The VORTEX approach is a cognitive aid designed to facilitate management of the unexpected difficult airway. This is the first case report of actual use in a prehospital setting.
by Dr Minh Le Cong
Peer reviewed by Dr Nicholas Chrimes
The author was tasked to undertake an aeromedical retrieval of a 40yo woman in a remote clinic, who had presented via family members with an intentional overdose of prescribed antidepressant and antihypertensives. In addition a large amount of alcohol was suspected to have been consumed. The family reported finding a suicide note , empty medication packets and empty 1 litre bottle of vodka spirits, next to the bed of the patient. She had been found unconscious in bed and it was estimated she had been in this condition for at least 1 hr.
On arrival at the remote clinic the author found the patient to be semirousable to painful stimulus, with strong smell of intoxicating liquor. The remote nurse had placed mask oxygen and gained peripheral venous access. BP 100/80, HR 50, SaO2 100% on 10L/min oxygen. BSL 5.0
The empty medication packets were 30x 100mg sertraline, 30 x 10mg perindopril.
ECG was performed and was unremarkable.
Further physical examination revealed reactive pupils, poor dentition, good neck motion, clear lung fields, normal heart sounds and the rest of the examination was unremarkable.
A decision was made to perform RSI to secure trachea with cuffed tube for aeromedical transfer.
Patient was positioned at 45 deg semi reclined head up and preoxygenation given with BVM/PEEP valve + nasal cannula at 15 L/min.
Flight nurse and clinic nurse were briefed on the primary airway plan of direct laryngoscopy with Macintosh 4 blade and bougie .
The VORTEX cognitive aid was displayed on the author’s iPad and the zones explained as well as the optimisations to be done.
RSI was initiated with ketamine and rocuronium. Cricoid pressure was applied by assistant. On direct laryngoscopy, a grade 4 laryngeal view was obtained with inability to visualise epiglottis. Cricoid pressure was released with no improvement in the view. The author performed bimanual laryngoscopy with external laryngeal manipulation and still the epiglottis could not be identified.
Use of the VORTEX cognitive aid optimisations list could be completed quickly and despite the SaO2 being maintained at 100% with the nasal cannula apnoeic oxygenation, the intubation attempt was therefore abandoned.
Following the VORTEX, Face mask ventilation was then initiated , using end tidal capnography to confirm adequate alveolar oxygen delivery.
The assistant nurse spontaneously declared “We are in the Green Zone” indicating the part of the VORTEX in which the patient is in relative safety.
The author , knowing the airway needing securing still, then declared moving to LMA zone of the VORTEX. The second assistant then passed a Fastrach ILMA to the author and this was quickly inserted. Capnography confirmed adequate alveolar oxygen delivery, indicating maintenance of the Green Zone status.
A blind intubation attempt was then performed with a 7.o reinforced silicone tipped ETT and successful tracheal intubation was confirmed with capnography.
Anaesthesia was extended with ketamine and fentanyl infusion and the Fastrach ILMA with ETT was left in situ entirely for transfer to ED.
The patient made an uneventful recovery and was extubated the next day.
This is the first reported use of the VORTEX cognitive aid in the prehospital setting. In this case of prehospital RSI with unexpected difficult airway, the VORTEX was found to be easy to use and facilitated an effective team approach to the airway emergency. The ability for team members to view the aid on an iPad was novel yet adequate for the situation of a small remote clinic.