# Blakemore tubes?



## blindsideflank (Jan 28, 2014)

Anyone have any experience with a Sengstaken–Blakemore tube particularly during transport? (Or any similar device)

I just worked my second disaster airway caused by ruptured esophageal varices and despite securing an airway both times my patients have died (last night was DOA). Just wondering if these are possible to be used by us. I know flight crews that have transported with them.

We are a tiered system and although uncommon, I wonder if we could justify carrying them. Do they work well for these cases?


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## VFlutter (Jan 29, 2014)

Eh, I would say no. Blakemore tubes are somewhat complicated and slow to insert. Also, I am pretty sure the standard of care is X-ray verification prior to inflation of balloons.

http://emcrit.org/procedures/blakemore-tube-placement/


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## Carlos Danger (Jan 29, 2014)

It would be nice to see something simpler designed for field use. Like a large Rhino Rocket with hemostatic agent on it.  

How about transporting these patients face down in a trendelenburg position?


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## WTEngel (Jan 29, 2014)

Tough break on the disaster airway man...what deity did you piss off to get that kind of call twice?!?

My experience with ruptured varicosities in the esophagus has been overwhelmingly negative also, both in the field and in the emergency department.

How long are your transport times? I think you managed to accomplish the most difficult task (getting the tube.) If the patient was so far gone that they still bled out, I am not sure how much difference a Blakemore inserted in the field vs. in the hospital would have made, assuming your transport times aren't ridiculously long.

Each time I have seen a case like this, it was doomed from the start.


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## KingCountyMedic (Jan 29, 2014)

WTEngel said:


> Tough break on the disaster airway man...what deity did you piss off to get that kind of call twice?!?
> 
> My experience with ruptured varicosities in the esophagus has been overwhelmingly negative also, both in the field and in the emergency department.
> 
> ...



Exactly.

I've had a fair few over the years, when it's bad. it's really, really BAD. Get the tube, suction, get a bunch of big lines, Levo drip or whatever and a huge diesel bolus. Make sure you are going somplace that can handle it and make extra sure they know what they are getting and can prepare for it. I don't think a Blake tube in the field is possible and that's not usually a first choice in house either from what I've seen. I think the mortality rate is pretty high once they rupture, even in hospital. Sounds like you kicked butt though. Strong work!


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## mycrofft (Jan 29, 2014)

ED surgeons reassure (?) me that esoph varices (varix?) are like a hand grenade in the shirt pocket and a pt can blow some in the OR and still die.


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## CANMAN (Jan 29, 2014)

Yeah tough break for field calls as everyone has said it's just a bad bad thing when it doesn't occur with cold steel, an endoscopy suite, and blood products close by. 

Depending on the rate at which they are bleeding if you have an air medical system close that carries blood products that might be something to consider. These patients will also likely need medications like Sandostatin or Vasopressin which reduces portal pressures and decreases blood flow through the liver.

These patients can be a pain to move interfacility depending on how they have the Blakemore secured. Best option is a football helmet and secure it to the cage. Some facilities are still using a bucks traction type of device which can slow things down a bit to get switched over.


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## TheLocalMedic (Jan 30, 2014)

Wow.  Looks like the insertion of the Blakemore tube is fairly complex and requires x-ray confirmation…  Not ideal for EMS, but an interesting concept.  

I've only had one esophageal varices call, and it was very early in my career as a medic.  It was horrible.  Guy was already crumping when we got there, and didn't last long after.  He was pretty big and I couldn't visualize anything to get a tube in, and a blind insertion didn't hit the mark.  I gave up and just started hauling a$$ to the hospital.  He coded en route and he was pronounced in the ER pretty much immediately on arrival.  

I didn't even know what was going on until the doc explained it to me afterwards.  But it sounds like those kinds of patients are pretty much doomed from the word 'go'.


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## blindsideflank (Jan 30, 2014)

lots of good info guys, thanks. I suppose the blakemore is not the answer, the rhino rocket idea is intriguing, but i guess it comes down to whether these people are even salvageable with something like that.

Just to share a little bit i learned on the call. 
The pooling of blood in the mouth made visualizing cords very difficult. i elevated the head and shoulders a bit to drain a bit down into the esophagus. a simple move we can often forget. I had someone suctioning at the corner of his mouth until i saw cords

once the tube was placed, compliance wasnt great. (probably bagged lots of blood into the lungs). bls was bagging and at one point and i turned to him pushing the tube in and he asked "we were at 23 cm right? AAAAHHHHH!!!  he was obese and difficult to hear breath sounds, and the ETC02 had plugged up with blood. My partner suggested running our bougie through the tube and sure enough it hit the carina. (this was a new technique for me to help confirm)

it was a great call for troubleshooting and since then i have been reading my airway books and this really reinforces the need for a staged approach


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## jwk (Jan 30, 2014)

mycrofft said:


> ED surgeons reassure (?) me that esoph varices (varix?) are like a hand grenade in the shirt pocket and a pt can blow some in the OR and still die.



Ya gotta remember this - varices are a symptom of a much larger disease process that ends in death sooner rather than later.


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## mycrofft (Jan 31, 2014)

jwk said:


> Ya gotta remember this - varices are a symptom of a much larger disease process that ends in death sooner rather than later.



Like chronic alcoholism or liver disease leading to portal stenosis and hypertension.

Wonder if a cricothyrotomy as airway of *first* choice after you get IV access and into the ambulance would make a difference.


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## chaz90 (Jan 31, 2014)

mycrofft said:


> Like chronic alcoholism or liver disease leading to portal stenosis and hypertension.
> 
> Wonder if a cricothyrotomy as airway of *first* choice after you get IV access and into the ambulance would make a difference.



Who's messing around with an IV and moving into the ambulance when the live patient with a pulse doesn't have an airway at all? I'm either intubating or cutting right where I find them, and quickly at that.


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## Medic Tim (Jan 31, 2014)

chaz90 said:


> Who's messing around with an IV and moving into the ambulance when the live patient with a pulse doesn't have an airway at all? I'm either intubating or cutting right where I find them, and quickly at that.



This^^


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## Ridryder911 (Jan 31, 2014)

I've inserted a few Blakemore tubes in my early career, definitely not a prehospital event. Their cuff is huge as it provides tension on the esophageal walls and are usually secured with the patient wearing a football helmet with the tube attached to the mask.

Yeah, definitely a strange look!  I do remember seeing rows of football helmets in the ICU and patient's in bed wearing the device. The device fell out of favor when more new and improved esophagus surgeries and treatment became popular. 

One may consider supraglottic airway that might impede and make visualization more probable to see the glottic opening. In older days; I used the esophageal airway (EOA) to be able to do this. Of course, surgical airway or more advanced airway should be considered if futile attempts. 

R/r911


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## wanderingmedic (Jan 31, 2014)

chaz90 said:


> Who's messing around with an IV and moving into the ambulance when the live patient with a pulse doesn't have an airway at all? I'm either intubating or cutting right where I find them, and quickly at that.



Have you ever cut before? I know its a skill we have, I just do not hear of it being used often.


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## chaz90 (Jan 31, 2014)

azemtb255 said:


> Have you ever cut before? I know its a skill we have, I just do not hear of it being used often.



Nope, never. I certainly wouldn't take it lightly, but I know that in the rare situation it is needed, the decision needs to be made and implemented rapidly.


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## mycrofft (Jan 31, 2014)

chaz90 said:


> Who's messing around with an IV and moving into the ambulance when the live patient with a pulse doesn't have an airway at all? I'm either intubating or cutting right where I find them, and quickly at that.



This is one of those "He's dead if he doesn't get to a hospital five minutes ago" deals the instructors like to confound their students with, and vice versa. Parallels massive closed chest trauma (like old-time steering wheel columns versus sternum without seat belts).

*CPR first*: pumping blood into the esoph, out the mouth and onto the floor. (Essentially a traumatic code, not likely to live anyway). No rescue breathing going in without pushing blood in front of it until bleeding stops (as it always eventually will…..).

*Airway first*: can't see to place it, early* bleeding is trying to clot in oropharynx and larynx where it has been aspirated, late DIC bleeding running all over the place. Pt may also be thrashing and vomiting. Rapidly losing circulating blood cells to carry O2 anyway.

*IV first*: no oxygenation taking place, also may be pulseless. Only real use for this besides drugs (before the heart stops) is to secure a route for replacing blood and platelets later, unless you are carrying them. 

*Transport firs*t: clock is ticking, oldest blood clotting, newer blood running away (DIC), airway non-patent, collapsing vascular bed will prevent any IV access for blood and drugs other than a central line or a lucky cutdown. 

