This paper was presented as a poster at 2019 XVIIIth Congress of the European Shock Society and IXth Congress of the International Federation of Shock Societies.
Intractable massive oronasal bleeding can become a life-threatening condition. The success rate of conventional bleeding control methods other than transarterial embolization (TAE) is not expected to be high. We investigated the efficacy of Sengstaken-Blakemore tube (SBT) balloon tamponade in patients with sustained and intractable oronasal bleeding secondary to facial injury.
This study is a retrospective chart review from traumatic patients with sustained and intractable oronasal bleeding who were admitted to the emergency center of Ajou University Hospital and Soonchunhyang University Bucheon Hospital from January 2014 to December 2016.
Twelve patients were included in the study, of whom nine (75%) were male. The median age was 31 years (range, 20–73 years). Bleeding was controlled in 11 of the 12 patients (91.7%) either temporarily or definitively. One patient without hemostasis underwent TAE. TAE was performed in an additional three patients out of the 11 patients with hemostasis who experienced continued nasal bleeding after the removal of SBTs. There were no complications from performing the procedure.
Using SBTs as a hemostatic tool will aid patients with life-threatening intractable oronasal bleeding. Furthermore, this method may be used in patients with continual and intractable oronasal bleeding after facial trauma as a bridging procedure from the emergency department or the intensive care unit to the interventional radiology.
The success rate of conventional oronasal bleeding control methods other than transarterial embolization is not expected to be very high. Transarterial embolization requires specialized equipment, so it cannot be commonly performed in all institutions.
Using Sengstaken-Blakemore tubes as a hemostatic tool will help the patients with life-threatening intractable oronasal bleeding. Furthermore, this method may be used in the patients with intractable oronasal bleeding after as a bridging procedure from the emergency department or the intensive care unit to interventional radiology.
Maxillofacial injury, accounting for 10% of all trauma patients, is often accompanied by numerous complications, such as airway compromise, intracranial hemorrhage, cervical spinal cord injury, and intractable oronasal bleeding [
Sengstaken and Blakemore described the Sengstaken-Blakemore tube (SBT) as a salvage therapy for esophageal varix bleeding in 1950 [
We hypothesize that the SBT is a useful hemostatic device for patients with oronasal bleeding secondary to facial injury. The esophageal and gastric balloons of the SBT play a role for tamponade, stabilizing the oronasal space. Morita et al. [
This study is a retrospective chart review from consecutive traumatic patients with sustained and intractable oronasal bleeding who were admitted to the emergency center of Ajou University Hospital and Soonchunhyang University Bucheon Hospital from January 2014 to December 2016. This study was approved by the institutional review board of Soonchunhyang University Bucheon Hospital (2018-12-008-001). Informed consent was waived due to the retrospective nature of chart review study. The inclusion criteria were age ≥18 years old, blunt trauma, facial injury with a face abbreviated injury scale score ≥3, transfusion of ≥3 units of packed red blood cells within 24 hours, and insertion of an SBT for hemostasis. We excluded patients who were pregnant or had a history of hematologic disease and patients with other organ injuries, e.g., hemothorax, hemoperitoneum, and fractures involving the major extremities.
We inserted SBTs into the patients to manage their life-threatening oronasal bleeding secondary to facial injury at emergency departments. Prior to the procedure, all patients received advanced airway management, such as endotracheal intubation, and the balloons of an SBT were tested for defects. We performed the procedure under aseptic conditions with a surgical drape, gown, sterile gloves, a mask, and headcover. The SBT was cautiously inserted along the floor of the nasal cavity and was aimed at the patient’s mandibular angle to prevent a possible basal skull fracture. This process was crucial for avoiding the significant fracture involving the midface and aggravated or displaced cribriform plate. Subsequently, the SBT was secured inside the oral cavity with its tip held firmly at the oropharynx. A second SBT was inserted into the other nasal cavity in the same manner (
We retrospectively investigated age, sex, mechanism of injury, diagnosis, laboratory findings, success rate of the procedure, initial vital signs including the Glasgow Coma Scale (GCS), and mortality. The success of the procedure was determined by visual assessment of bleeding control and hemodynamic stability. The balloon pressure for the esophageal balloon was maintained at 30 to 40 mmHg to avoid the development of ischemic necrosis in the nasopharynx mucous membrane, which was monitored every 6 to 8 hours. We removed the SBTs after three days of use. We described continuous data as mean and standard deviation or median and interquartile range.
