Hemoptysis Robert Corder, MD

Emerg Med Clin N Am
21 (2003) 421–435
Hemoptysis
Robert Corder, MD
Department of Surgery, Division of Emergency Medicine,
University of Maryland School of Medicine,
419 West Redwood Street, Suite 280, Baltimore, MD 21201, USA
Hemoptysis is the coughing up of blood from the respiratory tract. The
term comes from the Greek words haima meaning blood, and ptysis meaning
spitting. Respiratory disorders of many kinds include as a part of their
manifestations the complaint of hemoptysis. The emergency physician’s
expertise often is sought by the patient who has noticed blood in their
sputum. Hemoptysis bestows fright, anxiety, and the potential for a life
threatening condition to the patient. As the differential diagnosis is broad
and the severity of bleeding potentially great, the emergency physician must
have a structured approach to the initial assessment, stabilization, proper
use of diagnostic options, educated treatment choices, and appropriate referral to specialists. An introduction to bioterrorist agents that cause hemoptysis as part of their symptomatology is presented here. This article
attempts to assist the emergency physician in their approach and decision
making with the patient presenting with hemoptysis. Although any hemoptysis causes great concern for the patient, the amount of expectorated blood
dictates the course of diagnosis and intervention. Massive hemoptysis may
result in hemodynamic instability and impaired gas exchange in the alveoli,
whereas minor hemoptysis, defined as production of smaller quantities
of blood, will likely resolve spontaneously and recur infrequently. The literature varies when defining massive hemoptysis. The range of 200–1000 mL/
24 hr has been noted [1]. Most investigators in clinical papers, however,
use an amount of expectorated blood of 600 mL/24 hr as being massive,
because of the observance of impaired oxygen transfer when approximately
400 mL of blood is in the alveolar space [2].
E-mail address: [email protected]
0733-8627/03/$ - see front matter Ó 2003, Elsevier Inc. All rights reserved.
doi:10.1016/S0733-8627(03)00009-9
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Assessment
Differentiating hemoptysis from pseudohemoptysis (when blood in the
sputum originates in the nasopharynx or oropharynx) and hematemesis
(the vomiting of blood) is commonly a difficult task. Patients frequently
are unclear about the origin of the blood and the amount expectorated,
both of which are essential in forming a plan to diagnose and treat. A
thorough history helps make this distinction. The emergency physician
should ask about the color of blood, changes in color of stool, patterns of
bleeding, presence of fever, history of smoking, and complete review of
systems.
Blood in the lungs can originate from bronchial arteries, pulmonary
arteries, bronchial capillaries, and alveolar capillaries. Bleeding associated
with infection and inflammation is typically from bronchial capillaries and
often is accompanied by mucopurulent secretions. Bleeding from alveolar
capillaries tends to remain in the alveoli, often with scant hemoptysis, but
can be extensive and associated with severe respiratory decompensation.
Low-pressure pulmonary arteries are an uncommon source of hemoptysis,
but can result in massive blood loss when a tumor erodes and forms an
anastomosis with the bronchial tree. The higher systemic pressure bronchial
arteries are the most common source of bleeding in 90% of cases of massive hemoptysis. Massive hemoptysis, however, accounts for only 1.5% of
all hemoptysis [3]. These vessels are adjacent to the bronchial tree. When
chronic bronchial inflammation causes bronchial artery hypertrophy,
eventual rupture of the fused vessels to the walls of weakened airways
results in bleeding. This sequence is implicated in hemoptysis from bronchiectasis, tuberculosis (TB), and mycetomas. The appearance of the blood
can offer clues to its cause. Red, frothy blood mixed with purulent sputum
is likely associated with an underlying pulmonary infection. If a monthly
pattern of bleeding occurs in a menstruating woman, a diagnosis of pulmonary endometriosis or catamenial hemoptysis should be considered.
Prior weight loss may be an indication of cancer. Night sweats, generalized illness, and fever may suggest TB. Risk factors for other causes
in the differential diagnosis should be elicited. Age, smoking history, recent
travel, known valvular heart disease, trauma, other bleeding disorders, and
pleuritic chest pain with shortness of breath are factors in considering
causes.
A list of conditions known to cause hemoptysis follows.
