The Blakemore Tube

We EP's pride ourselves on our ability to remain unfazed by a frighteningly unstable patient (a skill that most other specialties do not possess, I'll mind you), but admittedly there is that set of presentations that give even us the chills.  I'm talking about the nightmare super-necky angioedema patient that needs a cric, the peri-arrest pregnant woman who's headed toward a crash section, and the spontaneously delivered 24-week preemie who requires an umbilical artery catheter.

How's about we throw in a cirrhotic with a massively massive variceal bleed into the mix? That's a sphincter flexing sight if there's ever been one.  Let's make the scenario a bit spookier by also having no endoscopist available (unlike our tertiary teaching institution). 

Enter the Sengstaken-Blakemore Tube, basically a last ditch effort for balloon tamponade.  This procedure is not a common one given the prevalence and efficacy of endoscopy (I honestly don't even know where I'd find one in our ED), but when you're all out of options it's either this or a body bag.

First, a little clarification. There are two kinds of tubes: the Sengstaken-Blakemore Tube, and The Minnesota Tube.  For the longest time I had assumed they were one in the same but they are not.  The Blakemore Tube has 3 ports: one for gastric aspiration, one for the gastric balloon, and one for the esophageal balloon.  The Minnesota Tube is essentially the same except it has a fourth port for esophageal aspiration. 

Before you even begin to insert one of these you almost certainly have to take the airway first--and with a massive bleed this alone will be far from easy.  Also, you'll need to make sure both balloons are intact per usual, and then make sure they are completely decompressed before insertion.

When it's time to pass the tube, you can do it either orally or nasally, but orally is generally preferred. Pass the tube in as far as it can go, and then hook up your aspiration port (s) to suction.  You'll need to confirm the placement with a CXR, and some have said that it makes it easier to visualize if you put 50 mL of air into the gastric balloon.

Then, hook up the gastric port to a manometer (doing it with syringes will take too long), and incrementally pump it up to the total volume, which is usually about 450 mL of air (it's a freaking huge balloon, and always use air, not liquid).  After this, you'll need to clamp it, pull back until you feel resistance of the diaphragm, and secure with traction.

Start lavaging with the gastric port.  If it doesn't clear, inflate the esophageal port as well (which requires much less air, usually only 45 mL).  Clamp this one too and monitor the aspiration.  If it continues you may need more traction on your gastric port.  

Here's Scott Weingart running through the drill with the Blakemore Tube (note his patient is already tubed!).

And here's another helpful video from Yale-New Haven Hospital:

Again, this procedure is almost always a last resort, especially as it is fraught with potential complications, including esophageal rupture (why it's so important to confirm placement of that gigantic gastric balloon), mediastinitis, and aspiration pneumonia to name a few.

Just as always, these posts are meant for medical professionals and are meant for EDUCATIONAL USES ONLY.  Do your own research, and be safe.  Stay cool out there!

jps

Sources:

Greenwald, B. (2004). The Minnesota tube: its use and care in bleeding esophageal and gastric varices. Gastroenterology Nursing : the Official Journal of the Society of Gastroenterology Nurses and Associates, 27(5), 212–7

Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition.  Chapter 41. 

Scott Weingart's YouTube Page 

YNHH Clinical Videos YouTube Page

The Nasopharyngeal Endoscope - Your New Best Friend

Often we are faced with patients with swollen uvulae (sp??), throat foreign body sensations, etc., and we desperately want to peek into that mysterious land known as the hypopharynx and see what the deal is. Just the other day I had an elderly yet high functioning man come into our shop with the stated chief complaint of, "I feel like there's a grapefruit in my throat!"

At our institution--a tertiary teaching hospital--the default is to call ENT to "come down and scope them."  However, if you're a DIY-minded emergentologist like us, that doesn't sit right.  And why should it?  While it has a bit of a learning curve it's a reasonably easy procedure that is definitely within our scope of practice (no pun intended). 

Boring disclaimer: We will not be addressing fiberoptic intubations with this post.  That is indeed an incredibly useful skill that despite the demand is not commonly mastered in our field in our time, but we'll tackle that barracuda at a different time.

To get started, you'll need to collect a few things.  Obviously you'll need some sort of flexible endoscope, but you'll also want to get a hold of some 4% lidocaine and an atomizer for local anesthesia. Nebulized lidocaine or 5% cocaine are also options.   You'll want to also use Afrin or Neo-Synephrine as an nasal decongestant as well.  

And be liberal with these guys!  You want them as comfortable as possible, so also give it time to work (we're talking 10-15 minutes, so go take care of other things for a spell while the meds take effect).

Allow the patient to sit up with their head free--you need to give them the ability to pull away in case you poke them in a turbinate.  You also should be directly in front of the patient to accommodate a smooth passage

Lubricate the tip, and slowly advance under the inferior turbinate until you get to the soft palate.  If you fog up at all, don't worry about a defogger--tapping the tip against mucosa will work just fine.  At that point curve down, and after advancing a bit you should have a great view.  You should clearly see any FB's or airway compromise.  Make sure you see the entire structure, including the piriform sinuses.  Check for mobility of the cords while having the patient say, "Eeeeeeee!"

When it's time to withdraw, make sure you come out gently, centering on the tissue so that you don't drag at all.  Easy, right?!?!?  Put it in your toolbox, because this one we can totally handle.  However, and just as it is for any other procedure we write about here, this post is for EDUCATIONAL PURPOSES ONLY.  Be smart!

jps

Sources:

Tom Ashfield's YouTube Page

Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition.  Chapter 63.

Airwaycam.com