Blakemore Tube Placement for Massive Upper GI Hemorrhage

blakemore

In recent lectures, I talk about a life-saving Blakemore Tube placement. I suspect some of you may need a reminder of the intricacies of this device, so I made a video and cheat-sheet.

What you need:

  • Blakemore
  • Salem Sump
  • 60 ml Luer-lock Syringe
  • 60 ml Slip-tip Syringe
  • 2 x-mas tree to male luer lock converters
  • 3 three-way stopcocks
  • 3 medlock caps
  • Surgilube
  • Roller-bandage
  • 1 1-liter bag of crystalloid
  • Optional: 2 Hollister ETAD ET tube securing devices
  • Possibly: Laryngoscope, Magill Forceps
gastric

Gastric Port

Esophageal Port

Esophageal Port

 

How to Do it:

  1. Patient should be intubated and the head of the bed up at 45 degrees.
  2. Test balloons on Blakemore and fully deflate. Mark salem sump at the 50 cm mark of the Blakemore with the tip 2 cm above gastric balloon and then 2 cm above esophageal balloon.
  3. Insert the Blakemore tube through the mouth just like an NGT. You may need the aid of the laryngoscope and sometimes McGill forceps. Make sure the depth-marker numbers face the patient’s right-side.
  4. Stop at 50 cm. Test with slip syringe while auscaltating over stomach and lungs. Inflate gastric port with 50 ml of air or saline.
  5. Get a chest x-ray to confirm placement of gastric balloon in stomach.
  6. Inflate with additional 200 ml of air (250 ml total)
  7. Apply 1 kg of traction using roller bandage and 1 liter IV fluid bag hung over IV pole. Mark the depth at the mouth. The tube will stretch slightly over the next 10 minutes as it warms to body temperature.
  8. After stretching, the tube may be secured to the ETAD tube holder.
  9. Insert the salem-sump until the depth marked gastric is at 50 cm on the Blakemore. Suction both Blakemore lavage port and salem sump. You may need to wash blood clots out of the stomach with sterile water or saline.
  10. If bleeding continues, you will need to inflate esophageal balloon.
  11. Pull salem sump back until the esoph. mark is at the 50 cm point of the Blakemore. Attach a manometer to the second 3-way stopcock on the esophageal port of the Blakemore. Inflate to 30 mm Hg. If bleeding continues, inflate to 45 mm Hg.
  12. Consider switching traction to Hollister ETAD Device.

Here is a cheat sheet for Blakemore Placement in PDF Form

blakemore-icon

Questions to be answered?

  1. Can ultrasound obviate the need for radiographic confirmation prior to inflation? One letter to the editor says yes, but the image doesn’t seem to confirm anything. ( Emerg Med J 2006;23:487)

The Iphone for Head Impulse Testing

Yes, there is an app for that

 

IVC Ultrasound for Non-Invasive Sepsis Protocol

We’re still working on the Greater NY Sepsis Initiative. The next step towards making a non-invasive protocol possible is to teach folks how to use ultrasound of the IVC to assess fluid responsiveness. I developed this video to get ED & ICU docs up to speed. If you can do ANY ultrasound exam, you can do this one.

If you want to see the most recent version of the non-invasive protocol:

Non-Invasive Protocol

The invasive protocol that goes with it can be seen here:

Invasive Protocol

photo from wikipedia

Bougie-Aided Cricothyrotomy by Darren Braude

Darren Braude, Aiway and EMS master from New Mexico demonstrates the use of a bougie to make the cric procedure MUCH easier. For more great Braude magic, see his site at airway911.com.

 

 

 

Procedure: Fiberoptic Stylet-aided Cricothyrotomy by Seth Manoach

This is a video by my friend Seth Manoach, MD. He has been an EM Physician for many years and now is in the midst of a three year critical care fellowship sojourn.

This video demonstrates the fiberoptic stylet-aided cric. In this case he is using a Levitan Scope, but an adult bonfils or any other rigid fiberoptic should work fine.

The airway he is using is the Melker cuffed cric catheter, but I have tried this in trach incisions with 6-0 ET tubes, and 6.0 trach tubes as well.

Here is the article seth put in the literature:

Resuscitation. 2009 Sep;80(9):1066-9.  Development of a rapid, safe, fiber-optic guided, single-incision cricothyrotomy using a large ovine model: a pilot study.