This study included 12 patients, of whom nine were male (75%). The median age was 31 years (range, 20–73 years).
We managed either to control bleeding temporarily or definitively in 11 of the 12 patients (91.7%). One patient without hemostasis underwent TAE (case 3). TAE was performed in an additional three out of the 11 patients with hemostasis who experienced continued nasal bleeding after the removal of SBTs (cases 1, 8, and 11).
One female patient was in cardiac arrest upon arrival at the hospital (case 10). The return of spontaneous circulation was achieved through cardiopulmonary resuscitation. SBTs were inserted to stop oronasal bleeding. Despite stopping the bleeding, cardiac arrest reoccurred due to a severe head injury. The patient died 7 hours post-arrival at the hospital.
The overall mortality rate was 41.6%. Hypovolemia was not the cause of death. Two of the patients died of disseminated intravascular coagulation (cases 2 and 8), and three patients died from severe head injuries (cases 4, 5, and 10). The time to death from hospital arrival ranged from 7 to 1,329 hours. The initial GCS scores for the expired patients were below 8. The GCS scores were 7 for two patients and 3 for three patients. Four of the seven survivors were discharged with a cerebral performance category (CPC) score of 1, and three survivors had a CPC score of 3.
The average initial hemoglobin level for the 12 patients was 11.33 g/dL. Three hours after the insertion of SBTs, the average was 10.17 g/dL. An average of 11.8 packed red blood cells was transfused within 24 hours.
Mean arterial pressure improved (average change from 60.82 to 84.73 mmHg) 3 hours after the SBT insertion in 11 patients with successful hemostasis. Heart rate did not significantly change after the successful hemostasis, with the average change from 100.45 to 105.73 beats/min.
No complications, e.g., malposition of the tube and necrosis of the mucous membrane, were reported in the patients who underwent the SBT procedure.
Sustained and intractable oronasal bleeding after blunt facial injury is rare [
Initial attempts to control the bleeding are carried out typically using non-invasive and easily applicable methods like gauze packing. This type of method uses a nasal tampon approach to compress the bleeding site directly with gauze packing, a urinary catheter, or Bellocq tamponade. However, their reported success rates for bleeding control are relatively low, ranging from 47% to 79% [
The subsequent selections for consideration to control the bleeding are MMF or TAE. Bleeding control by TAE in cases of maxillofacial bone fractures has shown a high success rate of 90% owing to the recent development of transvascular interventions, such as embolization [
In our study, SBTs were applied as a hemostatic procedure, which met the conditions mentioned above. The success rate of hemostasis was 91.7%, and all patients were stabilized hemodynamically. However, three patients underwent TAE because of prolonged bleeding following tube withdrawal.
Our method has the following advantages. First, the chance of success in controlling continual oronasal bleeding is high. Bleeding control can be achieved by dual functions of the balloons, i.e., direct compression on the bleeding sites as well as stabilization and temporary traction around the oronasal cavity. In many cases, the main culprit of sustained and intractable oronasal bleeding is the oral cavity that contains soft tissues only and no solid structures [
Possible complications are as follows. First, the direct compression on the soft tissues may cause soft tissue necrosis. It could be prevented by regularly deflating the balloons, or as needed, and re-inflating them. Second, for severe fractures like basal skull fracture and le Fort III, fracture displacement can be aggravated by the insertion of the SBT tube. Therefore, the procedure protocol should be thoroughly followed.
Life-threatening hemorrhage is defined as the loss of three units of blood in 2 hours and a decrease in the hematocrit level to less than 21% [
Our present study has several limitations. First, this study had a retrospective design that used medical records. Second, the number of patients included in the study was not sufficiently large, since the incidence of uncontrolled epistaxis due to facial trauma was 9.4% [
In summary, using SBTs as a hemostatic tool may be considered an option for the management of life-threatening intractable oronasal bleeding in the case of immediate unavailability of TAE. Furthermore, this method could be used in patients with lifethreatening intractable oronasal bleeding after facial trauma as a bridging procedure from the emergency department or the intensive care unit to the interventional radiology suite. Further investigation is necessary to evaluate the efficacy of using SBTs as a hemostatic tool in patients with traumatic and intractable oronasal bleeding.
