Arbeitsbereiche im Hochrisikobereich bedürfen einer klaren, strukturierten und konsistenten Kommunikation, um Informationsverluste möglichst gering zu halten. In der Notaufnahme mit Phasen hohen Patientenaufkommens und ungeplanten Belastungsspitzen kann es durch Notfallsituationen oder zeitgleiche Patientenaufnahmen und -Verlegungen zu Kommunikationsunterbrechungen kommen. Informationstransfers unter Zeitdruck und ggf. Ablenkung (z.B. während des Anschlusses von Monitoring) kann zu Kommunikationsdefiziten führen. Eine strukturierte Patientenübergabe nach dem SBAR- Konzept (Empfehlungen der DGAI und WHO) hat in wissenschaftlichen Untersuchungen im industriellen und medizinischen Kontext zu einer Reduzierung von Fehlern geführt, unerwartete Todesfälle reduziert und die Patientensicherheit erhöht. Dies ist auch das Ziel dieses strukturierten Übergabeprotokolls für die Notaufnahme.
Die strukturierte Patientenübergabe soll bei allen Transfers von Information zu einem Patienten immer nach dem gleichen Schema, dem SBAR- Konzept erfolgen. Diese Schnittstellen sind die Entgegenahme eines Patienten vom Rettungsdienst/ Notarzt, bei Visitenvorstellungen, bei der Fall- Präsentation gegenüber Konsilarien oder der Radiologie, bei Schichtwechseln und Übergaben an die Station. Das SBAR- Konzept beinhaltet vier Kernpunkte zu einem Patienten: Seine aktuelle Situation, der Hintergrund zu der Situation (Background), die Diagnostik und Therapie (Assessment) und der weitere Plan (recommendations) zur Patientenversorgung.
|S: Situation||Name, Alter, Art der Präsentation in der Notaufnahme (Selbstvorsteller/RTD/Notarzt), Leit-Symptom, Verdachtsdiagnose
|Anamnese (z.B. Unfallhergang), Befund der körperlichen Untersuchung, Vor- Medikation, Vor- Erkrankungen
|A: Assessment (Analysen und Behandlung)||ABCD- Kriterien, Vitalparameter, technische Untersuchungen (wie Labor, EKG, Röntgen, Sono, CT etc.) sowie erfolgte Therapie, Eingriffe oder Maßnahmen (Medikation, Gips, Konsil etc.)
|R: Recommendation (Empfehlungen/ Plan)||Plan zur Aufnahme/Entlassung, weitere Untersuchungen oder Konsile, therapeutischer Plan (med. Therapie, Elektrotherapie, CPAP etc.)
Allgemeine Regeln zur SBAR- Übergabe: Die Übergabe sollte in Anwesenheit aller beteiligten Personen erfolgen, um Wiederholungen zu vermeiden. Es sollte nur patientenspezifische, professionelle Kommunikation erfolgen („steriles Cockpit“, keine Privatgespräche, keine Unterbrechungen). Es spricht nur eine Person während der Übergabe. Der Anschluß an das Monitoring sollte bei stabilen Patienten erst nach der strukturierten Übergabe erfolgen (wie im Schockraum bei der Polytrauma- Übergabe). Kollegen sollten sich gegenseitig dazu anhalten, das Übergabe- Konzept einzuhalten (Gesprächsdisziplin).
Dossow V et al. DGAInfo: Strukturierte Patientenübergabe in der perioperativen Phase – Das SBAR- Konzept. Anästh Intensivmed 2016;57:88-90
Communication during patients hand-overs. WHO Patient Safety Solutions. Vol 1, solution 3/May 2007
Starmer AJ et al: Changes in medical errors after implementation of a handoff program. NEJM 2014;371:1803-12
De Meester K et al: SBAR improves nurse physician communication and reduces unexpected death: a pre and postintervention study. Resuscitation 2013;84:1192-6
Seit der Veröffentlichung der DGAI/BDA Empfehlungen zur prähospitalen Notfallnarkose (Bernhard M. et al. Handlungsempfehlung: Prähospitale Notfallnarkose beim Erwachsenen. Anästh Intensivmed 2015;56:317-335 ) und des prähospitalen Airwaymanagements (Timmermann T. et al. Handlungsempfehlung für das präklinische Atemwegsmanagement. Für Notärzte und Rettungsdienstpersonal. Anästh Intensivmed 2012;53:294-308) gibt es tragfähige Empfehlungen in Deutschland, an denen sich Notärzte orientieren können. Diese Empfehlungen sind aber immer noch sehr breit und diskutieren fast jedes nur verfügbare Medikament zur Narkose.
