Massive Hemoptysis
Considerations
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Emergency, full stomach, limited time to optimize
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Etiology of hemorrhage & patient comorbidities:
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Infection (tuberculosis), bronchiectasis, malignancy, arteriovenous malformation, pulmonary artery catheter, trauma
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Difficult airway & requirement for rapid lung isolation to prevent contralateral contamination & asphyxia
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Facilitation of subsequent definitive treatment: bronchial artery embolization, lung resection
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Resuscitation of hemorrhagic shock
Goals
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Prompt mobilization of resources (OR, surgeon, interventional radiology) & effective communication between various parties
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Rapid management: airway protection, resuscitation & stabilization, localization of bleeding site, & administration of specific therapy
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Rapid isolation of non-bleeding lung (double lumen tube vs bronchial blocker vs endobronchial intubation; bleeding lung down)
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↓ bleeding: bleeding lung up after selective bronchial intubation (↓ effective pulmonary artery pressure on that side), CPAP to bleeding lung (for tamponade effect), reversal of anticoagulation
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Optimization of oxygenation & ventilation to both lungs (good lung down, CPAP to bleeding lung)
Management
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Mobilize resources, call thoracic surgery
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Monitors, large IVs x2, 100% O2
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Lateral position with bleeding side down
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Call for blood, resuscitate if hemodynamically unstable, correct coagulopathy
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Secure airway if problems with gas exchange:
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Best done in the OR with thoracic surgeon/rigid bronchoscope available
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Awake intubation vs RSI
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Double lumen tube vs single lumen tube endobronchially or with bronchial blocker
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High frequency jet ventilation may be life saving
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Suction, suction, suction
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Once isolated, CPAP to bleeding side may help tamponade the bleeding site
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May need to urgently go to OR for rigid bronchoscopy or thoracotomy