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Hemoptysis: An EM primer

Author: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) // Edited by: Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF)

 

Basics

-Most episodes are mild and resolve on their own

-Disruption of blood vessels w/in airways (bronchial circulation is high-pressure system)

Don’t hesitate to ask for help from consultants, as even small amounts can cause asphyxiation

Definitions variable: Minor = small volumes in stable patient with no comorbid lung disease; Massive: 100 to >1,000mL / 24 hrs

 

Etiology

Infectious: acute bronchitis (most common), pneumonia, tuberculosis, lung abscess, fungal ball, parasites

Structural: COPD, bronchiectasis, hypersensitivity pneumonitis, AV fistula, tracheoarterial fistula, aortobronchial fistula

Neoplastic: lung/metastatic cancer, adenoma

Cardiovascular: PE w/ infarct, CHF, endocarditis, mitral stenosis, pulmonary hypertension, congenital heart disease

Iatrogenic: bronchoscopy, lung biopsy, pulmonary artery catheter

Traumatic: FB aspiration, lung contusion, deceleration injury, penetrating trauma

Vasculitides: SLE (diffuse alveolar hemorrhage, pleuritis), Goodpasture’s, Wegener’s, Behcet’s

Miscellaneous: anticoagulation therapy, cocaine/heroin inhalation, pulmonary endometriosis, NO2 inhalation

 

Clinical presentation

-Is this hemoptysis or epistaxis / hematemesis?

-Patient history semi-reliable for this clinical entity; tailor history-taking to rule in/out above etiologies

-Examine sputum if able

Airway evaluation up front

 

Diagnosis

Potential useful labs: CBC, BMP, coags, UA, type and screen

-Start with CXR, followed with chest CT if patient stable for transport

 

Management / Disposition

-Minor

CXR, labs above as needed

Reassurance, follow-up with primary care

 

-Massive

Airway management: intubate with large-diameter (8-0) ETT, cric set-up; affected lung down; consider intubating good lung or tamponading bleeding lung with Fogarty catheter

Resuscitate with IVF + blood products PRN // reverse coagulopathy

-Emergent IR consult: bronchial artery embolization

-Emergent Cardiothoracic surgery consult; who needs surgery => TI fistula, aortic aneurysm, thoracic trauma, iatrogenic pulmonary artery injury

CT chest: if HD stable, consider obtaining to guider further treatment

Bronchoscopy: assess for bleeding vessel and treat

ICU admission

 

References / Further Reading

– Rosen’s 8th edition

– Harwood-Nuss 6th edition

http://emergencymedicinecases.com/tracheo-innominate-fistula/

http://www.tamingthesru.com/blog/ebcp/hemoptysis

http://first10em.com/2015/03/24/massive-hemoptysis/

http://foamcast.org/2015/08/22/episode-33-hemoptysis/

http://www.ncbi.nlm.nih.gov/pubmed/25493149

http://www.ncbi.nlm.nih.gov/pubmed/24412020

http://www.ncbi.nlm.nih.gov/pubmed/23358891

2 thoughts on “Hemoptysis: An EM primer”

  1. Would love to see a paper on whether minor hemoptysis with no red flags for cancer, TB, coagulopathy, etc. needs a chest x-ray. Did you uncover any?

    1. No strong evidence that I found. Think what you propose is reasonable and thoughtful. Similar idea: not every CP pt needs a CXR…

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