Hier soll der Versuch gemacht werden, eine einseitige, visualisierte SOP/Checkliste vorzustellen, die sinnvoll eine Handvoll Medikamente vorschlägt. Hierzu gehe ich auf einige Medikamente besonders ein, während ich andere, die ich nicht favorisiere, auch nicht diskutiere.
Ich bin der Meinung, daß Es-Ketamin ein ausgezeichnetes Hypnotikum und Analgetikum ist und zudem sehr gut geeignet für das Atemwegsmanagement bei instabilen Patienten ist. Ich kann mir Es-Ketamin als primäres Einleitungsmedikament für alle Patienten, außer bei Kardio-Patienten, vorstellen.
Als Dosierung würde ich die DGAI- Empfehlung mit Es-Ketamin 1,0 mg /kgKG unterstützen.
Für die Notfall- Narkose für Kardio- Patienten würde ich persönlich Etomidate präferieren. Da ich aber aus der Diskussion zur Nebenniereninsuffizienz weiß, daß Etomidate in vielen Abteilungen unerwünscht ist, halte ich es für nicht zielführend Pro- und Kontra- Argumente in epischer Breite auszutauschen. Aus diesem Grunde orientiere ich mich an der DGAI- Empfehlung und würde Midazolam 0,2 mg/kgKG als Einleitungshypnotikum für kardiologische Patienten zur Notfallnarkose unterstützen. (Natürlich ohne Ketamin).
Bei der Wahl des Relaxanz geht es um die Minimierung der Gefährdung des Patienten und der Schaffung optimaler Intubationsbedingungen. Es gibt viele gut Gründe für Succinylcholin, wie die große Erfahrung mit dem Medikament und die kurze Wirkdauer zeigen. Dabei ist aber nicht das unerwünschte Wirkungsprofil mit Hyperkaliämie, Herzrhythmusstörungen bis zur Asystolie und Maligne Hyperthermie zu vernachlässigen.
Mit Rocuronium steht ein effektives und sicheres Medikament zur RSI zur Verfügung. Als Antagonist wird Sugammadex in fast allen Klinken auf der ITS, im OP und/oder im Schockraum vorgehalten. Die Gabe von Succinylcholin ist innerklinisch zur RSI unter diesen Umständen fast schon schwer zu rechtfertigen. Bei richtiger Indikationsstellung zur prähospitalen Notfallnarkose fällt außerdem der einzige Vorteil von Succi (nämlich die kurze Wirkdauer mit der vermeintlichen Möglichkeit zur Rückkehr zur Spontanatmung bei CV-CI-Situation) weg. Eine Empfehlung der DGAI zur Rückkehr zur Spontanatmung konnte ich in den Handlungsempfehlungen für das präklinische Atemwegsmanagement nicht finden. Des Weiteren erlauben die Daten der Lyon et al. (Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia Critical Care 2015, 19:134) für die Präklinik den Schluß zu, daß Rocuronium schnell und sicher optimale Intubationsbedingungen schafft. Darüber hinaus scheint Rocuronium ein besseres Sicherheitsprofil zu bieten, da die Apnoezeit länger sein könnte (Taha SK et al. Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction. Anaesthesia. 2010 Apr;65(4):358-61).
Ich würde die Wahl von Rocuronium 1,0 mg/kgKG (wie DGAI- Empfehlung) aus den oben genannten Gründen in der Präklinik und im Schockraum unterstützen.
Um diese Checkliste breit anwendbar zu machen, habe ich als Alternative des Weiteren Succinylcholin 1,0 mg/kgKG mit aufgenommen.
Was die Analgesie anbetrifft, würde ich auch die Empfehlung der DGAI mit Fentanyl 2 mcg/kgKG unterstützen.
Womit wir bei der einprägsamen Dosierung von 1-1-2 (Es-Ketamin 1 mg /kgKG + Rocuronium 1 mg/kgKG + Fentanyl 2 mcg/kgKG) im Standardfall wären.
Alle Notärzte müssen eine Qualifikation im Atemwegsmanagement vorweisen. Der Umfang ist in den Handlungsempfehlungen der DGAI zum präklinischen AW- Management nachzulesen. Nicht-atemwegskompetente Ärzte sollten keine Narkose machen.
CV-CI Situationen können im präklinischen AW- Management vorkommen. Die Rückkehr zur Spontanatmung ist in den Handlungsempfehlungen der DGAI nicht vorgesehen und wird nicht empfohlen. Die Rückkehr zur Spontanatmung ist bei richtiger Indikation zur Notfall-Narkose auch nicht möglich, da die Patienten entweder einen hämorrhagischen oder sonstigen Schock, eine akute respiratorische Insuffizienz mit NIV-failure oder schwerwiegende Bewustseinsstörungen mit Aspirationsgefahr haben. Der einzige richtige Weg präklinisch ist alternative Atemhilfsmittel einzusetzen und dann ggf. die Indikation zur Notfallkoniotomie zu stellen. Aus diesem Grund sehe ich auch nicht die Notwendigkeit Sugammadex präklinisch mitzuführen.
Parts of this presentation were presented at the DevelopingEM- conference 2014 in Salvadore de Bahia during the De-escalation Workshop.
For starting this presentation I want to begin with a case presentation of a prehospital mission. The fotos of this mission will be the backround of my slides, so you can imagine the circumstances.
There was a call to the border- bridge between Germany and Poland in a litte border town. The header for this mission was „man on bridge with weappon“. When we arrived there were police, firefighters and paramedics on site or were comming across. As it was the border-bridge, the same amount of people came from poland, too. And there were spectators on both sides of the bridge. First of all we noticed, that the weappon was a fishing rod, so we were happy not to be confronted with pure violence. Then we tryied to communicate with the patient. It turned out, that he was a polish citicen, but he was on german territory. As one of our paramedics was polish, she was choose to be the communicator with the man. For her safety she was lifted in the turntable ladder up to the patients level. There she was able to figure out the patients concerns. It seemed like he was depressed and afraid to be murdered by his family. He went for fishing on top of the bridge, because he thought there would be the best place for it. At the beginning, he was quite agitated and wanted to stay up there. It took at least one hour to establish report to the patient and to find an agreement how to get him to the ground in a safe way. Finally he went voluntary into the polish turntable ladder for admission in the german psychatry. Our paramedic had no special training in de-escalation. But she was the only one who was able to communicate properly with the patient. She stayed calm, found out the reasons for the agitation and was able to bring the level of arousal down to a safer place.
We were lucky that this patient was not aktivly aggressive against us. But about half of the health care workers had experienced at least one incident of physical or psychological violence in the previous 12 months: In figures 67 % in Australia and 46 % in Brazil.
Violence possibly accounts for approximately 30% of the overall costs of ill-health and accidents in health-care providors. So it’s quite important to have a strategy to deal with aggressions in health care settings.
Especcially Emergency departments and prehospital care settings, (apart of psychatric wards) are at greater risk for confrontation with agitated or aggressive patients. The reasons are manifold. Acute Pain, Fear and Helplessness are the circumstances many patients have to deal with. Some are Intoxicated or have Cognitive disorders, what lowers their personal control. There can be feelings of Rejection. And often they have limited access to informations about the proceedings and workflows of the environement. Or the bustle, noise and waiting time provokes aggressive behavior.
Aggressive behavior has traditionally been classified into two distinct subtypes. These were refered as instrumental and hostile aggression.
On one hand, there is the controlled-planned-proactive-offensive-constructive type for whom agression is conceived as a tool for solving problems. This type uses aggression for obtaining profit or advantages like power, money, control and domination. It is purposeful and goal-oriented. Thus, it’s requiring neither provocation nor anger. It’s the type „bank-robber“, who is less frequently our patient.
On the other hand, the hostile-impulsive-uncontrolled-unplanned-reactive type will more often show up in the emergency department. This kind of aggression has been conceived as being thoughtless or thought confusion emotionally charged. It can be driven by anger and characterized by loss of behavioural control. Psychologically, it is associated with disruptive behavior and deficits in interpretation. Physiologically, it is characterized by a marked sympathetic over-arousal.
Research has demonstrated that assaults on staff are often a result of interactions. An escalated person should not be seen out of it’s context. There you have the social system in which everyone interacts and the mental system of a person. Health-care providers have their roles in the health-care -systems. The expectations of a patient could be disappointed through the setting of the emergency department. That could be driven by anger and is characterized by loss of behavioural control, which can lead to violence. That can also occur as a reaction to some perceived provocation. As healthcare-providers we have to have the situation of the patient in mind and we have to act with empathy to the patient. Empathy and theory of mind for the patients are part of the key components to recognize a conflict and prevent an escalation.
