#EMconf: Gross Hemoptysis

-Epidemiology: True incidence unknown, males>females, age >40, smoking history
-Anatomy: Lung has duel blood supply: 1) Bronchial arteries (high pressure supporting structures of lungs)  2) Pulmonary arteries (low pressure/supply alveoli) 
-Causes: Infectious, neoplastic, cardiovascular, hematologic, alveolar hemorrhage, traumatic, inflammatory, iatrogenic 


-Massive Hemoptysis:
      -Only 5% of cases but 80% of mortality 
      -Definition varies but from 200ml to 1000ml in 24 hours or >150ml at one time 
      -If bleeding >1000ml in 24 hours; mortality approaches 60%, 80% association with malignancy
      -If bleeding <1000ml in 24 hours; overall mortality <10% but higher with underlying malignancy
      -Causes: Bronchiectasis, TB, cavitary lung cancer, lung abscess, tracheobronchial fistula, pulmonary angiodysplasia
      -Diagnostic Evaluation: CXR first, then CT and brochoscopy may be necessary 
      -Treatment: Secure airway first!   Threat is asphyxiation, not exsanguination 
      -Airway Considerations: 
           -Aim for 8.0 ETT: allows bronchoscopy, suctioning 
           -Position patient with bleeding lung down if possible 
           -Selective intubation: intubate normal, non-bleeding lung for ventilation 
           -Treatment Tips: Transfuse blood products as needed, consider TXA, early pulm/critical care consult, consider angiograpy and embolization, lobectomy/pneumonectomy last resort