Nothing but STAT major surgery, whole blood and platelets etc will give this pt any chance.   Sitting trying for an airway (or taking too long for an IV or even a pt survey) will not save the pt.

I propose get IV in during the small window it is still possible, run to ambulance, and  while in transit conduct other measures. 

It's an Alamo scene, you and the pt will lose virtually every time, you're playing for points.




Hey, does anyone have a protocol for this they want to share?


*This "early" and "later" bleeding is basically before and after DIC has set in, a matter of a few minutes and a dead heat race with hypovolemic shock.


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## 8jimi8 (Feb 1, 2014)

Ridryder911 said:


> I've inserted a few Blakemore tubes in my early career, definitely not a prehospital event. Their cuff is huge as it provides tension on the esophageal walls and are usually secured with the patient wearing a football helmet with the tube attached to the mask.
> 
> Yeah, definitely a strange look!  I do remember seeing rows of football helmets in the ICU and patient's in bed wearing the device. The device fell out of favor when more new and improved esophagus surgeries and treatment became popular.
> 
> ...



Rid,
What do you think about the intubating LMA?
Our service doesn't carry them, but i used them on cadavers at the SLAM airway conference.  
I'm curious why a crich came into the discussion, i thought the OP secured the airway with DL and ETI?


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## mycrofft (Feb 1, 2014)

I brought up the idea of going to cric promptly if the airway insertion looks dicey, rather than going into an insertion attempt or three where it's pretty obvious it is not going to happen at the outset, then trying a cric after time's up. Not a protocol as far as I know, just an idea.


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## 8jimi8 (Feb 1, 2014)

A crich is for a can't intubate/can't ventilate situation.


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## Handsome Robb (Feb 1, 2014)

Oh crap there goes the neighborhood.

Good to see you back brother


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## Carlos Danger (Feb 1, 2014)

8jimi8 said:


> What do you think about the intubating LMA?



Intubating LMA is awesome. I personally much prefer the Air-Q over the Fastrach. I've placed many of both types, and intubated through them a few times. 

The i-gel is supposed to be the shiznit, but I have yet to use it except on a manikin.

I have no clue why the ILMA hasn't gained more popularity in EMS. They are great devices and have probably done more to (virtually) eliminate emergent crics in the hospital than anything else.

In the setting of a massive GI bleed, an ILMA would be very appropriate IMO.


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## VFlutter (Feb 1, 2014)

Robb said:


> Oh crap there goes the neighborhood.
> 
> Good to see you back brother



RNs are taking over the thread! :rofl:


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## mycrofft (Feb 1, 2014)




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## KingCountyMedic (Feb 1, 2014)

Halothane said:


> Intubating LMA is awesome. I personally much prefer the Air-Q over the Fastrach. I've placed many of both types, and intubated through them a few times.
> 
> The i-gel is supposed to be the shiznit, but I have yet to use it except on a manikin.
> 
> ...



I haven't touched a scalpel since we started carrying the I-Gel, one of the best tools ever.


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## Ridryder911 (Feb 1, 2014)

Fortunately; I've only worked a few ruptured esophageal varices in the field and alike what is most discussing without really saying it; it's a no win situation. I have never seen a _small_ bleed varices and looking at post cadavers with them I could understand why. This is why I cautious or refuse to place an NG/OG tube in high risk patients, (alcoholic; GI bleeds).   

Let's visualize this patient, they have copious amount of bleeding, their vomiting, gurgling, and the suction units containers are filling up pretty fast. Not only an airway problem but they are bleeding and going into shock as well. 

One might say they would immediately crich a patient. Technically I would not disagree on  of these cases. Some of the problems I have encountered on these presentations is locating visualize landmarks on those that are obese, that have anterior or no-neck type  and to make things worse is the large amounts of blood that is is usually associated. Even performing a crich can cause some moderate bleeding (especially that are diluted with ETOH or on anticoagulants)

Unless you really can occlude the esophagus with some type of  occluding device, chances of visualizing the glottic opening is very low; no matter what device you use to intubate. 

In regards with LMA alike with combitubes; it might be worth a try; again since it's the airway from HE*L,  and at this point .... would it hurt? I have used them on those with profuse vomiting and bleeding. 

One can only do what they can at the time. Airway compromise, bleeding that cannot be controlled, one can easily predict the outcome. 

R/r 911


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## rwik123 (Feb 1, 2014)

The box contraindications along with my local protocols contraindicate king use with known esophageal disease. Just food for thought.


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