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
4 thoughts on “Hemoptysis: An EM primer”
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?
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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