CURRENT Essentials of Critical Care.pdf

96 Current Essentials of Critical Care■■■Life-Threatening HemoptysisEssentials of Diagnosis• Hemoptysis with large volume in patient with normal pulmonaryfunction, or smaller volumes if impaired cardiopulmonary function,cough, consciousness• Tuberculosis, tuberculous cavity with aspergilloma (mycetoma),trauma, mitral stenosis; less common with lung cancer• 600 mL hemoptysis in 16 hours has 75% mortality withoutsurgery; 600 mL about 5% mortality• Respiratory failure occurs before hemodynamic compromisewith hemoptysis• Risk factors: coagulopathy, infection, thrombocytopenia, renalfailure• Bronchial arteries source 90%, pulmonary arteries 10%Differential Diagnosis• Severe epistaxis• Upper gastrointestinal bleedingTreatment• Establish and maintain patent airway• Consider endotracheal intubation if cough inadequate; doublelumensplit bronchial intubation useful, but requires experiencedpersonnel to position• Measure quantity of blood expectorated over time• Establish severity of underlying lung disease (chest radiograph,CT scan, arterial blood gases)• Localize bleeding site with fiberoptic bronchoscopy (if mild tomoderate bleeding) or bronchial arteriography• Control bleeding; bronchial artery embolization preferred overemergent surgical resection• Definitive therapy requires surgery but outcome better if delayed• Treat underlying infection (bacterial, tuberculous), correctthrombocytopenia or coagulopathy■ PearlDon’t worry about the patient’s loss of blood; if there is that muchhemoptysis, the patient will asphyxiate first.ReferenceJean-Baptiste E: Clinical assessment and management of massive hemoptysis.Crit Care Med 2000;28:1642. [PMID: 10834728]