The patient's initial laboratory results are as follows:
While in the emergency department, the patient has an episode of coughing and shortness of breath. He brings up approximately 600 mL of blood. His blood pressure is 105/61 mm Hg and pulse is 122/min. He is intubated, and fresh blood fills the endotracheal tube. Which of the following is the most appropriate next step in management of this patient?

Question

The patient's initial laboratory results are as follows:
 While in the emergency department, the patient has an episode of coughing and shortness of breath.  He brings up approximately 600 mL of blood.  His blood pressure is 105/61 mm Hg and pulse is 122/min.  He is intubated, and fresh blood fills the endotracheal tube.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d1fa_200e_bc81_d7c2b12874e0_MD0003_00 This patient has an episode of massive hemoptysis, defined as >600 mL of expectorated blood over a 24-hour period or a bleeding rate >100 mL/hour. The greatest danger in massive hemoptysis is not exsanguination but asphyxiation due to the airway flooding with blood. Initial management involves establishing an adequate patent airway, maintaining adequate ventilation and gas exchange, and ensuring hemodynamic stability. The patient should be placed with the bleeding lung in the dependent position (lateral position) to avoid blood collection in the airways of the opposite lung. Bronchoscopy is the initial procedure of choice in such patients as it can localize the bleeding site, provide suctioning ability to improve visualization, and include other therapeutic interventions (eg, balloon tamponade, electrocautery). (Choice B) High-resolution CT scan of the chest can be used in patients with mild-to-moderate hemoptysis to better visualize the underlying lung pathology. However, this patient is actively bleeding and needs a therapeutic procedure first. (Choice C) Fresh frozen plasma should be given to patients with known or suspected coagulopathy (eg, International Normalized Ratio >1.5) as the cause of hemoptysis. There is no such indication in this patient. (Choice D) Pulmonary arteriography should be performed when there is persistent bleeding and the initial bronchoscopy is unable to localize the source. It can precisely identify the bleeding vessels and be used for therapeutic embolization to stop the bleeding. (Choice E) Urgent thoracotomy and surgical intervention are reserved for patients with unilateral bleeding who continue to bleed despite initial bronchoscopy and/or pulmonary artery embolization. Educational objective: Initial management in hemoptysis involves establishing adequate patent airway, maintaining adequate ventilation and gas exchange, and ensuring hemodynamic stability. Patients should be placed with the bleeding lung in the dependent position (lateral position). Bronchoscopy is the procedure of choice to identify the site and attempt early therapeutic intervention. References: Massive hemoptysis. Assessment and management. (http://www.ncbi.nlm.nih.gov/pubmed/8200191)

The Patient's Initial Laboratory Results Are as Follows