As you can see there are different phases of escalation to distingush. After a triggering impulse, there is an escalation phase, which can lead to a crisis in the metal state of the patient. Autonomy safing De-escalation strategies interveen during the escalation. When it has come to a crisis with the risk or the occuring of an assault, de-escalation strategies turn to authorative interventions with physical or chemical interventions.
De-escalation techniques will be an important, but not sole factor in achieving non- violent situations. Clinical managers should aim to provide safe and structured environments with adequate staffing levels and skill mix. There should be a focus on activity and positive interaction between staff and patients. In addition to the use of de-escalation techniques, health-care providers must aim to maintain self-awareness throughout all interactions and focus on developing effective therapeutic relationships, to reduce the frequency of escalating incidents. Maintaining personal control and using of verbal and non-verbal skills are also key components in de-escalation.
Deciding on a strategy for de-escalation is an instinctive and intuitive process, which is requiring flexibility and creativity and is based on the individual needs and characteristics of each patient displaying aggression.
Early Intervention, depending of dangerousness of the patients are recommended. There should be only one communicator, which the one with the best chance to de-escalate. Listening to the patient, use of empathy, and interpretation of non-verbal cues were considered useful in terms of accurate assessment of the individual’s emotional state and the formulation of appropriate interventions.
Effective de-escalators are open, honest, supportive, self-aware, coherent, non-judgemental and confident, without appearing arrogant. They express genuine concern for the patient, appear non-threatening and have a permissive, non-authoritarian manner. These qualities help to gain the patient’s trust. This is making appeals for self- control more likely to be accepted. The ability to empathize is also vital, because it makes the patient feel understood and reduces the need for aggressive behaviour.
The importance of appearing calm when faced with aggression is emphasized throughout studies. The sense of calm conveyed by the staff helps the patient to manage their feelings of anger and aggression. Calmless communicates to the patient that, despite their anger, they are trusted not to be violent. Calmness conveys also, that the member of staff is in control of the situation, whereas fear can increase anxiety and make the patient feel unsafe or even that they have gained the ‘upper hand’.
Feelings of anger or offence should be suppressed and it is crucial that personal feelings toward the patient are avoided.
Some common signs show obviosly, that a person has become escalated: The sympathetic over-arousal lead to Raised, High-pitched Voice and Rapid Speech. There can be Excessive Sweating and Excessive Hand Gestures or Balled Fists. Erratic Movements and Aggressive Posture or Shaking signal the escalation of the patient.
Staff must be aware of their body language in terms of posture, eye contact, proximity and touch. Body language should express concern for the patient. A degree of eye contact is necessary to maintain rapport and the patient’s attention, Loss of eye contact may be interpreted as an expression of fear or lack of interest. Fixed eye contact is not recommended as it may be seen as a threat or challenge. There are some ambiguity regarding the use of touch. It could be calming for some patients, yet threatening for others. Personal space should not be invaded. Minimize your body movements and keep a relaxed and alert posture. Stand up straight with feet about shoulder width apart and weight evenly balanced. Positioning of yourself for safety is essential and never turn your back for any reasons.
Using a calm, gentle and soft tone of voice is central to the technique. Tactful language and the sensitive use of humour are also evident, although care is required that this is not perceived by the patient as belittling. Reasoning with an enraged person is not possible. The first and only objective in de-escalation is to reduce the level of patient arousal so that discussion becomes possible. Do not get loud or try to yell over a screaming person. Wait until he or she takes a breath, then talk. Speak calmly at an average volume. Respond selectively and be honest. Lying to a patient to calm them down may lead to future escalation if they become aware of the dishonesty. Do not be defensive even if comments or insults are directed at you. But be very respectful even when setting limits or calling for help. The agitated individual is very sensitive to feeling shamed and disrespected. Trust your instincts.
Attempts should be made to find out the reason for the patient’s agitation. The patient should be asked what the problem is, what can be done to resolve it, and what normally helps the patient to feel calmer. Guidance should be given to the patient without appearing commanding. Staff should avoid threats of sanctions or entering into power struggles. The focus should be on establishing rapport, answering questions, and finding agreements without making unreasonable concessions or appearing uncompromising. The patient should be encouraged to communicate openly with staff about their emotions and discuss feelings of anger and frustration. Recognizing the right to expression of anger (provided the patient can do so without harming themselves or others) is viewed as a key factor in successful de-escalation of patients displaying aggression.
