55yM with who presents with gradually worsening shortness ...



I. Title: Massive Hemoptysis

II. Target Audience: Medical Students, Residents

III. Author/Affiliation: Christian Young, MD – Dept. Emergency Medicine. Northwestern University School of Medicine

IV. Learning/Assessment Objectives

Recognition

❑ Recognizes indication for continuous pulse oximetry

❑ Recognizes hemoptysis as cause of worsening oxygenation

❑ Recognizes and addresses hypotension

❑ Recognizes pulmonary hemorrhage as cause for hypotension and hypoxia

❑ Identifies left hemithorax as site of hemorrhage.

Management

❑ Appropriate treatment of hypoxia

❑ Anticipates need for escalating O2 requirement – preparations made for airway control

❑ Appropriate reversal of anticoagulation (FFP, Vit K)

❑ Administers fluid bolus in response to worsening hypotension

❑ Places 2nd large bore IV in setting of volume loss

❑ Appropriately orders PRBC transfusion with refractory hypotension

❑ Intubates patient for impending hypoxemic respiratory failure (Large diameter ETT)

❑ Performs selective Right mainstem intubation

❑ Positions patient appropriately (seated more upright, or turned to the left)

❑ Disposition – Was pt admitted to ICU bed?

Data Gathering

❑ CBC, BMG

❑ Sends appropriate labs for anticoagulated patient (PT/INR/PTT)

❑ Blood products ordered in a timely manner

❑ Chest Xray ordered in a timely manner

❑ CT Scan ordered before pt became unstable

❑ EKG ordered

❑ Cardiac Labs ordered

Teamwork:

❑ Appropriate mobilization of staff

❑ Appropriate use of consultants (IR and/or CT surgery)

Systems Related Issues:

❑ Makes appropriate arrangements for ICU admission

❑ Recognizes need for personal protective equipment (respiratory precautions)

Critical Actions:

❑ Supplemental Oxygen to correct hypoxia

❑ IV Fluid orders

❑ Reverses coumadin with FFP and Vit K

❑ Blood Product Orders (PRBCs)

❑ Intubation for hypoxemic respiratory failure

❑ Notification of IR or CT surgery for definitive treatment

V. Source Material:

• Eddy, JB. Clinical assessment and management of massive hemoptysis Crit Care Med 2000; 28:1642-47

• Corey R, Hla KM. Major and massive hemoptysis: re-assessment of conservative management. Am J Med Sci 1987; 294: 301-9

• Weinbergeer S. Etiology and evaluation of hemoptysis. , 1999

• Young CF, Pang P. Hemoptysis. In: Rosen P, Barkin RM, editors. 5-Minute Emergency Medicine Consult. 3rd Edition. Pending Publication. Philadelphia. Lippincott Williams & Wilkins.

• (EKG Visual Stimulus) – Used with Permission

• Lordan JL, ,Gascoigne A, Corris PA. The pulmonary physician in critical care illustrative case 7: assessment and management of massive haemoptysis. Thorax 2003;58:814-819

VI. Environment: ER at a community medical center, with specialty consultants available. 1 dedicated nurse. Additional personnel as needed.

VII. Actors: 1 Nurse or assistant. 1 person to act as consulting physician by telephone

VIII. Case Narrative/Setting:

Upon entering the room, you encounter a mildly dyspneic, but alert and pleasant 55 year old male who presents with gradually worsening shortness of breath over the last 12 hours. The patient has just been transferred to the gurney from the EMS stretcher. The nurse has just placed him on the cardiac monitor. Paramedics have placed an 18 gauge IV in the Left AC.

Phase 1 – Initial Interview

Pt is conversant, awake, but fatigued and mildly short of breath, coughing frequently, but able to give a history and speak in complete sentences

• Mildly Tachycardic (a fib) on the monitor.

• Patent Airway

• 95% RA ( 98% on 2LNC (This information may be withheld until candidate asks for patient to be placed on continuous pulse oximetry)

• Equal breath sounds.

