"A 61-year-old white male with previous history of pulmonary right upper lobectomy is admitted to the ER with chief complaint of hemoptysis. While in the ER he coughed up 700cc of blood and started to become short of breath". What would you do?"
Primary causes of hemoptysis are:
TB and/or Lung abscess (or fungal ball), TB is the most common cause of massive hemoptysis in ER.
Arteriovenous fistula (rare).
Cardiac causes (mitral stenosis).
Most massive hemoptysis are from an erosion into a bronchial artery and not the pulmonary artery branches (that have low pressure), and massive hemoptysis by definition is the expectoration of more than 600cc of blood in a 48 hour period.
The management of hemoptysis is as follows:
Turn the patient to the side of bleeding lung with the good side up (if known or from the CXR). Take a brief history.
Give 100% 02 by mask, start IV, get CBC and PT, PTT and T&X match, and CXR.
Take the patient to the OR and perform a rigid bronchoscopy, suction well and find out which side is bleeding.
If the bleeding is coming from the left bronchus, insert #8 Fogarty occluding catheter into the left bronchus and inflate the balloon. Remove the rigid bronchoscope and intubate the trachea. If the bleeding is coming from the right bronchus, you will not be able to tamponade it by the Fogarty catheter because the right bronchus is very short. It is better in this case to remove the rigid bronchoscope. Thread an ET tube over a flexible bronchoscope and intubate the left bronchus with the flexible bronchoscope assistance and inflate the ET tube balloon.
Your goal here, obviously, is to protect the good lung from aspiration of blood. Once you have an ET tube in place and you are ventilating a good lung, you should send the patient to arteriogram and selective bronchial arteries embolization. If this fails or the patient becomes unstable from continuing bleeding, thoracotomy and pulmonary resection becomes mandatory. (For Hemoptysis during Swan Ganz insertion see Miscellaneous chapter).