The focus should be on promoting the autonomy of the patient, through minimizing restriction as far as possible. The patient should be made to feel valued and respected. Aggression is often a response to lost dignity and feeling respected enables the patient to reclaim their sense of dignity.
Find aggreements and list consequences of inappropriate behavior. Alternatives to aggression should be highlighted to the patient. Depending on the degree of risk to the patient or others, giving the patient the choice of a ‘cooling off’ period might be an option. Several studies emphasize the importance of offering ‘face-saving’ alternatives, which involve negotiation of a mutually agreed alternative to aggression. The aim is to empower the patient to feel they are choosing to de-escalate, rather than being forced by staff.
To sum up: The process of de-escalation is about establishing rapport to gain the patient’s trust. Therefore Remaining calm, Valuing the patient and Reducing fear is of great importance. Enquiring about patient’s queries and anxiety and Providing guidance to the patient are autonomy saving interventions to work out possible agreements.
That will bring the level of arousal down to a safer place.
But over all Take no risk
ILO/ICN/WHO/PSI (2002). Framework guidelines for addressing workplace violence in the health sector. Geneva: ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector.
Di Martino, V. (2002). Workplace violence in the health sector – Country case studies Brazil, Bulgaria, Lebanon, Portugal, South Africa, Thailand, plus an additional Australian study: Synthesis Report. Geneva: ILO/ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector, forthcoming working paper.
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE. Centre for Clinical Practice
Review of Clinical Guideline (CG) 25: Violence: The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments
NAU J. Et al. (2009) The De-Escalating Aggressive Behaviour Scale: development and psychometric testing. Journal of Advanced Nursing 65(9), 1956–1964.
RAMIREZ, J.M. Et al. Aggression, and some other psychological constructs (Anger, Hostility, and Impulsivity). NEUROSCI BIOBEHAV REV 21(1) 2005
Price O., Baker J. Key components of de-escalation techniques: A thematic synthesis International Journal of Mental Health Nursing (2012) 21, 310–319
Cowin L et al. De-escalating aggression and violence in the mental health setting. Int J Ment Health Nurs. 2003 Mar;12(1):64-73.
Hockenhull JC. A systematic review of prevention and intervention strategies for populations at high risk of engaging in violent behaviour: update 2002–8. NIHR Health Technology Assessment programme: Executive Summaries.
Walter G. Aggression und Aggressionsmanagement: Praxishandbuch für Gesundheits- und Sozialberufe. Verlag Hans Huber 2012
Parts of this presentation about the VORTEX- approach were presented in October 2014 at the DevelopingEM- conference at Salvador de Bahia, Brasil.
The presentation is about airway-management, especially about a new kognitive aid for airway- management. The VORTEX- approach was intended by Nicholas Chrimes and Peter Fritz from Melburne in Australia and first published in the internet in 2013.
The beauty of the vortex is it‘s universality and it‘s ease to remember, because it‘s not a flowchart or an algorithm but a three-dimensional- approach to airway-management. You will understand later.
First of all I want to point out the goal of airway-management. During the last century the main effort in AW Management was put on avoiding an aspiration. Mendelson described 1946 obstetrical cases with a respiratory syndrome which showed a dramatic onset of cyanosis, dyspnea and tachycardia. This started two to five hours after aspiration and lead to shock. The mortality of the Mendelson‘s syndrom was up to 60% and led to the focus on avoiding an aspiration in relations to anesthesia. The techniques for rapid sequence induction inproved and the therapy for servere lung injuries improved too. One of the lates publication concerning ARDS of Guérin et al. in the New Engl J Med from 2013 showed a reduction of Mortality in servere ARDS down to 23% while Prone Positioning in the ICU. Another study of Sakles et al., also from 2013, analysed the Importance of First Pass Success When Performing Orotracheal Intubation in the Emergency Department. They found an aspiration rate in non-fasted emergency patient of around 1 to 6 %. They analyzed also the incidence of Desaturation. In 9-37% of these rapid sequence inductions was a significant desaturation detected. As everybody knows can hypoxia led to servere brain damage in a short period of time. Other studies showed also, that the priorisation on avoiding aspiration can led to desaturation with harm for the patient. The priority was put on maintaining alveolar oxygenation while securing the airway. Desaturation can occure quickly after anesthesia induction and apnea. Even when adequate preoxygenated the Saturation starts to drop after 2 to 5 minutes. The former imperative for non-ventilation during RSI can led to Hypoxia. This is depending on the conditions of the patient and the duration until a alveolar oxygenation is established. Especially obese patients, ill patients and children are at risk for early desaturation. In respect for this data the recommendations for RSI for children were adapted in 2006 in Germany. Pressure controlled (bag mask) ventilation is now indicated until the conditions for endotrachel intubations are optimized. Oxygenation has the highest priority during RSI.
