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The Vortex in Action

The Vortex Approach, a cognitive aid tool created by Nicholas Chrimes, that provides a simple and consistent template for airway management.
OK, you should be fully relaxed. OK, let’s take a look. First attempt at endotracheal intubation.
OK, I’ve got a 3b view. Can just ease up in the cricoid a little bit? Easing cricoid. OK, still no good. Take the cricoid off, please. Cricoid off. And yep, I’ve still got a 3b. Can I have some external laryngeal pressure please? And we’re getting sucked into the vortex. Can you run us through the optimizations for endotracheal tube, please, Sure. Manipulations of the head and neck. Done. Does he have dentures? No. Manipulations of the larynx? Yes. We’ve taken off cricoid, and we’re doing external laryngeal pressure. Sure. Manipulation of the device? Unsuitable. Sats are falling 93%. All right. OK, let’s go to face-mask ventilation, and get the sats up a little bit.
Maria, can I have the hyperangulated blade ready for the next intubation attempt please? Hyperangulated blade ready to go. OK, first attempt at face-mask ventilation. Let me just take you through the remaining options and the tracheeal intubation optimization. Adjunct? I’ll have a steerable bougie please Ready. Size and type? We’re going to change the laryngoscope, and I’ll have a 7 and a half bullet tip tube. 7 and 1/2 bullet tip tube ready to go. Suction. not suitable Muscle tone? Done. Can you squeeze the bag? Sure. Sats are 88%, and there’s no CO2. We’re still stuck in the vortex. Let’s take CICO status to ready. CICO status ready.
Charlie, can you call the in-charge phone, tell them we’re at CICO status ready and have not been in the green zone? Sure. Maria, can pass me be CICO rescue kit and the CICO status tool? OK. And can you run me through the optimizations for the face mask and give me an oropharyngeal airway [INAUDIBLE]?? Sure. This is a second attempt at face mask. Manipulations of head, neck, and larynx are done. Manipulation of the device. You want to try the Vice-Grip? Yeah, sure. Good thought. Adjuncts? I put an oropharyngeal airway in. Sats are at 85%, no CO2. Still in the vortex. Do you want a nasopharyngeal airway? Yep. Suction? Yeah, I guess. Maria, can you suction? OK.
This will be the third attempt at face-mask ventilation and complete a best effort. Having some trouble? You’re in charge now. Sure. Carolyn, you’re in the vortex. Have you ever been in the green zone at 85? No. Sats are 75. No CO2. That’s best effort at face-mask ventilation. CICO status is set. Are you happy to do that? Yeah, I’ll do that. Charlie, hit the buzzer. Have you had a best effort at anything else? A hyperangulated blade will compete the best effort at intubation if you haven’t tried a supraglottic airway yet. Yeah, haven’t tried the supraglottic airway at all. And the sats are low. So rather than that, can we try the supraglottic airway, please? I’ll have an LMA 3 please.
This is our first attempt at a supraglottic airway. Charlie, can you help Stewart? Sats are 70%. OK, that feels good, and the chest is rising. And yeah, we’ve got CO2. [BEEPING]
OK, so now the sats are starting to come up. We’re in the green zone. Maria, can you get that video on the laryngoscope ready to go, please? Hang on. We’re in the green zone. Should we stop and think for a moment? Actually, yeah. You’re right. We’re in the green zone. We should stop. Stu, can you stay at CICO status set? And Hash, can you run us through the green zone tool please? Sure. I’ll get the tool. OK, our priorities are to oxygenate, to assemble resources, and to develop the strategy. Oxygenation– our saturations are coming up, but we still need to extend the safe apnoea time. Assembling resources– do we need any other personnel or equipment?

This simulation video, demonstrates the Vortex Approach in action and shows how it can be used in a “Can’t Intubate, Can’t Oxygentate’ (CICO)’ situation happening during a Rapid Sequence Induction (RSI). It is directed by Dr Nicholas Chrimes, who created the concept.

Take a moment to reflect: How did you feel watching this video? How are Human Factors and Ergonomics incorporated in The Vortex? Do you already use the Vortex Approach in your healthcare setting? Do you think it would be useful to implement?

If you are interested in finding out more about the approach, this article will give you a more detailed overview.

CICO and emergency Front of Neck Airway will be the focus of the next activity. We will discuss RSI in Week 3 of Airway Matters.

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Airway Matters

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