Known causes of hemoptysis
Pulmonary parenchymal disease
Bronchitis
Bronchiectasis
Tuberculosis
Lung abscess
Pneumonia (bacterial, viral [4])
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Cavitary fungal infection (aspergilloma)
Lung parasites (ascariasis, schistosomiasis, paragonimiasis)
Pulmonary neoplasms
Pulmonary infarction/embolism
Trauma
Arteriovenous malformations
Pulmonary vasculitis
Goodpasture syndrome
Pulmonary endometriosis
Wegener granulomatosis
Cystic fibrosis
Pulmonary hemosiderosis
Extrapulmonary disease
Heart failure
Coagulopathies
Mitral stenosis
Drugs (anticoagulants, cocaine, penicillamine)
Iatrogenic
Rupture of pulmonary artery by balloon-tipped catheter
Bioterrorism
Pneumonic plague
Tularemia
T2 mycotoxin
Tuberculosis is the most common cause of hemoptysis worldwide. The
tuberculosis bacillus has infected an estimated 2 billion people worldwide,
with 5%–10% expected to develop the disease [5]. The most common causes
of blood in the sputum in the United States and other industrialized
countries are bronchitis, bronchiectasis, and bronchogenic carcinoma, with
prevalences of 2%–40% [6]. Acute and chronic bronchitis are estimated to
account for up to 50% of cases. The underlying cause of 15%–30% of cases
is never found and is referred to as cryptogenic or idiopathic hemoptysis [7].
Bronchogenic carcinomas account for 90% of lung cancers, with 20% of
sufferers complaining of hemoptysis at some point and 7% being diagnosed
from an initial presentation for hemoptysis.
Hemoptysis is unusual in children. Cystic fibrosis, vascular anomalies,
aspiration of foreign bodies, and bronchial adenomas are the most common causes of hemoptysis in children. More than 50% of bronchogenic
neoplasms in children are bronchial adenoma [8]. Persons returning from
travel in or being native to Asia, South America, and the Middle East may
present with hemoptysis as a result of parasitic infections, including paragonimiasis or schistosomiasis. Emergency physicians also should be sensitive to unusual geographic and temporal clustering of illness or unusual age
distribution of common diseases as indicators of intentional release of a
biologic agent. Historical facts give clues to other diagnostic possibilities.
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A smoker over the age of 40 years with duration of hemoptysis lasting longer
than 1 week is at higher risk for carcinoma as its cause [9]. Goodpasture
syndrome should be considered if hematuria accompanies a person’s
complaint of hemoptysis. A complaint of dark stool color together with
blood in the sputum may signal a gastrointestinal source of bleeding or could
result from hemoptysized blood that has been swallowed. Patients with
massive hemoptysis have described a warm sensation or ‘‘gurgling’’ in the
chest that may correspond with the site of bleeding. A recurrent complaint of
blood in the sputum over time should place arteriovenous malformations,
bronchiectasis, and cystic fibrosis higher on the list of differential diagnoses.
Local chest pain may accompany hemoptysis being caused by pulmonary
embolism (PE), pneumonia, or carcinoma. At times the emergency physician
is faced with the obtunded patient, requiring other resource use. Patient
charts, EMS personnel, family members, and possible observers must be
queried about past medical history, events of trauma, and medications.
Physical examination
Evaluations for respiratory and cardiovascular compromise are critical
elements in the emergency physician’s initial efforts in assessing hemoptysis.
The patient with bleeding to the degree of causing impairment of gas
exchange, the interference with ventilation, or cardiovascular instability requires prompt, decisive action. Supporting oxygenation and ventilation with
endotracheal intubation using an endotracheal tube sufficient in size to
allow the passage of a bronchoscope is necessary. Securing vascular access
adequate for invasive hemodynamic monitoring and infusion of fluids and
blood products for resuscitation also should be performed. Most patients
presenting with hemoptysis, however, allow for a thorough history and
physical examination.
Although useful in assessing cause and sometimes severity of bleeding,
the physical examination can be unreliable in localizing the site of bleeding.
Inspection of the thorax may be helpful in the case of the patient with
hemoptysis in the context of trauma. Looking for signs of blunt and
penetrating injury are important and likely will provide information in
localizing the site of bleeding. Auscultation of stridor, wheezing, diffuse
crackles, or diminished focal breath sounds may cause suspicion for focal
obstruction from a foreign body, bronchiectasis from chronic obstructive
lung disease, congestive heart failure, or consolidation of blood. The
emergency physician should bear in mind that a normal lung examination
can be present with most causes of hemoptysis. Pseudohemoptysis should be
considered if a source of bleeding is observed in the nasopharynx or
oropharynx. The heart examination may reveal an S4 or diastolic murmur
consistent with congestive heart failure from uncontrolled hypertension or
mitral stenosis.
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The prompt assessment of vital signs assists the emergency physician in
deciding initial and subsequent steps in the management of hemoptysis.