No potential conflict of interest relevant to this article was reported.
Sengstaken-Blakemore tube application procedure for controlling intractable oronasal bleeding. (A) Insertion toward the mandible angle. (B) Grasping the Sengstaken-Blakemore tube tip at the pharynx. (C) Inflation of the gastric balloon. (D) Inflation of the esophageal balloon.
A patient with the Sengstaken-Blakemore tubes’ insertion due to intractable oronasal bleeding. Informed consent for publication of the clinical image was obtained from the patient.
Brain computed tomography scan images of a patient who received the Sengstaken-Blakemore tubes. (A) Inflated esophageal balloons (*) in the nasal cavity. (B) inflated gastric balloon (+) in the oral cavity. Informed consent for publication of the clinical image was obtained from the patient.
Demographic characteristics of patients with life-threatening intractable oronasal bleeding
Case | Age/sex | Mechanism | Diagnosis (fractures) | Pre-SBT |
RBC (units) | Post-SBT (3 hr) |
E | Result |
|||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
GCS | BP (mmHg) | HR | Hb (g/dL) | BP (mmHg) | HR | Hb (g/dL) | CPC | D | TTD (hr) | ||||||
1 | 20/F | TA Passenger | B, O, N, Z, Mx, Mn | 15 | 106/70 | 117 | 12.6 | 4 | 119/73 | 112 | 7.3 | + | 1 | ||
2 | 29/M | TA Driver | B, O, N, Mx | 7 | 140/59 | 116 | 12.6 | 14 | 142/75 | 99 | 12.5 | 5 | + | 1,329 | |
3 | 73/M | TA Pedestrian | O, N, Z, Mx | 11 | 142/75 | 100 | 8.9 | 16 | 65/46 | 96 | 5.9 | + | 3 | ||
4 | 27/M | Fall 10 m | B, O, N, Mx, Mn | 3 | 86/47 | 148 | 14.1 | 17 | 106/53 | 118 | 7.2 | 5 | + | 40 | |
5 | 42/M | TA Driver | O, N, Z, Mx, T, S | 3 | 53/31 | 88 | 9 | 14 | 81/50 | 94 | 10 | 5 | + | 9 | |
6 | 29/M | TA Driver | O, N, Z, Mx, Mn | 15 | 140/59 | 116 | 11.2 | 18 | 142/75 | 99 | 11.5 | 1 | |||
7 | 43/M | Fall 8 m | O, N, Z, Mx, Mn | 15 | 75/40 | 120 | 9.6 | 7 | 140/85 | 125 | 8.5 | 1 | |||
8 | 54/F | TA Pedestrian | B, N, Mx, S | 7 | 95/54 | 68 | 9.8 | 5 | 110/75 | 100 | 11.5 | + | 5 | + | 678 |
9 | 33/M | TA Driver | N, Z, Mn, S | 14 | 78/56 | 112 | 13.5 | 10 | 95/60 | 113 | 13.5 | 1 | |||
10 | 25/F | Fall 12 m | B, O, N, Z, Mx, T, S | 3 | 0/0 | 0 | 16.3 | 13 | 73/54 | 60 | 11.3 | 5 | + | 7 | |
11 | 54/M | TA Passenger | B, O, N, Z, Mx, Mn, T, S | 11 | 60/30 | 110 | 10.3 | 7 | 130/73 | 120 | 11.5 | + | 3 | ||
12 | 29/M | Fall 7 m | N, Z, Mx, Mn | 11 | 121/81 | 110 | 6.8 | 8 | 130/93 | 123 | 10.7 | 3 |
SBT, Sengstaken-Blakemore tube; GCS, Glasgow Coma Scale; BP, blood pressure; HR, heart rate; Hb, hemoglobin; RBC, red blood cell; E, embolization; CPC, cerebral performance category; D, death; TTD, time to death; TA, traffic accident; B, basal bone; O, orbital bone; N, nasal bone; Z, zygoma; Mx, maxillary bone; Mn, mandible; T, temporal bone; S, sphenoid.