Sonographisch gestützte Identifikation des Ligamentum conicum in der Kopf-Hals-Ultraschalllehre

Zusammenfassung

Hintergrund Verlegungen der oberen Atemwege stellen akute Notfälle dar. Ultima Ratio zur Sicherung der Atemwege ist die Durchführung einer Koniotomie nach Identifizierung des Lig. conicum. Hier kann die Sonografie unterstützen. Ziel dieser Studie war die Etablierung eines Trainings zur Vermittlung dieser Kompetenzen.

Material Methoden Das Training bestand aus einer theoretischen Schulung mit anschließender Videopräsentation (je 10min) sowie einem praktischen Training (45min). Zur Messung der Vorerfahrungen, der Zufriedenheit mit dem Training sowie des subjektiven und objektiven Kompetenzlevels wurden vor (T1) und nach (T2) dem Training Evaluationen bearbeitet. Zu T2 wurde zudem eine praktische Prüfung von n=113 Teilnehmenden (TN) absolviert. Die Ergebnisse der praktischen Prüfung wurden durch einen standardisierten Bogen dokumentiert.

Ergebnisse Der größte Teil der TN hatte weder eine Koniotomie gesehen (64,6%) noch eigenständig durchgeführt (79,6%). In der subjektiven Kompetenzeinschätzung konnte eine signifikante Verbesserung (T1 zu T2) gemessen werden (p<0,001). Das Trainingsprogramm wurde in allen abgefragten Items positiv bewertet. In den praktischen Prüfungen erreichten die TN durchschnittlich 89,2% der möglichen Punkte und benötigten für die Identifizierung des Lig. conicum im Mittelwert 101±23 Sekunden.

Schlussfolgerung Strukturiertes Training zur sonografischen Identifizierung des Lig. conicum führt bereits in kurzer Zeit zu einer deutlichen Verbesserung der subjektiven Kompetenzen sowie zu einem hohen objektiven Kompetenzlevel. Zukünftig sollten solche Trainingsprogramme standardisiert in der Kopf-Hals-Ultraschallausbildung etabliert werden.

Abstract

Objective Upper airway obstructions are usually acute emergencies. Coniotomy is the last option to secure the airway and can be supported by sonography. The aim of this study was to establish a training program to teach these skills.

Material and methods The training consisted of theoretical training with an additional video presentation (10 minutes each) and practical training (45 minutes). Evaluations were completed before (T1) and after (T2) the training to measure prior experience and satisfaction with the training as well as subjective and objective competence levels. At T2, a practical test was also completed by n=113 participants. A standardized evaluation form was used to document the results of the practical test.

Results A large proportion of the participants had neither seen a coniotomy (64.6%) nor performed one independently (79.6%). Significant improvement (T1 to T2) was measured with regard to the subjective assessment of competence (p<0.001). The training received positive ratings for all items tested (scale ranges 1–2). During practical tests, the participants achieved an average of 89.2% of the possible points and needed a mean of 101 ±23 seconds to identify the conic ligament.

Conclusion Structured training for sonographic identification of the conic ligament leads to significant improvement in the subjective assessment of competence and a high objective competence level in a short period of time. This type of training should be standardized in head and neck ultrasound training in the future.

Schlüsselwörter

Kopf-Hals-Sonographie - Atemwegsmanagement - Ultraschallausbildung - Koniotomie - Ligamentum conicum - Ausbildung - ultraschallgestützte Interventionen - coniotomy

Keywords

Direct observation of procedural skills (DOPS) - Head and neck ultrasonography - airway management - ultrasound training - ultrasound-guided interventions - direct observation of procedural skills (DOPS)

