Posted by Matthew Mac Partlin on Wednesday, March 6, 2013

Yet another development in airway management has appeared. I came across it about a month ago and it's worth having a think about how it might fit in with motorsports resuscitation.

It is called the Vortex Approach and is designed for use when you find yourself in an unexpected difficult or failed airway situation. The Vortex Approach is a cognitive model developed by two Australians, Dr Nicholas Chrimes, an anaesthetist at Monash Medical Centre and Dr Peter Fritz, an ED and retrieval physician also at Monash and Adult Retrieval Victoria. Both are involved in airway teaching and simulation and also run the Clinical Cred website.

The prompt for them to develop the Vortex Model was trying to understand and assist clinicians to get past the cognitive barrier to picking up a scalpel and performing an emergency surgical airway (ESA, cricothyroidotomy) once it was identified that standard efforts to secure the patient's airway were failing. There have been a number of publications decrying the fact that often poor outcomes are not due to the clinician's inability to perform an ESA, rather the result from the delay in performing it.

The two authors acknowledge that airway algorithms already exist, including the widely publicised Difficult Airway Society guidelines, that cover a standard approach, an anticipated difficult airway approach and a failed airway approach. There is also the Shock Trauma Centre algorithm (click here for Dr Scott Weingart's modified version), developed specifically for use in the trauma setting. However, they feel that many of these algorithms are overly complex and difficult to memorise, particularly for the other team members, such that there is a barrier to a shared mental model.

So they developed the Vortex Approach.

At first glance, there's a bit of a "so what" feel to it; that it is not really offering anything special. What is obvious though, is that it is really simple and so is very easy to remember and explain, which matters in stressful situations.

It also does appear to achieve its purpose of breaking down the cognitive barrier to performing an ESA by the way that it is structured. Others have already commented that its design lends itself to giving the operator permission to go ahead and pick up the scalpel. You don't even have to actually attempt all 3 non-surgical techniques. For instance, if there is facial trauma and facemask ventilation is failing, it might be immediately obvious that an EGA and ETT will not work, so you are immediately on to the ESA.

There has been some concern expressed that this "permission" might lead to an increased incidence of unnecessary ESAs and while that seems less likely we won't know for a little while yet. However, its simplicity does allow for other team members to interject in both directions, either to prompt the airway person to perform an ESA once the non-surgical options have been exhausted, or to remind him that 2 other options exist before picking up the scalpel.

Interestingly the authors state that it is entirely plausible that the airway doctor might exhaust all 3 non-surgical airway options and proceed to an ESA while the SpO2 is still 100%! This is entirely consistent with current thinking, whereby securing a patent airway in advance of desaturation is strongly advocated, as rescuing a desaturating airway is much harder to recover from, both for the patient and the medical team.

As a personal thing, I'd argue for 2 best non-surgical airway attemps before proceeding to the ESA, rather than 3, as I think if you don't get it in 2, a third go is unlikely to be different and the hypoxia clock is ticking.

For more information you can watch the Vortex Approach video produced by Drs Chrimes and Fritz and visit their website for more demonstration videos and resources.

There is a pdf article written by Chrimes and Fritz that explains the background and how to of the Vortex, which you can read freely here.

They have also been interviewed on this topic by Dr Minh Le Cong on his PHARM site, which you can watch here.

I'd be interested in your thoughts on this model, particularly as it applies to motorsports rescue and resuscitation, so as usual, leave your comments below, on the Rollcage FaceBook page or by email and Twitter.

Take care.