular to the manubrium

c) verti cal to the body of the sternum

d) aimed toward the heart

6. The Introducer is powered by:

a) pneumati c force

b) batt eries

c) springs

d) muscles

7. How should force be applied to the Introducer?

a) with a quick thrust

b) smooth, increasing unti l release

c) steady, decreasing for 5 seconds

d) any of the above is acceptable

8. The FASTx can be left in place for:

a) 24 hours

b) 1 hour

c) only unti l the pati ent 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 Ringer’s 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, Tiff any, 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 evaluati on of an adult intraosseous infusion system. Prehospital and Disaster Medicine 2006; 21(5), 329–335.

David L Johnson; Judy Findlay; Andrew J Macnab; Lark Susak: Cadaver testi ng 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: Elasti c Properti es of the Human Chest During Cardiopulmonary Resuscitati on. Criti cal Care Medicine 1983; 11(9):685-692.

REFERENCES

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Documents

Trainer’s Manual - Pyng Medical FASTx... · This Trainer’s Manual is an essenti al component of the ... Connect the IV line, ... achieves mastery of psychomotor skills at a diﬀ