Publication History

Received: 22 December 2023

Accepted after revision: 25 March 2024

Article published online:
03 June 2024

• Literatur

• 1 Piepho T, Kriege M, Byhahn C. et al. S1 Leitlinie Atemwegsmanagement 2023. AWMF online. 2023
• 2 Apfelbaum JL, Hagberg CA, Connis RT. et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022; 136: 31-81 DOI: 10.1097/aln.0000000000004002. (PMID: 34762729)
• 3 Kornas RL, Owyang CG, Sakles JC. et al. Evaluation and Management of the Physiologically Difficult Airway: Consensus Recommendations From Society for Airway Management. Anesth Analg 2021; 132: 395-405 DOI: 10.1213/ane.0000000000005233.
• 4 Law JA, Duggan LV, Asselin M. et al. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient. Can J Anaesth 2021; 68: 1373-1404 DOI: 10.1007/s12630-021-02007-0. (PMID: 34143394)
• 5 Mutzbauer TS, Keul W, Bernhard M. et al. Invasive techniques in emergency medicine. IV. Cricothyrotomy in emergency situations. Anaesthesist 2005; 54: 145-154 DOI: 10.1007/s00101-004-0768-z. (PMID: 15654613)
• 6 Ruppen W, Besmer I, Schlegel C. et al. Notfallkoniotomie bei oberer Atemwegsobstruktion infolge Epiglottitis beim Erwachsenen. 2000
• 7 Walls RM. Cricothyroidotomy. Emerg Med Clin North Am 1988; 6: 725-736 (PMID: 3056708)
• 8 Aziz S, Foster E, Lockey DJ. et al. Emergency scalpel cricothyroidotomy use in a prehospital trauma service: a 20-year review. Emerg Med J 2021; 38: 349-354 DOI: 10.1136/emermed-2020-210305. (PMID: 33597217)
• 9 Heymans F, Feigl G, Graber S. et al. Emergency Cricothyrotomy Performed by Surgical Airway-naive Medical Personnel: A Randomized Crossover Study in Cadavers Comparing Three Commonly Used Techniques. Anesthesiology 2016; 125: 295-303 DOI: 10.1097/aln.0000000000001196. (PMID: 27275669)
• 10 Chrisman L, King W, Wimble K. et al. Surgicric 2: A comparative bench study with two established emergency cricothyroidotomy techniques in a porcine model. Br J Anaesth 2016; 117: 236-242 DOI: 10.1093/bja/aew174.
• 11 Poole O, Vargo M, Zhang J. et al. A comparison of three techniques for cricothyrotomy on a manikin. Can J Respir Ther 2017; 53: 29-32 (PMID: 30996627)
• 12 Nakstad AR, Bredmose PP, Sandberg M. Comparison of a percutaneous device and the bougie-assisted surgical technique for emergency cricothyrotomy: an experimental study on a porcine model performed by air ambulance anaesthesiologists. Scand J Trauma Resusc Emerg Med 2013; 21: 59 DOI: 10.1186/1757-7241-21-59. (PMID: 23890359)
• 13 Andresen ÅEL, Kramer-Johansen J, Kristiansen T. Percutaneous vs surgical emergency cricothyroidotomy: An experimental randomized crossover study on an animal-larynx model. Acta Anaesthesiol Scand 2019; 63: 1306-1312 DOI: 10.1111/aas.13447. (PMID: 31287154)
• 14 King W, Teare J, Vandrevala T. et al. Evaluation of a novel Surgicric cricothyroidotomy device for emergency tracheal access in a porcine model. Anaesthesia 2016; 71: 177-184 DOI: 10.1111/anae.13275. (PMID: 26572240)
• 15 Kleindienst R. Memorix Notfallmedizin. In: Müller S. Memorix Notfallmedizin. Stuttgart: Georg Thieme Verlag KG; 2017. DOI: 10.1055/b-0041-181292
• 16 Chang JE, Kim H, Won D. et al. Comparison of the Conventional Downward and Modified Upward Laryngeal Handshake Techniques to Identify the Cricothyroid Membrane: A Randomized, Comparative Study. Anesth Analg 2021; 133: 1288-1295 DOI: 10.1213/ane.0000000000005744. (PMID: 34517392)
• 17 Hung KC, Chen IW, Lin CM. et al. Comparison between ultrasound-guided and digital palpation techniques for identification of the cricothyroid membrane: a meta-analysis. Br J Anaesth 2021; 126: e9-e11 DOI: 10.1016/j.bja.2020.08.012.
• 18 Campbell M, Shanahan H, Ash S. et al. The accuracy of locating the cricothyroid membrane by palpation – an intergender study. BMC Anesthesiol 2014; 14: 108 DOI: 10.1186/1471-2253-14-108. (PMID: 25844061)
• 19 Kristensen MS, Teoh WH, Rudolph SS. Ultrasonographic identification of the cricothyroid membrane: best evidence, techniques, and clinical impact. Br J Anaesth 2016; 117 (Suppl. 01) i39-i48 DOI: 10.1093/bja/aew176. (PMID: 27432055)
• 20 Kristensen MS, Teoh WH. Ultrasound identification of the cricothyroid membrane: the new standard in preparing for front-of-neck airway access. Br J Anaesth 2021; 126: 22-27 DOI: 10.1016/j.bja.2020.10.004. (PMID: 33131758)
