The vortex- approach to the difficult airway is a cognitive aid, illustrated and published by an australian anesthesist named Nicholas Chrimes and his colleague Peter Fritz from Melburne in 2013 (http://www.vortexapproach.com/Vortex_Approach/Vortex.html).
The congeniality of the vortex approach is it’s focus on alveolar oxygen delivery and the imperative progress in airway- management in case of failure. The choise of airway tool is made by the provider, depending on the circumstances and training. You have three attempts for each of three non-surgical airway techniques. These techniques represent the anatomic levels of airway access as extraglottic like face- mask, supraglottic like laryngeal- mask and transglottic like endotracheal intubation. Goal is to provide one “best” attempt. After each attempt is to consider, what to change in the management to succeed. No try should be done without an improvement. If there is no prove of oxygen delivery after these attempts it’s committed to proceed an emergency surgical airway, even if there is no desaturation happened jet. Prove of alveolar oxygenation is done indirectly by confirmation of etCO2. In the vortex this is symbolized by the green border. The blue funnel stands for the apnoeic time when no oxygen flow is established.
The induction of anesthesia is the start of a controlled resuscitation.
In vortex words you jump of the green zone into the blue funnel and the goal is to reach the green zone again, without harming the patient. If you can’t deliver oxygen to the alveoli, you will circle in the blue funnel to the left side or the right side until you drop out of the open end. Then it’s time for a emergency surgical airway.
I like to see the vortex as a cornucopia of airway- tools. In a vortex you can lose control and get disorientated. But as an airway- manager you have to keep the mind of a resuscitationist and you have to control the situation. So you stay better outside of the airway- tornado and grab the right tool for the right moment out of those tools, which are available in your environment (and reach). Some education and training is required to chose the tool wisely. Managing the vortex is not a happy- meal for airway- rookies. The surprise would be unsatisfactory. If you are trained to manage an airway, the idea of the vortex approach opens up your mind. There are no instructions which tool to take. The only rule is to reassess permanently and not to repeat the noneffective procedures.
I love the vortex because of it’s 3D- structured design and logic, with what a very complex procedure is imaged in a very simple manner. I advice to take the vortex as a cornucopia with plenty of airway donations to enrich the professional habit of airway- managers.
Clincal use of the Vortex Approach is reported in a letter to the British Journal of Anaesthesia Br. J. Anaesth. (2014) 112 (4): 773-774
Yes you can make it happen: Travel and Emergency Medicine. DEM 2013 at Cuba was such an event I want to talk about. The conference was promoted as “A Conference with a Difference” and really, it was a very special conference.
No advertisement of big Pharma.
No industrial exhibition.
Familiar and relaxing ambiance.
Lectures of heros of emergency medicine.
Intercultural excange with dozens of local cuban doctors.
All this exellent organized.
For me it started wit a big bang: Welcome drinks at Hotel National de Cuba, I took my Mojito and stand shy at a round table don’t knowing anybody. Then I mentioned the lady in front of mine and read her name: Jeanne Lenzer. “Hello, are you the Jeanne Lenzer, who published “Why we can’t trust clinical guidelines” at BMJ three month ago?” Yes, of course. Incredible. For me it was like meeting Laura Poitras on the streets of Berlin. Next one who I met, was my twitterfriend Amy from Australia. Social Media makes the world go small. I was happy. Further on I got introduced to Jerry Hoffman. As a german anesthesist in emergency medicine, where we don’t have the speciality of EM I didn’t realise at this moment, what was going on. But I enjoied the peaceful, open and friendly spirit of all participants, which continued during the whole conference. Also I learned to know a lot of emergency physicians from Wollongong near Sydney :)
We had scientific lectures of Judith Tintinalli, Joe Lex and Hall Haywood which were great. The outstanding lectures were in my opinion the political ones about the cuban medical system and the consequences of the US blockade on Cuba, as well as those about international projects from all over Latin America and Africa.
Did you know, that Cuba had to construct an unterwater- line to Venezuela to get internet access? That no US- products are avilable because of the embargo? That even the Worldbank is not allowed to give credits? And despite this, cubans live longer and the childhood mortality is lower than in the USA. Cuba exports medicine. Most of foreign doctors helping at Haiti are Cuban doctors. More than 30.000 patients from Latin America got operated at their eyes for free at Cuba. Tourist hotels were shut down to host these patients. Medical access is for free for all Cubans.
We learned to know a new structured approach in obstetrics in developing countries as ALSO, which is getting implemented at Mexico. There are projects of the Global Emergency Care Collaborative at Uganda to build up Emergency Medicine. Later on we were invited to look into our inside. What means to be a professional? How much are we influenced by advertisement and little gifts!? Did you know that industry recruits primarily Cheerleaders as pharmaceutic promoters? And everyone thinks oneself is independent in behavior, but others are not.
Apart of the conference we enjoied Havana, visiting the Museo de la Revolution, full of devotional objects of the rebells from 1959 like blood soaked shirts and pistols of Fidel and Che. We checked out Daiquiris at Hemingway’s Bar and cuban rum at the Gala Dinner in front of the old Cathedral of old Havana. Not forgetting the incredible taxi-rides in Oldtimers you weren’t allowed to touch in the western world. When the conference was over, I stayed tree more days and did a one-day-trip to Vinales to support the lokal agriculture brigardes testing their tabacco products. Spending some time at Playa del Este was no mistake neither.
Cuba is a poor country but worth while to visit, even if there is no medical event held.
The whole conference was origanised by Mark Newcombe and Lee Fineberg. They did a great job.
So I can strongly recommend to participate for DevelopingEM 2014 going to be held at Salvador de Bahia. http://www.developingem.com/
See you there
Im Rahmen des Vorbereitungskurses für die Kenntnisstandsprüfung für Nicht-EU-Ausländer habe ich einen Crashkurs Notfallmedizin an der Charité International Academy abgehalten und stelle die Dias online.
viel Spaß beim Lesen und viel Erfolg bei der Kenntnisstandsprüfung!
Greg Lemonde won 1989 Tour de France after introducing aerodynamic handlebars as a new technic to traditional cycling. Like these handlebars, which were used in Triathlon before, the thenar eminence grip for better bag ventilation introduced by emergency physicians will revolutionary change the approach to BMV in anesthesia and emergency Medicine.
See also: How to Overcome Difficult-Bag-Mask-Ventilation: Recents Approaches
airway management set free of algorithm and yes / no decision. a new approach to oxygenation and avoiding hypoxemia. has to be proven in reality – but sets free the mind. i like it…
very interesting discussion with the authors…
and the original: