THE CRUX by Dr Harold Shim
Just woken up on the first morning of SMACC 2013 and in the true spirit of FOAMEd, got an email from a listener of the PHARM podcast, all the way from Middle East. He has kindly consented for me to reproduce the email and diagram he shared.
I just started catching up with some of the podcasts that I missed over the last couple of months and I heard your podcast wrt the VORTEX.
I really like it! Was thinking I should have published this diagram I made for teaching my airway students. I call it the CRUX. Like the authors of the VORTEX I was continually frustrated at the multiple airway algorhythms that were too hard to remember and frustrated me because I would always think that I forgot something. For exactly the same reasons the authors developed the vortex I developed this picture to burn into the students head. I guess I could simplify the diagram and make it pretty with colors like the vortex but I kind of like my poor artistry, people might remember such a horrid drawing!
Anyway the only thing that is slightly different in my diagram is that I stress that CENTRAL to the theme of any active airway management is EFFECTIVE BAGGING ideally with ETCO2 to confirm a patent airway or not (either through TWO handed BVM or my now preferred method: two handed mask and Oxylator – I’m recently an OXYHEAD as Romy Worner the CEO of the company would say).
I think the vortex is good in the fact that you can drop into their funnel at any point but in reality any active airway management usually (not always but usually) starts with trying to BAG the patient. If you can bag the patient usually you have a bit more time to organize an ETT plus or minus RSI. Then if you can’t tube’em you have to go back to BVM and try again. 2 More tries (MAX) with different techniques and devices and you have to go to LMA but usually via the BVM because you already knew you could bag the patient. This would hold true if you went the LMA route first rather than ETT.
So you see the rules of the game are the outside circular patterns (BVM – ETT or LMA – BVM) or the figure 8 pattern from ETT to BVM to LMA) can each be given max 3 tries before you knife the patient. But this is only true IF you can Bag a patient! Go around and around too much and I tell students and in my lecture you’re now behind the 8 ball!
If BVM doesn’t work with the best techniques this blocks the circuit. You can give one other device one more try or the same device one more try while you or someone else mentally prepares to go to the knife.
It maybe just semantics but as I said I think Bagging the patient is CENTRAL to the theme of airway management and if you can’t do this your attempts with any device should really be limited because the stress and adrenaline levels start to get to unhelpful levels and the patient’s oxygenation is likely going the other way fast.
To be perfectly honest I have never done an Emergency Cric on a real patient in my over 20 years of practice. Maybe I didn’t see enough patients, maybe I should have done a cric on a few that I didn’t and got luck getting the tube in or maybe I don’t know what I’m talking about.
Anyhow I think the VORTEX and my CRUX diagram tries to get to the same point. Simplifying the concept of airway management in emergencies.
Dr. Harold Bob Shim
M.D., C.C.F.P.(EM), Dip. Sport Med.
Clinical Medical Director
Presidential Medical Wing
Thanks Harold! It certainly sounds like you know what you are talking about!