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Enter the Vortex

Why Design Matters When Preparing for the High Stakes Emergency Airway Environment

When it comes to managing the emergency airway it’s all about prioritizing oxygenation over intubation. This important concept often gets lost for new providers focused on gaining confidence with their intubation skills. Even for experienced providers, the stress of an unanticipated difficult or failed airway can trap them into a spiral of bad decisions despite their extensive training.  That is why I am so enthusiastic about the Vortex Approach discussed here, and will be including it in our airway training from here on out as part of our Oxygenation Over Intubation course curriculum.


Until recently, the approach to emergency airway management has been hampered by historical and tribal legacies: guidelines created for the operating room were extrapolated and imposed on airway care beyond the operating theater. These algorithms often failed to account for the exigencies of other unique environments, or the diversity of providers facing these airway emergencies.

Dissemination of these approaches also routinely suffered from badly designed teaching tools. Failure to factor into the design process the effects of stress led to the dissemination of complex flow charts and detailed airway algorithms that were often ineffective in translating that knowledge into successful clinical action.

The Elaine Bromley case is a notable real world lesson in this reality. It highlights the  direct consequences stress has on even highly skilled clinicians during an airway emergency. I have spoken before on the effects of stress in the failed airway, but still longed for a better way to provide comprehensive airway training that inoculates clinicians against stress, and supports them in effectively prioritizing oxygenation over intubation in any airway emergency.

The Vortex Approach

Enter Nicholas Chimes, and the Vortex Approach with an elegantly simple but remarkably robust and adaptable tool that is built to work in the real world, and designed to account for the effects stress has on providers in an actual airway emergency.  There are many things to love about this approach, but what I love most is that by design it’s focused on reminding the clinical team during a stressful airway that the primary goal is not intubation but oxygen delivery. In my experience the stress induced focus lock on “passing a tube” is a frequent cause of prolonged hypoxia in patients requiring a definitive airway.

The visual representation above is designed to assist with learning by “conceptual imprinting.” What does this mean? Well, compare this to the traditional airway “algorithms” (below) and you can immediately see the difference: while the standard airway algorithm flowchart may be technically correct, it’s neither intuitive, nor is it designed to enhance your recall of those critical actions needed during an airway emergency. As a cognitive tool in an emergency, the flowchart below is also too complex for the stressed brain to rapidly access.


In contrast, the Vortex graphic is a described by Dr Chimes as “high stakes cognitive tool” designed to harness the brain’s natural ability to rapidly absorb visual information, and to assist in the rapid recall of vital information when it’s needed.  For a great introduction to his approach watch the video below before going on.

Here Are the Key Concepts

1. Stay in the Green Zone

The Green Zone refers to any situation in which adequate alveolar oxygen delivery can be confirmed and the patient is no longer at imminent risk of critical hypoxia.

2. Use Your Lifelines

There are three basic lifelines in emergency airway care that can be used to maintain your patient’s oxygenation within the green zone.  Successfully staying in the green zone means skilled use of these tools. Which tool you use depends on the clinical context, the culture of the local environment, and the skill set of the team faced with this emergency.

When successful, the three upper airway lifelines of face mask (FMV), supraglottic airway (SGA) and endotracheal tube (ETT) are equally able to fulfill the goal of alveolar oxygen delivery

3. Optimize Those Lifelines (Best Effort)

When we fail to achieve adequate oxygenation with our current upper airway tool, often we abandon what we are doing rather than optimizing the tool we have to achieve our “best effort.”  Strategies for optimizing each tool can be organized into simple categories (below) so that they can be taught and recalled easily. This vital aspect of airway training is often overlooked in traditional airway algorithms.  Why abandon your BVM when all that may be needed is a jaw thrust, an NPA, or a better two-handed technique?


4. Move On & Prepare for CICO Rescue

With each optimized lifeline attempt that fails to effectively deliver adequate oxygen, the need to prepare for a surgical airway increases.  As you leave the green zone and spiral inward on the vortex, the need to prioritize oxygenation over repeated attempts at an upper airway strategy also increases.



The Vortex Approach is education innovation and design at its finest.  Using a current understanding of how we learn, combined with the realities of how stress affects our proficiency, its creators have built an approach to the emergency airway that is rapidly accessible and easily translated to any any environment where the management of a rapidly deteriorating airway is involved.

Finally there is an approach to the emergency airway that transcends tribal biases,  and can be customized to meet the needs of any clinical environment. The graphics here are from the Vortex website which is beautifully designed and overflowing with great learning and training tools. It wins the award in my book for best medical education design and is my pick for one of the great airway teaching tools of recent years.

Flipping the Airway  – The Vortex Approach
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