Esophageal Balloon Tamponade

1. Indications
   1. Esophageal Varices with Exsanguination
      1. Stabilize until emergent endoscopy
2. Precautions
   1. Emergent endoscopy is preferred if immediately available
3. Contraindications
   1. Esophageal Stricture
   2. Recent esophageal or gastric surgery
4. Mechanism
   1. Balloons inflated within Stomach and esophagus
      1. Applies direct pressure on bleeding Varices
      2. Applies pressure to left gastric vein (supplies the esophageal venous plexus)
5. Types
   1. Linton Tube
   2. Sengstaken-Blakemore Tube
      1. Four proximal ports
         1. Gastric and esophageal balloon ports
         2. Gastric esophageal port (central at proximal end)
         3. Esophageal aspiration port (2-3 cm below the level of the other ports, along the tube)
      2. Long esophageal balloon
      3. Short Stomach balloon
      4. Nasogastric Tube type distal ports for gastric aspiration
6. Technique: Sengstaken-Blakemore Tube Technique
   1. Preparation
      1. Gown and glove with full personal protectection equipment
   2. Endotracheal Intubation
      1. Secure airway
   3. Device
      1. Test balloons for air leaks prior to insertion
   4. Insertion
      1. Insert balloon device in same manner as a Nasogastric Tube and feed to the 50 cm mark
      2. Apply continuous suction to gastric port and esophageal port
   5. Gastric balloon
      1. Inject air into balloon while auscultating over Stomach
      2. Insert 50 cc air into gastric port
   6. Confirm positioning on XRay
      1. Gastric balloon must be in Stomach (not esophagus), otherwise risks Esophageal Rupture
   7. Further inflate gastric balloon
      1. Attach manometer using Y-Tube, and check pressure at every 100 cc of inflation
      2. Inflate gastric balloon to 250 cc by inserting another 200 cc
      3. Balloon filled with Contrast Media and water to allow for confirmation of tube position
      4. Marked increase in pressure may indicate tube displacement
   8. Secure Gastric Tube closure
      1. Apply clamp, red Rubber tubing or tape to gastric port (not hemostats)
   9. Apply traction to tube
      1. Apply counter-balance with the weight of IV fluid bag
   10. Secure the tube
       1. Use an Endotracheal Tube holder
   11. Evaluate for further bleeding
       1. Suction ports
       2. Inflate esophageal balloon to 30 mmHg (using manometer and Y-adapter) if bleeding persists
       3. May further inflate balloon to 45 mmHg if bleeding still persists
   12. Monitor for tube dislodgement
       1. Immediately cut tube to decompress
7. Imaging
   1. Confirm tube placement with xray or Bedside Ultrasound
   2. Serial position checks are required to confirm gastric balloon remains in Stomach
8. Efficacy
   1. Successful for stabilization in >60% of cases
9. Complications
   1. Inability to control bleeding (resulting in death)
   2. Respiratory obstruction
   3. Aspiration pneumonitis (if placed in non-intubated patient)
   4. Mucosal injuries (ulcerations of oral, esophageal or gastric mucosa)
   5. Tracheal rupture
   6. Duodenal rupture
   7. Esophageal Rupture
10. References
    1. Sampson (2016) Crit Dec Emerg Med 30(4): 14-5
    2. Spangler, Swadron, Mason and Herbert (2016) EM:Rap C3, p. 8