Ep 188 Hemoptysis – ED Approach and Management

Hemoptysis can be a hair-raising presentation to the ED. Stellar management of patients with massive hemoptysis requires understanding a few key principles and a flexible approach. In this podcast Anton is joined by EM and intensivist trained Dr. Bourke Tillmann and Dr. Scott Weingart to explore both an approach to life-threatening hemoptysis and one to hemoptysis that is not life-threatening. They answer questions such as: what are the factors to consider in the decision to intubate patients with massive hemoptysis? How can one reliably distinguish hemoptysis from pseudohemoptysis? What is the evidence for tranexamic acid in patients with hemoptysis? What are the best strategies for suctioning blood from the airway to improve visualization during endotracheal intubation in crashing hemoptysis patients? What is the role of bronchoscopy and how should it be integrated into the hemoptysis management algorithm? How does one's hemorrhage control strategy change when pulmonary embolism is the underlying diagnosis? and many more... Podcast production, sound design & editing by Anton Helman; voice editing by Braedon Paul Written Summary and blog post by Alex Chan, edited by Anton Helman November, 2023 Cite this podcast as: Helman, A. Weingart, S. Tillmann, B. Hemoptysis - ED Approach and Management. Emergency Medicine Cases. November, 2023. https://emergencymedicinecases.com/hemoptysis. Accessed December 6, 2024 Résumés EM CasesHemoptysis key principles  * Patients are poor at identifying the source of bleeding expelled from the mouth and often confuse hemoptysis with an upper airway or GI source; it is imperative to differentiate hemoptysis from pseudohemoptysis * Early diagnosis, usually by chest CT with contrast, is important in guiding management * Source control of the bleeding, which is usually from bronchial arteries, is the ultimate goal in management, which usually requires early involvement of interventional radiology and/or thoracic surgery and/or respirology; call for help early * Once the side of bleeding in the lungs is identified by either chest X-ray, CT or during mainstem bronchus intubation, patients should be positioned bleeding lung down in lateral decubitus to prevent contamination of the contralateral lung * Hemorrhage control measures including consideration for nebulized tranexamic acid (TXA) should be employed as a bridge to definitive treatment/source control * Death from hemoptysis is most often due to respiratory arrest, akin to drowning, rather than exsanguination, and management should be directed accordingly * Patients are generally better at clearing blood from their lungs by coughing compared to suctioning and airway control measures, so keep the patient spontaneously breathing and coughing whenever feasible; definitive airway management should be considered carefully and only when the patient is no longer able to clear blood spontaneously * The definition of massive hemoptysis is unclear; more importantly, life-threatening hemoptysis can be identified by signs of respiratory distress, airway obstruction or abnormal gas exchange * Suctioning of blood with either a meconium aspirator or Ducanto suction catheter is recommended to allow for adequate visualization during endotracheal intubation; standard suction catheters such as Yankauer catheters may not be adequate * Cricothyrotomy should be performed in situations where su...