The video demonstrates management of an airway which is expected to be straightforward. It would be unusual in most Australian institutions for appropriately experienced senior ED trainees to call an anaesthetist to intubate such a patient and I think this is quite reasonable. I agree all opportunities to optimise PRIOR to inducing patient should be taken advantage of (demonstrating good head position in the mannequin is difficult so that is a sim phenomenon!).

The point is that it was a difficult airway and they were initially unable to ventilate, so yes it did take a while to ventilate. The "rapid" in RSI refers to minimising the time between the patient's drug induced loss of airway protective reflexes and the protection of the airway via a cuffed ETT. If an ETT cannot be placed, however, the goal of ensuring alveolar oxygen delivery takes precedence over "rapid" airway protection. This is a key message of the Vortex approach.

The real question for me is: Why didn't they have a video laryngoscope on hand? Every emergency intubation must be expected to be a difficult airway and in every shock and resuscitation room there should be a video laryngoscope, ideally even a bronchoscope, at the ready. Right after the first intubation attempt, they should have gone to video laryngoscopy.

I agree that all possible optimisations should be implemented pre-induction to maximise the first pass success. The premise of the video is that this has been done as evidenced in the planning phase. The intention of the video was to illustrate use of the Vortex approach when a difficult airway arises, rather than demonstrate an "ideal" attempt at intubation or ways in which difficult intubation could be avoided. To focus on this issue we did not address haemodynamics or apnoeic oxygenation.

Not impressed. If this was not an emergency why were not the anaesthetists called before starting. I would also be critical of the standard of laryngoscopy and the head positioning. As an example of a difficult airway algorithm it is not too bad. I would argue that the best approach to this is to have a true airway expert present if there is time as there clearly was in this case. This is what we call in the UK a can't intubate CAN ventilate scenario. Many of which are avoidable.

Certainly other adjunctive strategies can be used to supplement the Vortex approach. The "Airway Safety Lines" presentation, illustrates how these other strategies articulate with the Vortex.

I appreciate your efforts to improve patient safety and introduce a simple and shared terminology, and I like the term 'green zone'. However better attention to basics would likely render its use unnecessary in this patient. Essential components of 'successful first look', 'no desaturation' and 'no hypotension' were omitted, suggesting the doc might have needed some supervision prior to starting. Despite bravely showing the reality, has an educational opportunity been missed? Cliff Reid

Not convinced by the plan for a classic LMA. Deteriorating conscious state means this patient *will* need a definitive airway. Using an iGel or an intubating LMA means that a successfully placed SGA won't have to be removed to facilitate intubation and therefore there is no risk of losing the airway that you do have. You also can maintain sedation safely meaning a second induction won't be necessary.

Why were they moving so slow? It took awhile to ventilate in my opinion. Nothing was Rapid about this.

Regardless of whether you believe a difficult intubation could be avoided in this specific circumstance, we know these situations can occur despite the best possible preparation. The intention of the video was to demonstrate how the Vortex approach would be instituted if a difficult intubation scenario did arise.

Not one single BP measured 👌🏽😂