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)

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Comments

  1. Brian Geyer says:

    Hey Scott,
    Thanks for the great post. We had a run of bad UGIB at my institution of which I was able to participate in the placement of two of these tubes. We placed the tubes through the nose (just like an NG) in both intubated patients with good effect and no immediate complications. Any thoughts on this?

    • wouldn’t be my 1st choice. I’d rather place a bougie blind with intubating LMA, though usually the LMA is enough to shield the glottis and allow fiberoptic intubation.

      • Brian Geyer says:

        Thanks for the quick reply. As busy as I am sure you are, this is a huge deal and your blog fans really appreciate it.

        I ha e to appologize for being unclear. By “tube”, I meant Blakemore tube. The patient was already intubated. Any issues you are aware of with nasal Blakemores?

        On a personal note, I saw you lecture a few years back at ACEP about Adame, et. al 2006 AEM Jan 13(1):114-6. Norberto Adame is a mentor of mine and he dedicated that technique to his friend with the nickname “Mac” who was a flight medic who died in an air ambulance crash. When I told him that it was still being discussed 6 years later at ACEP it brought tears to his eyes. Thanks for that. –Brian

        • Ahhh, gotcha. Yes, you can definitely go nasal. IN the ICU, we prefer to keep the nose free of big tubes (just tiny little feeding tubes). But in this case there are bigger issues and if you can get it in the nose, but not the mouth, go for it.

          Thanks for that personal note.

  2. I’m trying to push for the use of Blackmore tubes in cases of massive GI bleed where endoscopy couldn’t be done in a timely manner. I was wondering if there is any evidence that it works! That will make it easier for me to advocate it’s use.

  3. Scott

    Wondering if you have ever left a SGA ie combitube or king LT in place and then do a VL intubation? I have done a few with a glidescope where you visualize the balloon – place pressure against the balloon to keep air pushed down into the esophageal portion of the balloon while a assistant ie my attending withdraws 10 cc of air at a time. Eventually the cords come into view and are easily intubated with an 8.0 ett and a glidescope stylet. The beauty of this technique is that my RT is ventilating and oxygenating the patient through the SGA. I don’t think this would work with an intubating LMA but if a patient comes in with a combitube or king LT it works really well and I have had no difficulties with this technique. Thoughts?

    • My friend Jim DuCanto is the master of the maneuver you describe and he has done a bunch. He has some great videos of the technique. For me, I’m pulling it, getting my ideal shot at video. If I fail, I immediately place an intubating LMA that will allow me continuous oxygenation/ventilation while intubating through it.

  4. Thank you for this excellent video and inspiring me to practice Blakemore placement!
    Please forgive me if this is a dumb question… When you measure pressures while inflating the esophageal balloon, why do you attach a 2nd 3-way stopcock with an iv extension set? Why not just attach the sphygmomanometer tubing to the free port of the first stopcock? (It looks like that is what Dr. Taddei does in her video.)
    Thanks again for another amazing podcast and video.

  5. The tubes that our hospital carries have a gastric lavage port that looks like the one in your video, but the other 3 ports are much smaller, too small to fit a Christmas tree adapter (link to a pic below). I spoke to the GI guy who uses them fairly often, and he says he puts in some air, takes the tip off of the sphygmomanometer and attaches it directly to the end of the port to see what the pressure is, then adjusts the amount of air from there. Seems really clumsy – any better ideas?

    https://www.google.com/search?q=blakemore+tube&espv=210&es_sm=93&source=lnms&tbm=isch&sa=X&ei=-v-UUtP3IITxkQe_y4CoCQ&sqi=2&ved=0CAcQ_AUoAQ&biw=1040&bih=860#facrc=_&imgdii=_&imgrc=aTs77MjqHIiHtM%3A%3B52JqMZ4_AtAQvM%3Bhttp%253A%252F%252Fstevens.ca%252FProducts%252FMedia%252Ffs%25255C180-204803180.jpg%3Bhttp%253A%252F%252Fstevens.ca%252Fproduct.htm%253FProduct%253D180-204803180%2526Source%253DCategory%2526Category%253DHS-CI02%3B288%3B192

  6. Thanks for the wonderful work as always. I can’t begin to say how much I’ve learned from your site.

    A few questions though:

    Is the point of the gastric ballon to prevent the tube from slipping out, or are you trying to directly tamponade any culprit ulcer, gastric varix/gastropathy bleeder, Dieulafoy lesion, or the like?

    If the pt is bleeding from esophageal varices when you inflate the gastric balloon I’d imagine that all that blood that was making them hypotensive would be coming up rather than down! In which case if you’re placing a Blakemore for esophageal varices then that esophageal suction seems essential. Why not tape a salem sump to the Blakemore with a single piece of cloth tape 2cm proximal to the esophageal balloon to provide continuous esophageal suctioning? That way when you insert the Blakemore you’re also inserting a drain for the esophagus that is exactly where you want it to be and isn’t going anywhere.

    Presumably the pt I’m going to consider placing a Blakemore tube in is already intubated, which means that I may have already placed an orogastric tube anyways. In which case, should I remove that OGT before placing the Blakemore tube?

    Also because you question if ultrasound can be used to detect gastric cannulation, there is some work out there that says “yes”: http://www.ncbi.nlm.nih.gov/pubmed/22100480

    -Matt Wong, @MatthewLWong

    • Matt, the gastric balloon is directly cutting off the blood supply of most of the esophageal varices–it is directly treating them. taping the salem sump makes insertion harder (it already kind of sucks). If you already have an OGT in, it is a toss up whether you should take it out first. Sometimes it stents the esophageal sphincter allowing easier placement, but when you need to yank it (and you will before you inflate the balloon) it may yank out the blakemore.

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