The second important issue I want to highlight are the lessons learned by the NAP4 publication in 2011 in the British Journal of Anesthesia. A national audit was published which analyzed the death by airway problems in Great Britain. Apart of many other reasons for these dead patients, there was a failure to plan for failure detected. At a certain point there was a kind of mental blockade causing a leak of progress in the proceedings for difficult airway management. Even if there are lots of difficult airway flowchats published, many are to complicated to remember under stress or to specialized for anesthesia purpose. So some providers stuck in an unsuccessul activity without beeing able to escalate their airway-management. To have a simple and memorable cognitive tool in mind is a big advantage in situations when action on brainstem level is needed.
And third of all I want you to remember 5 possible accesses to alveolar oxygenation. There we have three non-surgical airway techniques like an extraglottic airway which means to provide oxygen with a face mask, the supraglottic airway in terms of placement of a laryngeal mask in the hypopharynx and the transglottic airway for the endotracheal tube. Furthermore we can achive the airway via a surgical procedure. There are two possibilities for an emergency surgical airway like a cricoidotomy or a tracheotomy.
Now I want to explain the concept of the vortex approach.
It‘s not that complicated. As you can see: The vortex is build three dimensional like a cone with a green zone at the top and a blue funnel which is open at the bottom end. The green zone symbolizes the situation with an oxygenated patient with access to alveolar oxygenation. The primary goal is to reach the green zone. The blue funnel symbolizes apnea and the need to establish alveolar oxygenation again.
We leave the green zone through induction of anesthesia with apnea or by desaturation of a respiratory compromised patient. The VORTEX is constructed three- dimensional. That allows at the beginning of the airway- management to choose between one of the three non-surgical airway- techniques. The airway provider can decide whether to use a face- mask, a laryngeal mask or the endotracheal tube. Which tool is approriate is depending on the circumstances of the airway-management. The VORTEX approach gives you the choise to choose the right tool for the right moment. But it allows only a maximum of three attempts at each non-surgical airway-technique. In case the green zone is not reached again, the VORTEX suggestes to progress to an emergency surgical airway. One of the three attempts on each airway-technique should be done by the most experienced clinican available. More than three attemps on each airway- technique are not indicated.
The primary goal is to provide alveolar oxygenation. The second goal is to maintain airway patenty.
The vortex-approach recommends fife optimisation strategies to apply on every attempt, which are Manipulation, Adjunct, Size, Sucction and Muscle tone.
For the practical approach, it means on every attempt to manipulate the position of the head, neck, larynx and or the device. Then to use an adjunct like an orophayngeal and/or nasopharyngeal airway- device. You shoud consider to change the size of the airway- device and try to to succ secretion out of the pharynx for a better view. And last but not least it is to check the pharyngeal muscle tone. Then you can decide whether to wake up the patient or to deepen relaxation and anesthesia.
You see the numbers 3 and 5 take a great place in the VORTEX- approach. Three attempts on three non-surgical airway techniques. Fife optimization strategies and 5 airway-levels. It is wise to go through these points for each try.
To confirm alveolar oxygenation endtidal carbon dioxide should be messured. As there is almost no carbon dioxide in the air the detection of etCO2 signals gas exchange with the lungs. And where gas comes out, logically gas went in, too. There you have an indirect prove of alveolar oxygenation. To wait for a change of saturation during airway- mangement takes to long and is too uncertain to trust. Furthermore endtidal CO2 gives information not only about ventilation but also lung- perfusion, cardiac output and the metabolism.
