LAUSR

Introduction: Esophageal rupture is a known complication of tamponade balloon placement for variceal upper GI hemorrhage. These balloons are placed infrequently and under stressful circumstances by inexperienced providers. We describe a patient with variceal hemorrhage who was transferred from an OSH to a tertiary facility by a physician staffed helicopter EMS agency, in which dangerous balloon placement by the OSH was recognized and corrected prior to transport. Description: Patient was a 66 yo M with alcoholic liver cirrhosis who had presented 1 day prior with massive variceal hemorrhage in whom band ligation had been attempted but failed. Transport for TIPS had been arranged. He was on multiple vasopressors including norepinephrine, vasopressin, epinephrine, phenylephrine, and dopamine with a MAP of 62 mmHg. He was intubated and per report had a Blakemore tube in place with both the gastric and esophageal balloons inflated and on traction. On inspection of the tube however it was found to be a Minnesota tube rather than a Blakemore tube. CXR revealed that the gastric balloon was appropriately placed just below the GE junction but under-inflated with only 250 mL of air, which would be appropriate for a Blakemore tube, but not a Minnesota tube which requires 500 mL of air. More concerning however was that the esophageal balloon was dangerously overinflated. The esophageal balloon pressure was found to be >120 mmHg. The recommended range is 30-45 mmHg. Only after 2-3 seconds of gas release did the pressure fall below 120 mmHg and into measurable range. After deflation brisk hemorrhage recurred which resolved with inflation of the gastric balloon to 500 mL, and the esophageal ballon to 45 mmHg. With administration of additional blood and calcium the patient’s vasopressors were weened and he was safely transported. Discussion: This case highlights both the dangers and utility of balloon tamponade devices. Intensivists may find themselves on the receiving end of these patients in transport. It is critical they have an algorithm for ensuring the devices have been placed correctly and are not causing patient harm. Following this case a checklist for both placement and identification of tamponade balloons was created which has been successfully utilized on subsequent transports and in the hospital.