Please note: The sheep in this video was treated with the utmost respect and ethics. It was heavily sedated throughout with tons of thiopental plus ketamine and xylazine.

 

Download the video here

Procedure: Open Cricothyrotomy

The only way I recommend performing cricothyrotomy since 2011 is the Bougie-Aided Cricothyrotomy

Here is an actual Cricothyrotomy

My friend Yen made this cheat sheet for bougie-aided cric

For historical purposes only, here is my video on performing open cricothyrotomy in 3 situations: with a trach set and an assistant, with a trach set when alone, and when you only have a scalpel.

I did a podcast on cricothyrotomies

and then I debated Minh Le Cong on Needle vs. Knife for surgical airways

My friend Ram Reddy has a bunch of great videos expanding on this topic

 

EMCrit Podcast 4 – Awake Intubation

The video for this lecture is up at this link.

Awake intubation can save your butt.

It requires forethought and humility–you must be able to say to yourself, “I am not sure I will be able to successfully intubate this patient.” However, the payoff for this thought process is enormous. You can try an intubation in the ED with very few downsides. If you get it, you look like a star, if you don’t you have not made the situation worse.

Two of my critical care resident specialists, Raghu Seethala and Xun Zhong, volunteered to intubate each other awake. The purpose of this was to let them gain experience, understand what their patients would feel during the procedure, and to prove that awake intubation can be done without complicated nerve block injections or fragile equipment, such as a bronchoscope.

Here is the procedure for ED Awake Intubation–EMCrit Style:

DRY THEM OUT (Do All)

If you can give it early 10-15 min before topicalizing, it will be most effective.

  • Glycopyrolate: 0.2 mg IVP (No central effects – does not cross BBB. You can use atropine, but more side effects are possible)
  • Suction and then pad mouth dry with gauze – you want the mouth very dry!

TOPICALIZE (Do All)

  • 5 cc of 4% lidocaine nebulized @ 5 liters per min
  • Gargle with viscous lidocaine (4% best, 2% ok). Place a blob (~3 cc) on a tongue depressor, put it in the back of the throat and have the patient gargle and then spit
  • Spray the epiglottis, cords, and trachea with 4% lidocaine (3 cc) in a Mucosal Atomizer Device (MAD). The patient will cough during this spraying, wear eye/face protection
  • Have another syringe loaded with 4% lidocaine to spray with during the procedure

Note: the systemic and pulmonary absorption from this method is quite low. The only place to watch out is spraying the trachea. I would not spray more than 2-3 cc down the ol’ windpipe.

SEDATE (Choose one!)

  • Ketamine and propofol in the same syringe makes Ketofol. The classic mix is 50 mg of ketamine to make 5 cc and 50 mg of propofol to make 5 cc. Put these both in a 10 cc syringe and shake. Depending on the patient’s hemodynamics, I sometimes will use more ketamine (75% instead of 50%). Give 1-2 cc every minute until you have the patient relaxed, but still breathing and arousable.
  • Ketamine alone also works just fine. Start with 20 mg and give 10 mg every minute or so.
  • If you have it, Dexmedetomidine also works very well as long as your patient is not bradycardic.
  • If you have neither of these 2 mg of midazolam will do just fine.
  • Preoxygenate with NRB

  • Optimally position (ear to sternal notch) with the head tilted all the way back

  • Restrain both arms with soft restraints to prevent the “grabbies”

  • Switch to nasal cannula

  • INTUBATE with Fiberoptic laryngoscope and bougie

  • If the patient coughs or is uncomfortable after placing the bougie through the cords, push the remainder of the ketofol syringe.

  • Thread  the tube over the bougie with the laryngoscope still in the mouth

  • Confirm tube placement

That’s all for this week

For more info on awake ED intubation, you can view a complete lecture here

Thanks to Raghu and Xun for risking their singing careers and to Jimmy & Anita for technical support. *
The opinions on this site and in the video represent the author’s and not the opinions or policies of the Mount Sinai School of Medicine or Elmhurst Hospital Center. It is not my intention to provide specific medical advice for any individual patient. Please confirm anything on this video with your own clinical judgment and the policies and procedures of your institution. This video is for education purposes only; it does not represent a standard of care or clinical advice.
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