The Vortex-approach is an universal cognitive aid to airway-management. It does not exclude any airway-device. When the green zone is established, the right tool for a difficult airway can be choosen. When the aim was to perform endotracheal intubation and it was not reached after three attempts, but a laryngeal mask was established, then there is time to plan for the next step. If the tools are available and a trained clinician is on site, every device from any difficult-airway algorithm can be put in place. The vortex approach does not supply a solution for every difficult airway problem. It is not a flow-chart or an algorithm. The Vortex approach is a cognitive aid to focus on goals like alveolar oxygenation and progression in airway-management. It gives practical support with optimisation strategies and limits the trys on each airway-technique. That supports the provider to go ahead even up to an energency surgical airway.
But what shall we do when it comes to perform an emergency surgical airway? When we did three atempts on each non-surgical-airway-technique but we didn’t reach the green zone, when there is no alveolar oxygen delivery? How shall we perform the surgical airway?
What does Airway- societies say? I didn‘t find any clear recommendations when and how to perform an emergency surgical airway.
Don’t you think it’s allready to late when it comes to hypoxia with bradycardia in a difficult airway- situation ? Do we still have the rescources and time to safe the patients life?
The VORTEX- approach provides a clear strategy when to perform an emergency surgical airway. It does not recommend to wait and try until the saturation dropps. If there were up to three attempts on each non-surgical airway-technique performed with at least one optimal attempt and no alveolar oxygen delivery was detected, an emergency surgical airway is indicated.
To lower the barriers to perform finaly a surgical airway, the preparation for the surgical procedure should be done during the airway-managment and with every airway technique, which is faded, the preparation to perform an emergency surgical airway should be escalated.
But which technique should be used? The data are not consistent and there are suggestions to start with a needle cricoidotomy and progress to a surgical emergency airway in case of failure.
I recommend the technique you are trained in and you are comfortable with. Do you have a surgical background? Take the blade. Are you experienced with Seldinger- Technique? Use the MELKER set. And so on… Most important is JUST DO IT. And therefore is the VORTEX approach.
It’s an universal and easy to remember cognitive aid, which guides you to the next step, even if it is to perform an emergency surgical airway.
So, don’t forget to plan for Failure,
Use all 5 airway techniques availlable
Don’t stand still like a rabbit in front of a snake and take the next step in airway-managment.
And at least I whish you NO-DESATURATION for your patients
*American Society of Anesthesiologists: Practice guidelines for management of the difficult airway: Anesthesiology 2003; 98:1269–1277. update: Anesthesiology 2013; 118:251–70
J. J. Henderson et al. Difficult Airway Society guidelines for management of the unanticipated difficult intubation http://www.das.uk.com
A. Timmermann et al. Handlungsempfehlung für das präklinische Atemwegsmanagement* Anästh Intensivmed 2012;53:294-308
T. M. Cook 1 et al. On behalf of the Fourth National Audit Project. British Journal of Anaesthesia 106 (5): 632–42 (2011)
Christopher T. et al. The Success of Emergency Endotracheal Intubation in Trauma Patients: A 10-Year Experience at a Major Adult Trauma Referral Center. Anesth Analg 2009;109:866–72
Chesters A. et al. Prehospital anaesthesia performed in a rural and suburban air ambulance service staffed by a physician and paramedic: a 16-month review of practice. Emerg Med J. 2014 Jan;31(1):65-8.
Ellis DY et al. Cricoid pressure in emergency department rapid sequence tracheal intubations. Ann Emerg Med 2007;50:653-65
Bernhard M et al. Developing the skill of endotracheal intubation: implication for emergency medicine. Acta AnaeScand 2012;56:164-171
Alexander F. Arriaga et al. Simulation-Based Trial of Surgical-Crisis Checklists NEJM 2013; 368:246-253
Müller JU et al. The use of the laryngeal tube disposable by paramedics during out-of-hospital cardiac arrest: a prospectively observational study Emerg Med J. 2013 Dec;30(12):1012-6.
Schalk R. et al. Disposable laryngeal tube suction: standard insertion technique versus two modified insertion techniques for patients with a simulated difficult airway. Resuscitation. 2011 Feb;82(2):199-202
John C. Sakles et al. The Importance of First Pass Success When Performing Orotracheal Intubation in the Emergency Department. Academic Emergency Medicine Volume 20, Issue 1, pages 71–78, January 2013
Guérin et al. Prone Positioning in Severe Acute Respiratory Distress Syndrome (PROSEVA). New Engl J Med 2013;epublished May 20th
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!