• Mildly hypotensive (100/68)

History:

Pt complains of a “cold” that he’s been fighting off this past week. He notes a persistent cough, with no shortness of breath (initially), but mild exercise intolerance. He attributed this to fatigue from his cold.

Though he thinks this is a cold, he notes no fevers. No chills. No sick contacts. No chest pain. No palpitations. No lower extremity edema. He comes in today because his cough got worse over the past few hours, and he even noted it to be tinged with blood at times. No prior similar symptoms. He decided to come in because his Dyspnea was worsening and he began to notice more blood in his sputum.

PMH: Hyperthyroid

A-fib

High Cholesterol

Mild hypertension

PSH: Angio 2 years ago (“some blockages” but no intervention)

Meds: No aspirin-a-day (due to coumadin)

Lipitor

Atenalol

Coumadin

Prevacid

MVI

SH: Retired construction worker

Smokes 2 PPD

Social Alcohol Use

No illicits

FH: Not sure

ROS: Positive for: Cough, bloody sputum, mild (but worsening) shortness of breath, mild nausea. Otherwise negative

EKG available at phase 1

CXR and labs pending

Phase 2 – Desaturation

Pt is getting more anxious, more dyspneic, and beginning to cough more, asks for something to spit in to get blood out of his mouth. Begins to speak in incomplete sentences. (Rig suction device to control room to simulate increasing volume of expectorated blood in suction canister)

• Dyspnea improves somewhat if O2 is changed to NRB.

• Patent Airway

• 88% RA ( 90% on 2LNC ( 94% on NRB

• Breath sounds diminished on left

• Still mildly hypotensive (100/68)

• Still A-fib, but rate increases to 110s-120s. (down to 100s if fluid bolus given)

Phase 3 - Initial Imaging and Lab Data back:

Pt notes worsening Dyspnea, despite NRB

Starts to complain of slight chest pain, slightly worse on the L. Non-pleuritic. Non-positional.

• Tachycardia continues.

• Sats decrease to 92% on NRB

CXR back: shows a mild left sided infiltrate, similar to that of an early pneumonia

CBC is normal (no leukocytosis should point away from infectious etiology of the infiltrate)

Chem panel: K: 3.1, otherwise normal.. Normal BUN/Cr.

UA (if ordered): Normal

PT/INR: 3.7

ABG (if ordered): 7.38 / 48 / 80 / 26 / +1

Phase 4 – Decompensation

Pt notes worsening Dyspnea. Begins to get slightly agitated and confused. Nurse comments that bleeding is worsening (along with increased blood in the suction canister).

• SaO2 is now 8ml/kg/day in children)

• While only 1000mL/24hr, mortality increases significantly: 58%. (80% if malignancy present)

• If bleeding rate < 1000ml/24hr, motality is 8 French endotracheal tube to facilitate suctioning and subsequent bronchoscopy

o Supplemental Oxygen as needed

o Continuous pulse oximetry and cardiac monitoring

• Massive Hemoptysis

o Principle risk to life is asphyxiation, not exanguination

o Maintain dual large-bore IV access

o Volume resuscitation with crystalloid or type specific blood as needed

o Selective intubation of non-bleeding lung with single or double lumen endotracheal tubes may be required

ED TREATMENT

• Respiratory and droplet precautions for ED staff

• Antibiotic therapy if infiltrate present on chest radiograph

• Correct hypoxemia and/or coagulopathy

• If massive hemoptysis

o Large bore IV or central access with volume resuscitation as needed

o Early involvement of pulmonary, anesthesiology, interventional radiology and/or thoracic surgery

o Pt should be positioned upright, or with side of hemorrhage in most dependent position

o Administer blood products as needed

o Intubation for airway protection, impending respiratory failure, or to facilitate bronchoscopic evaluation of hemoptysis

o Endobronchial tamponade with foley or Fogarthy ( ................
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