PHARM Podcast 58 : The Vortex – management of the unexpected difficult airway


Hi folks!

Meet these two guys..

pfitzDr Peter Fitz, Emergency Physician and Retrieval Specialist

NCDr Nicholas Chrimes, Consultant Anaesthetist

Dr Nicholas Chrimes and Dr Peter Fritz from Melbourne published a FREE eBook with accompanying Youtube powerpoint presentation on their approach to emergency airway management using simple cognitive aid to assist in the unexpected difficult airway case. Its called VORTEX!

What you say? Another airway algorithim to remember! Didnt Scott Weingart just post a blog about the Shock Trauma Airway algorithm? Why do we need another one?

Vortex is different. Its 3 D! Not linear..its circular. thats cool. Its Non Surgical airway pillars ( tracheal intubation, laryngeal mask airway and bag/valve face mask) are all considered equal and the goal is Alveolar oxygen delivery ( AOD). They even support needle cricothyrotomy! I can feel the glare from Mr EmCrit all the way from NYC!

Vortex Cognitive Tool

They were generous with their time to come onto the show and record a podcast on their work. Tune in and have a listen. Then spread the word about VORTEX! THIS IS THE TRUE SPIRIT OF FOAMEd.

Show note references

  2. Vortex brief presentation
  3. AIRWAY SAFETY LINES Presentation

Now on to the Podcast

Right Click and Choose Save-as to Download the Podcast.

23 thoughts on “PHARM Podcast 58 : The Vortex – management of the unexpected difficult airway

  1. Hi Minh I listened the podcast….. I very enjoyed it…Great presentation by Dr. Fitz and Dr. Chrimes and I’m looking forward to using Vortex and the definitive Emcrit airway checklist to make comparisons ASAP……Just have a doubt: Vortex put at the same level of importance face mask with LMA and ETT as a way to get in the green zone….but ventilating a pt. using face mask even for a short time especially in prehospital and ED settings doesn’t put the pt. Too much at risk for vomiting and inhalation??!…..endeed the aim of RSI and DSI is to preoxigenate in order to avoid Face mask ventilation……..

    1. Hi Valerio, you are quite right, an unfasted patient remains at risk of aspiration if the green zone cannot be achieved with an ETT. The equality of the 3 NSA techniques relates only to their ability to provide oxygen to the alveoli, not to achieve secondary goals like airway protection. That is exactly the reason for sequencing your attempts at the various NSA techniques according to context (which determines the direction you will spiral into the Vortex) so that your initial choices will also achieve your secondary airway management goals in addition to AOD.

      In an emergency setting (whether in the operating theatre or ED/ICU) where the patient is at risk of aspiration, the intended initial definitive airway will always be an ETT (via RSI). If you are in the position where you can’t achieve the green zone via your optimal attempt at an ETT, though, then you must achieve it by one of the other NSA techniques or let the patient die. These are your only options.

      There’s no point in protecting an airway to maintain the oxygen exchanging ability of alveoli you can’t get oxygen to anyway. So yes, avoid using a NSA that does not also offer airway protection if you can, but remember the priority is to deliver oxygen to the alveoli and if your best attempt at intubation is unsuccesful you have no other choice.

      There are plenty of case reports where patients have suffered hypoxia related morbidity/mortality due to a fixation on the need to protect the airway whilst losing site of the bigger picture – the necessity to deliver alveolar oxygen. It is this that the “equality” of the three NSA techniques in the Vortex seeks to avoid.

      For further clarification see the “Goals of Airway Management” section of the Vortex article where this is dealt with in detail.

      Glad to hear you find the Vortex concept useful. We hope to have a teaching manual out explaining how to train staff in use of the Vortex (and other strategies involved in the “Airway Safety Lines” approach) in the next few weeks.

      1. Put more simply… the equal division of the “funnel” into three sections reflects the EQUALITY of the 3 NSA techniques in achieving ALVEOLAR OXYGEN DELIVERY, the sequence in which you decide to attempt them (which determines the order in which you spiral down) reflects their INEQUALITY in being able to achieve other SECONDARY GOALS like airway protection. That’s why the airway operator has a preferred airway.

  2. I was a sceptic – then saw the youtube clip of vortex in action (albeit in a sim). Previously a fan of the DAS algorithms, I like Vortex for it’s availability (chart at head of bed can be taken down and used as a prompt), it’s simplicity and use of three tiers of nonsurgical airway management, and the fact that as a cognitive aid it brings the team together – good for team training, yet fluid

    Gonna do some in-house training with this one…

    1. thanks Tim! I admit when I first read the full Vortex publication, I had trouble visualising how it would work better than what we have or have not been doing. But the video demo is a great demonstration of its applicability and I really like the team based emphasis..few if any airway oriented cognitive aids promote such a team focussed approach to the unexpectedly difficult airway.

      yes when I saw the printed Vortex poster taken down from the wall and handed to one of the staff(Nic Chrimes I believe no less!). and how he used it as a real time prompt..almost like a checklist

      that sold Vortex to me!

