I recently got an email from the creators of a new approach to airway management
What these two gentlemen have crafted is a paradigm called the vortex approach. It is best represented by this diagram:
And here are versions with even more information:
I could write about the method, but to do it true justice, it is better to watch this video:
The Shock Trauma Algorithm
Now you folks know I am partial to a modified-version of the Shock Trauma Algorithm for Failed Airway Management. It is bar none the simplest, most effective (and validated) algo I have come across. Or at least it was until I started parsing the Vortex Approach. The reason is that the Vortex Approach encompasses the STC algorithm in a way that is universal to all specialties and settings.
Ebook
Nicholas and Peter wrote a free ebook about the concept, which is available in a number of formats.
Websites
They also have a website set up for the Vortex Approach as well as other projects on their Clinical CrEd Site. The Vortex site also has videos demonstrating the approach in action in both an emergency department and operating theater intubation.
Podcast
Minh Le Cong did an interview with the two of them on his PHARM podcast site that is definitely worth a listen.
Apps I Liked
I was sent free evaluation copies of 2 IOS applications:
- The IOS version of PressorDex from the EMRA folks. The pocket-book was good; the app is even better.
- An application listing the most important critical care papers and a short summary of their impact. The app is called ICU Trials by Sean Kane. The link goes to the free lite version; if you like it buy the full version.
Now on to the Wee…
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- EMCrit Wee – Webinar I Gave to Pulm/Crit Care Fellows on Avoiding Intubation and Initial Ventilation of COVID19 Patients - April 4, 2020
- EMCrit 269 – Rationing of Critical Care and Ventilators in COVID19 with Reub Strayer - March 31, 2020
- EMCrit Wee – Stop Kneejerk Intubation with the EMCrit Crew - March 30, 2020
Vortex.
It works.
It’s simple.
It beautiful.
Now I have to own up to a conflict of interests here; I’m in love with Peter Fritz.
We’ve worked together on and off for 14 years and I was lucky enough to attend one of his early Vortex training days while working for Adult Retrieval Victoria. (With @PreHospitalPro & friends.)
For me the crucial difference is that it’s not telling you how to do these things but when to move on; the lessons of NAP 4 in a visual cognitive aid.
It’s the best way to describe what I try to do.
I just use too many words doing it!
I want to have Vortex Hats made; like conical witches hats that we could all wear during Sim training with the Vortex diagram on the inside and outside.
There should perhaps always be a Vortex Hat somewhere in your department at all times! (May be even at home?)
Peter would probably let me do that but I’ll have to ask Nicholas.
(I’ve not spent time with Nicholas Chrimes but unlike @rfdsdoc I hope to spend an hour chatting with him over a glass of Pinot at a Mornington Peninsula Vineyard rather than 3 days of tweets!)
Take Care.
Doug (@TheTopEnd)
Damn! I want you to write all of my advertising copy; you have missed your calling. I want a VORTEX HAT; I WANT A VORTEX HAT!
Vortex Hat;
It’s going to go viral!
(or at least mycobacterial.)
Scott, I’m glad you have the fashion sense to see the potential of the Vortex hat.
I’ll try and explain it to Nicholas.
And I’ll spruik your stuff any day of the week just for the joy of it!
Hoorah!
Doug, definitely up for a chat over wine. Same style of catch up @emcrit & I indulged in in NYC! We all love @pzfritz. What exactly would the hats do??
The Vortex Hat. What does it actually do? 1. It makes you look extremely cool. 2. It makes you look like a complete idiot. 3. By having the vortex closer to the brain the concept will seep in across the skull and lives will be saved. (Studies suggest results vary with baldness.) 4. If its very sharp at the tip Minh Le Cong will fashion a surgical airway with it or at least do so with one of our Mannikins at the Royal Flying Doctor Service. The Vortex is a Cognitive aid. It’s a fantastic piece of work. It’s a 3 dimensional concept. I’m (humourously) proposing it for several reasons. By having it built in 3-D form it aids teaching the approach. It lends itself to this by its structurally simple design. I’d pop a lighthearted segment into a Vortex teaching day and have the group MAKE their own Vortex Hats. By drawing and colouring the Vortex and creating the hat they would process the design/concept in a totally different way; bringing in 3-D spatial awareness, hand eye co-ordination and basically a different set of wires in the brain. If the group dynamics permit wearing the hat during talks and… Read more »
Great pitch. You sold me! I’m in.
true indeed.
