Blakemore Now – Bleed Less Later

Gregory Wanner, DO, PA-C
Emergency Medicine Resident, PGY-3

Dimitrios Papanagnou, MD, MPH, EdD(c)
Assistant Professor, Emergency Medicine

It’s 3 am on a Saturday and you’re covering the emergency department at a community hospital. You hear a nurse’s firm but slightly nervous-sounding voice down the hall “umm, I need some help in here.”

You enter the room and find a geyser of blood erupting from the mouth of a middle-aged male patient. His family informs you that he is a heavy drinker and has “liver problems.”

After applying a triple-G (gown, gloves, and goggles) you walk into the room and begin to perform the critical actions of securing the airway, placing large bore IV access, transfusing blood, starting octreotide and calling GI. GI is unavailable and the patient keeps bleeding. He is now severely hypotensive.

  • [expand title=”What else can you do?”]
    The patient is exsanguinating from a likely esophageal variceal bleed. You have tried all other options and GI is not able to help. At this point the use of a gastroesophageal balloon tamponade (GEBT) tube can be considered. The GEBT—more commonly known as a Sengstaken-Blakemore tube or Minnesota tube—is infrequently used and rarely practiced with, but potentially life-saving in certain situations.

    TubeInsert
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  • [expand title=”What is a GEBT tube?”]
    Two types of GEBT tubes are most often available: The 3-lumen Sengstaken-Blakemore tube (often just referred to as a “Blakemore”) or the 4-lumen Minnesota tube. The Blakemore includes a gastric balloon, esophageal balloon, and a gastric aspiration port. The Minnesota tube adds an esophageal aspiration port as well. The function of both tubes is similar—to apply internal pressure in an attempt to stop gastric or esophageal variceal bleeding.[/expand]
  • [expand title=”When would I consider using a GEBT tube?”]
    This device is considered as an option of last resort. A “Hail Mary” play when other treatments have failed and the patient has a high risk of mortality. Starting medications (octreotide), volume replacement (blood products), and a discussion with GI should, ideally, occur before using a GEBT tube. Major complications from the GEBT tube, such as esophageal perforation, occur in up to 16% of patients. Mortality directly related to GEBT tube use is 3-6%. Variceal hemorrhage mortality, however, ranges from 20-80% depending on the reference. [1-2][/expand]
  • [expand title=”How do I use a GEBT tube?”]
    Attempting to learn how to use a GEBT tube while a patient is actively hemorrhaging in front of you is not ideal. A better method would be to review some teaching materials beforehand.
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Here are some resources:

Review these items now (before the exsanguinating patient comes in).

Where is the GEBT tube at Jefferson?
Our GEBT is in the far bed of the trauma/resuscitation bay (room 33T) in the cabinet labeled “Blakemore Tube” for easy recognition, although we actually have a Minnesota 4-lumen tube (image 1). In the cabinet we now have a kit which includes the Minnesota tube plus step-by-step instructions and supplies needed to begin using the tube (image 2).

[tooltip title=”Minnesota 4-lumen” position=”bottom” text=”Located in 33T”]
Bmore33T
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[tooltip title=”Kit” position=”bottom” text=”Step-by-step instructions included”]
BmoreKit[/tooltip]
[expand title=”References”]

  • Cook D, Laine L. Indications, technique, and complications of balloon tamponade for variceal gastrointestinal bleeding. J Intensive Care Med. 1992; 7(4): 212-218. PMID: 10147943
  • Winters ME, Panacek EA. Balloon Tamponade of Gastroesophageal Varices. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Saunders Elsevier; 2014: 831-836.
  • Wanner G, Papanagnou D. Massive Upper Gastrointestinal Bleeding with Gastroesophageal Balloon Tamponade. MedEdPORTAL Publications; 2015. Available from: https://www.mededportal.org/publication/10177
  • Weingart S. Blakemore Tube Placement for Massive Upper GI Hemorrhage. EMCrit website. http://emcrit.org/procedures/blakemore-tube-placement October 13, 2013. Accessed March 5, 2016.

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