    2. Thanks Tim & Minh, that’s great to hear. Pete and I hope to have a manual out in the next few weeks that will outline much of the background content required to train staff to use, not only the Vortex, but all the techniques involved in the “Airway Safety Lines” strategy for difficult airway training. As outlined in the Vortex article, the training program for using the Vortex is at least as important as the tool itself. There is a whole process for teaching staff how to simplify clinical decision making under pressure which allows them to get the most out of the Vortex approach.

  3. Cool concept… seems quite practical.
    I appreciate how the green zone puts the emphasis on oxygenating the lungs as opposed to securing the airway. In this respect, the non-surgical techniques should indeed be considered equivalent. I am struggling a bit with the concept in the critically ill patient, however, where waking the patient up isn’t generally a reasonable alternative. If ETT and LMA have failed, but BVM is working well, you reliably get yourself into the green zone but still need to secure an airway. It is less intuitive to me from the algorithm, where to go from here, ie. stuck in the green zone without a clear way out. I suppose though, that from the green zone, you have time to plan out your next steps. Much worse places to be stuck.

    1. Sean you’re on the money! There is certainly more work to be done once the “green zone” is achieved. Unless you get into the “green zone” with your planned “definitive airway” it’s not an end point – but having “stopped the clock” ticking on the patient progressing to critical hypoxia & death, a whole lot of new options in terms of assembling techniques and equipment have opened up (or in a retrieval setting even just “phoning a friend” to double check your reasoning and making sure you haven’t overlooked any options). How long you are happy to remain in the “green zone” with an unprotected airway depends on a balance between 2 things:

      1. The urgency to achieve secondary airway management goals (eg. airway protection)

      2. The perceived risk that another intervention might turn a compromised airway into none at all it fails.

      Thus there might well be situations where you get into the green zone in a patient with a small bowel obstruction, are able to gently face mask ventilate with ease and are confident that with by changing something further at the next attempt at intubation you will be able to intubate the patient – and that if you are wrong, mask ventilation will almost certainly be possible. Here the balance clearly falls in favour of taking a couple of breaths then moving forward and intubating the patient. You don’t HAVE to stop in the green zone, it just provides an often overlooked opportunity.

      Conversely, if in the same patient you have a grade IV view of the larynx despite an “optimal attempt”, can only just FM ventilate with maximal supports and are concerned that any further instrumentation of the airway might cause enough trauma that subsequent mask ventilation will become impossible too – you might elect to get your ESA equipment ready and continue to mask ventilate, despite the risk of aspiration, whilst waiting for an anaesthetist or an ENT surgeon to come to you. In the situation where you are inexperienced with an ESA yourself (as most of us are) and the patient looks like that might be difficult too (as may of the same anatomical factors which pre-dispose to a difficult NSA can also pre-dispose to a difficult ESA) the amount of time you’re willing to wait for resources might be considerable! Conversely if you are confident you can do an ESA and use that to susbsequently secure a definitive airway which protects the patient from aspiration you might elect to proceed with that rather than expose the patient to a prolonged wait with an unprotected airway.

      The Vortex approach doesn’t tell you WHAT to decide it just prompts you to consider options appropriately when you do. It thus provides support for the airway operator to think clearly in a crisis and best apply their own expert judgement to keep the patient as safe as possible in a given situation.

    1. Thanks for the great feedback and support.
      We’re really happy that the Vortex is appealing to the whole spectrum of Crit Care not just in ED and anaesthetics where we practice.

      1. Its good stuff. Already referencing the Vortex along with DAS in my SMACC2013 talk for next month…

        I think it wins over the DAS as a team-trainign exercise and easy cognitive tool at the head-f-bed – in ED, ICU, OT or austere environs

        For me it is easier to empathise (can one do that with an algorithm?! Perhaps visualise?) with the sudden swirl down into the ‘hole’ of CICO and use the three pillars to ensure AOD takes place

        Once back int he green zone, re-group, re-plan and take another dive into the ‘vortex’

        More examples pls on youtube. Very powerful to convince naysayers

        Have taken the liberty of posting about Vortex on int eh EM form – so far no comments! Stunned silence from the masses?

  4. Dear Colleagues from Down-under,

    thank you for the brilliant concept with all the explanatory stuff (podcast, videos and ebook). As a Neurointensivist I am one of these unfrequent intubators and took some time to work myself through all the different algorithms and came up with something close to the shock-trauma algorithm. But it was always hard to explain my decisions to the younger colleagues as I already used the „VORTEX“ in my mind in the actual intubation scenario – but I would have never been able to verbalise of visualise it that intuitive way. I am sure that the VORTEX-concept together with the simple chart on the wall will complement the intubation checklist perfect and will bring intubation as a team sport to the next level of patient security.

    Thanks a lot and carry on!

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