I dont think u can fashion the ASA Difficult airway algo into a hat
😉
Doug I think you make some really important points:
Firstly that the Vortex approach is goal rather than technique directed. This is part of what gives it its context independence. It also allows clinicians to use the techniques that work for them in the particular situation facing them which I think will improve adherence to the approach in a crisis.
Secondly, the comment you make that the Vortex describes what you already do (or at least think you SHOULD do – that’s not always what we end up doing under pressure!) when faced with an airway crisis, is a common one. I think it indicates again that the Vortex approach is simply prompting clinicians to move forward using their own familiar strategies rather than imposing specific techniques on them. It is simply facilitating clinicians to make the best of their own skills/expertise. Encouraging clinicians to use the techniques familiar/useful to them should make the approach easier to use and hopefully more successful.
The ability of the Vortex to concisely encapsulate the reasoning/approach of experienced staff to more junior staff also makes it a valuable teaching tool.
Hi Nick or Peter,
I love the versatility and conceptual approach of your technique, as you said it remains independent of context but rather skill and goal oriented. Question though :
1) Inspite of context independence, if you anticipate a difficult airaway – obese, hypoxic ( 02 90), pneumonia septic patient in which I find the DSI technique useful – how do I apply the vortex technique? Is it still applicable? or do I simply marry the two techniques ? Because if I cant intubate this patient after induction, and assuming the CPAP and high flow nasal prongs ( in DSI) is already considered the face mask in the vortex approach, should I then proceed to attempt LMA to buy time?
By this stage ( shit creek), I would prob have little faith that the LMA is gonna help but would need back up to go for the surgical airway instead.
Thanks very much!
kim ( perth)
ED/ ICU reg
Kim,
DSI and CPAP Preox all precede vortex. You enter the vortex after induction or after relaxant adminsitration in the case of DSI. Before then you remain in the green zone.
Hi Kim,
It is just as Scott said. You are in the GZ before you induce the patient and at any point after that where you can confirm alveolar oxygen delivery (AOD). Otherwise you are in the funnel of the Vortex. Our airway safety lines video (under AIRWAY at clinicalcred.com) might give you a clearer idea of how the NODESAT priniciples fit in with the Vortex.
In the specific scenario you describe therefore you would only have had an optimal attempt at ETT (upto 3 tries – but should be aiming to have best attempt at first try) & optimal attempts at FM & LMA (again upto 3 tries at each) are still available. I would think there is a significant likelihood that the LMA would be potentially helpful in establishing AOD in this situation – if only to prevent critical desaturation whilst you establish a more definitive, protected airway for this patient – either fibreoptically via the LMA or via an infra-glottic surgical approach.
Hi Nick and Scot,
thanks so much for the clarificant. I have been in theatre and applied in theatre without it really being realised it was the vortex approach. LMA didn’t work, so out, face mask with guedel, didn’t work so quickly we decided in seconds to intubate, and the same came be applied in ED. Only thing is 3 tries with ETT and LMA FM each seems a lot for me! I would certainly be doing what u say with fibreoptic, or C-mac with d blade, or ILMA if my LMA Is saving the day then, certainly fibreoptic or c mac would be best bet, and if not ready for someone to cut the neck.
Many thanks guys!
I love the approach
Kim
Thanks Kim. Agree re number of tries. 3 is a limit but is not mandatory to achieve an optimal attempt. Aim is to have an optimal attempt in as few tries as possible.
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Right, I’m expecting an EMCrit airway avalanche come July…
C
Touché, Monsieur Nickson.
Have we settled on what you’re giving up for #FOAM-lent?
Can the good Doctor go three months without airway? Tough, very tough.
we shall see…
The better question is can I go three months without airway from you! LOL
blame Nickson!
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