• 21 Siddiqui N, Yu E, Boulis S. et al. Ultrasound Is Superior to Palpation in Identifying the Cricothyroid Membrane in Subjects with Poorly Defined Neck Landmarks: A Randomized Clinical Trial. Anesthesiology 2018; 129: 1132-1139 DOI: 10.1097/aln.0000000000002454.
• 22 Siddiqui N, Arzola C, Friedman Z. et al. Ultrasound Improves Cricothyrotomy Success in Cadavers with Poorly Defined Neck Anatomy: A Randomized Control Trial. Anesthesiology 2015; 123: 1033-1041 DOI: 10.1097/aln.0000000000000848.
• 23 Bair AE, Panacek EA, Wisner DH. et al. Cricothyrotomy: a 5-year experience at one institution. J Emerg Med 2003; 24: 151-156 DOI: 10.1016/s0736-4679(02)00715-1. (PMID: 12609644)
• 24 Shetty K, Nayyar V, Stachowski E. et al. Training for cricothyroidotomy. Anaesth Intensive Care 2013; 41: 623-630 DOI: 10.1177/0310057X1304100508. (PMID: 23977914)
• 25 Andresen Å EL, Kramer-Johansen J, Kristiansen T. Emergency cricothyroidotomy in difficult airway simulation – a national observational study of Air Ambulance crew performance. BMC Emerg Med 2022; 22: 64 DOI: 10.1186/s12873-022-00624-6. (PMID: 35397493)
• 26 You-Ten KE, Wong DT, Ye XY. et al. Practice of Ultrasound-Guided Palpation of Neck Landmarks Improves Accuracy of External Palpation of the Cricothyroid Membrane. Anesth Analg 2018; 127: 1377-1382 DOI: 10.1213/ane.0000000000003604. (PMID: 29958219)
• 27 Kristensen MS, Teoh WH, Rudolph SS. et al. Structured approach to ultrasound-guided identification of the cricothyroid membrane: a randomized comparison with the palpation method in the morbidly obese. Br J Anaesth 2015; 114: 1003-1004 DOI: 10.1093/bja/aev123.
• 28 Kristensen MS, Teoh WH, Rudolph SS. et al. A randomised cross-over comparison of the transverse and longitudinal techniques for ultrasound-guided identification of the cricothyroid membrane in morbidly obese subjects. Anaesthesia 2016; 71: 675-683 DOI: 10.1111/anae.13465. (PMID: 27037981)
• 29 Oliveira KF, Arzola C, Ye XY. et al. Determining the amount of training needed for competency of anesthesia trainees in ultrasonographic identification of the cricothyroid membrane. BMC Anesthesiol 2017; 17: 74 DOI: 10.1186/s12871-017-0366-7. (PMID: 28577552)
• 30 Yıldız G, Göksu E, Şenfer A. et al. Comparison of ultrasonography and surface landmarks in detecting the localization for cricothyroidotomy. Am J Emerg Med 2016; 34: 254-256 DOI: 10.1016/j.ajem.2015.10.054. (PMID: 26614580)
• 31 Barbe N, Martin P, Pascal J. et al. Locating the cricothyroid membrane in learning phase: value of ultrasonography?. Ann Fr Anesth Reanim 2014; 33: 163-166 DOI: 10.1016/j.annfar.2014.01.006. (PMID: 24582109)
• 32 von Elm E, Altmann DG, Egger M. et al. Das Strengthening the Reporting of Observational Studies in Epidemiology (STROBE-) Statement. Der Internist 2008; 49: 688-693 DOI: 10.1007/s00108-008-2138-4.
• 33 Deutsche Gesellschaft für Ultraschall in der Medizin e.V. Kurscurriculum der Sektion Kopf-Hals. Berlin:Deutsche Gesellschaft für Ultraschall in der Medizin. 2015 Accessed October 15, 2023 at: https://www.degum.de/fileadmin/dokumente/sektionen/kopf-hals/KPF_2015__Kurscurriculum_2015–05–18.pdf
• 34 Höhne E, Recker F, Dietrich CF. et al. Assessment Methods in Medical Ultrasound Education. Front Med (Lausanne) 2022; 9: 871957 DOI: 10.3389/fmed.2022.871957. (PMID: 35755059)
• 35 Austin DR, Chang MG, Bittner EA. Use of Handheld Point-of-Care Ultrasound in Emergency Airway Management. Chest 2021; 159: 1155-1165 DOI: 10.1016/j.chest.2020.09.083. (PMID: 32971075)
• 36 Nielsen MB, Cantisani V, Sidhu PS. et al. The Use of Handheld Ultrasound Devices – An EFSUMB Position Paper. Ultraschall Med 2019; 40: e1 DOI: 10.1055/a-0881-5251. (PMID: 30577046)
• 37 Weimer JM, Rink M, Müller L. et al. Development and Integration of DOPS as Formative Tests in Head and Neck Ultrasound Education: Proof of Concept Study for Exploration of Perceptions. Diagnostics 2023; 13: 661 DOI: 10.3390/diagnostics13040661. (PMID: 36832149)
• 38 Kristensen MS. Ultrasonography in the management of the airway. Acta Anaesthesiol Scand 2011; 55: 1155-1173 DOI: 10.1111/j.1399-6576.2011.02518.x. (PMID: 22092121)
• 39 Deutsche Gesellschaft für Ultraschall in der Medizin e.V., Arbeitskreis Notfalsonographie. Accessed March 16, 2024 at: https://www.degum.de/fachgebiete/arbeitskreise/notfallsonografie/kurscurriculum/aufbaukurs.html