[Ventricular fibrillation caused by a misplaced Sengstaken tube]

Uncontrollable hemorrhage from esophageal varicose veins in portal hypertension and cirrhosis of the liver may be treated with a Sengstaken-Blakemore tube. A case of ventricular fibrillation caused by a misplaced Sengstaken-Blakemore tube is described. Patients with a Sengstaken-Blakemore tube in place should be checked by a trained nurse for early signs of misplacement of the tube.