Balloon Tamponade of Gastrointestinal Bleed

I’d like to apologize for the recent dearth of updates.  However, we now have a nice backlog of new content to share with you, and it should be going up quickly over the course of the day.

First up, regular contributor and fourth year UK Med stud Chris Belcher shares some thoughts on the Minnesota Tube and its use in the ED.  Take it away, Chris:

 

So pretend that you’re a hot shot resident on your second night of moonlighting in a small community ED.  For conversation’s sake, let’s pretend that you’re way out in the hills of Eastern Kentucky (it’s clinically relevant).  You’re cool as a cucumber because your last shift was smooth sailing—you converted an SVT with a whiff of adenosine, sewed up a few lacs, and eased the fears of the worried well.  You expect nothing but blue skies.

An hour into your shift a patient is rushed into your ED on a stretcher and there is blood EVERYWHERE.  And it appears to be coming straight from the patient’s mouth. Excessively.  And let’s pretend that on quick glance this Eastern Kentucky patient has a large, protruding abdomen with a tint of yellow to both the skin and eyes (along with shades of rouge now from all the blood.)

Vitals are BP 90/40, HR 130, O2 sat 90% on NC on full blast, RR 30 and the patient is obviously having trouble breathing because of all the blood.

Most likely, a (BAD) variceal bleed in a cirrhotic patient.  Who is actively trying to die.

So, Maverick, what will you do?

Firstly, two things. The patient can’t protect their airway.  They need some plastic in their throat (DUAL MEANINGFORESHADOWING!)   And the patient is bleeding out.  Activate a massive transfusion protocol of some type.

But now how will you control the bleeding?  Endoscopy, right?  But you’re in the middle of nowhere Kentucky and the closest GI doc is sleeping soundly in their bed an hour away.  This patient is actively trying to elope from your ED in the worst possible way.  So how you gonna control the bleeding without endoscopy?!?   If your own HR is less than 100 bpm at this point, you must be beta blocked.  For a temporary and possibly lifesaving fix, we turn to our great friends of the North and the great state of Minnesota for their contribution to the world of GI bleeds—The Minnesota Tube.

MT1

Note:  Dr. Sakib actually had nothing to do with the creation of the Minnesota Tube.  But is there living the awesome intern life.  Enjoy winter, my Yankee friend.

MT2

What is this Tube of the North?

The Minnesota Tube is a 4-port tube placed in the esophagus in order to tamponade bleeding—most commonly bleeding esophageal varices.  The four ports connect to two balloons (an esophageal and gastric balloon) and two aspiration ports (again, eso and gastric).

The original idea is credited to Blakemore and Senkstaken and was a 3-port design with no esophageal aspiration port.  This was appropriately named the Senkstaken-Blakemore tube but is most commonly referred to as the Blakemore.

MT3

Minnesota tube with four ports.  Also note pt vomiting sparklers.

MT4

Blakemore with no esophageal aspiration port

When does one use this Blakemore?

Indications for both tubes are when your patient is actively trying to expire due to ruptured esophageal varices or other gastro-esophageal bleeding issues that may be suspectible to tamponade.  More commonly seen in cirrhotic patients or others who are susceptible to increased portal pressures and varices. Once again, it’s less likely that either tube is necessary if GI is available for scope unless the patient’s status can’t wait for GI or GI isn’t able to stop the bleeding.  In short, use as a last ditch effort to stop bleeding when medical or endoscopic treatment fail or aren’t available.

MT6

Strawberry ice cream or esophageal varices…?

MT5What do I do with my hands..? (aka how to use it)

Chris Nickson has already done a very easy to follow step-by-step guide on lifeinthefastlane.com so I won’t reinvent the wheel.

http://lifeinthefastlane.com/education/ccc/senkstaken-blackmore-and-minnesota-tubes/

But some key points:

  1. Know your equipment (at least have practiced with it before trying to pull it out for the first time in this situation)
  2. Always have the patient intubated beforehand.  If they have enough bleeding to warrant a Minnesota tube, they’re not able to protect their airway. And emesis (and aspiration) is more likely after tube placement.
  3. Consider sedation.  These are not comfortable.  And they should be intubated already.
  4. Test pressures of inflated gastric balloon beforehand to help decide if you’re in the stomach when inflating inside the patient.  Major cause of morbidity/mortality is inflating the gastric balloon in the esophagus. Don’t be that guy.
  5. Consider confirming position of gastric balloon with x-ray before inflation.
  6. This is only a temporary measure until definitive treatment can be made due to the high risk of complications.

 

End result/Complications

-Complications are numerous–emesis/aspiration, perforation of the esophagus or GE junction, very uncomfortable for pt, more bleeding, balloon migration, and necrosis

-Balloon migration is especially dangerous in the non-intubated patient as the balloon can block the hypopharynx.  Yet another reason to go ahead and intubate beforehand.

-Different sources cite different lengths of time but the balloons should not be left in place due to the risks of complications, especially pressure necrosis.  Less than 24 hrs. is a good goal.

 

MT7

End product. Strong work, Maverick.

Quick Hits Summary

– Blakemore and Minnesota Tubes are used for tamponade of bleeding varices

-Blakemore= 3 lumens (gastric balloon, eso balloon and gastric aspiration ports); Minnesota= 4 lumens (above+esophageal aspiration port)

– Used when medical treatment and endoscopy fail/aren’t available

-TEMPORIZING AGENT before definitive therapy; can’t leave in long

– intubate before and check placement of gastric tube before and after inflating

– watch for complications

Contributor: Chris Belcher

References

1. Attar BM. Chapter 52. Balloon Tamponade of Gastrointestinal Bleeding. In: Reichman EF, Simon RR, eds. Emergency Medicine Procedures. New York: McGraw-Hill; 2004. .

2.  Witting MD, Hooker EA. Chapter 89. Gastrointestinal Procedures and Devices. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011

3.  Nickson, C.  Sengstaken-Blackmore and Minnesota Tubes.  http://lifeinthefastlane.com/education/ccc/senkstaken-blackmore-and-minnesota-tubes/

 

 

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: