#EMConf: Massive Hemoptysis
What makes massive hemoptysis massive? - Classic teaching is 100 cc/h but really it's an amount of blood that is causing hemodynamic instability, airway obstruction or abnormal gas exchange.
Why did this patient go into cardiac arrest? - Asphyxiation as the tracheobronchial tree can hold ~ 200 cc.
Why does this patient have massive hemoptysis? - Likely secondary to the fungus ball eroding into bronchial artery.
- 90% of bleeds secondary to involvement of the high pressure bronchial arteries.
- 10% of massive hemoptysis involve pulmonary arteries which give off larger volumes but at lower pressures.
What are some etiologies for massive hemoptysis?
- The Big 3 for massive hemoptysis are:
- Infection: TB, Pneumonia, Lung Abscess, Cavitary lesion like Mycetoma
- Mass/ Neoplasm
- Other etiologies include PE, AVM, Connective Tissue Disease, Diffuse Alveolar Hemorrhage, Trauma
- More on management and the resolution of this case to be discussed next week.
- Airway or Asphyxiation
- Reverse coagulopathy, resuscitate for hemorrhage
- Localize the bleed
- Refractory hypoxemia on mechanical ventilation is a shunt problem; some ARDS maneuvers are applicable in this situation
- Early consultation
- Pulmonary for bronchoscopy
- IR and CTA when stable for embolization
- Thoracic Surgeon
- Consider systemic TXA