Baseline changes in blood pressure are unusual except in some cases of
massive hemoptysis or sepsis. Pulse oximetry can be used as a guide in
measuring oxygenation but its accuracy is limited when patients are hypoxic
and hemoglobin saturation is less than 90%. It also provides no measure of
arterial CO2 tension. An arterial blood gas measurement may be necessary
to determine adequacy of efforts of ventilation and circulation. The assessment of hemoptysis also includes diagnostic radiology, sputum examination, laboratory studies, computed tomography, bronchoscopy, and
arteriography.
Chest roentgenogram
Chest radiographs are an essential component of the assessment of every
patient presenting with hemoptysis. If possible, a posterior-anterior (PA)
and lateral film should be obtained. If the clinical scenario prohibits this,
then an anterior-posterior (AP) film is needed. Results may show conditions that predispose to hemoptysis or distribution of extravascular blood
in the lungs. They may show signs, however, of chronic lung disease not
directly associated with the current complaint of hemoptysis. Pathology
may include cavitary lesions, infiltrates, atelectasis, or tumors. A fine
reticulonodular pattern can represent intra-alveolar bleeds or a pneumonia.
Not only can the chest radiograph help in diagnosing the cause and in
localizing bleeding, but also it can identify patients needing specific urgent
further diagnostic measures, specific interventions, and possible outpatient
elective procedures. Interpretation of chest radiographs is normal or nonlocalizing in 20%–40% of patients with hemoptysis [10].
Sputum examination
Examination of sputum is an adjunctive test whose necessity is guided
by the differential diagnosis. If an infectious etiology to the hemoptysis is
suspected, sending a sputum sample for Gram stains and acid-fast stains
should be done. Cultures for bacteria, fungus, and mycobacterium should
be obtained if clinically indicated. A sputum smear for cytology may be obtained if cancer is suspected by history, if the patient is a smoker, is older
than 40 years of age, and has suspicious findings on chest radiograph. This
may prove unnecessary, however, if bronchoscopy is anticipated. If there is
doubt that the sputum contains blood, a chemical test for occult blood
should be performed. If the pH of the blood is alkaline, it is likely to be from
the respiratory tract. If acidic, the blood is likely from another source. If
alveolar macrophages are present, the blood is likely hemoptysis, but is
hematemesis if there are food particles present.
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Additional laboratory studies
The severity of bleeding, the most likely cause of bleeding, and the
patient’s past medical history, associated symptoms, and current medications are among the considerations when the emergency physician is
deciding what laboratory tests will be useful in the diagnosis and management of a patient complaining of hemoptysis. A complete blood
count with differential may help quantify blood loss, provide support for
an infectious etiology, or show a sign of coagulopathy in the case of
thrombocytopenia. Prothrombin time and partial thromboplastin time
determination also is recommended if a coagulopathy is suspected based on
the history of anticoagulation use or clinical appearance of ecchymoses or
petechiae. If the patient is hypotensive, has a new anemia, has apparent
massive hemoptysis, or has an anticipated course that includes further blood
loss, sending blood for typing and cross match is indicated. Arterial blood
gases should be sent to assess oxygenation, ventilation, and circulatory
adequacy in patients with signs of hemodynamic instability and respiratory
impairment. If fluid resuscitation is indicated, serum chemistries should be
sent for evaluation of baseline values. Urine analysis is not commonly required in the assessment of hemoptysis unless a vasculitis or Goodpasture
syndrome is suspected. Urine output should be monitored in all patients
presenting in shock and requiring resuscitation.
Computed tomography
The role of high-resolution computed tomography (CT) has changed
over the last decade, during which it served primarily an adjunctive role. The
decision to obtain a chest CT should be based on the pretest probability of
specific findings and the acuity of the clinical situation at hand. A patient’s
initial treatment is rarely formulated based on the results of an initial CT.
In cases of massive hemoptysis with hemodynamic instability, resuscitation
and stabilization are initially required before CT. Bronchoscopy, arteriography or radioisotopic ventilation–perfusion scans may be earlier in the
algorithm. CT is the modality of choice for diagnosing bronchiectasis [11].
In cases of hemoptysis with normal chest radiographs, the CT has proven to
be helpful. In a study by Millar et al [12], causes of hemoptysis were found in
50% of patients evaluated by CT who had normal chest radiographs and
normal fiberoptic bronchoscopy. Given the 20%–40% rate of presentations
of hemoptysis with normal chest radiographs, CT is preferred over other
modalities in the stable patient complaining of hemoptysis. The optimal CT
technique described by Naidich et al [13] consists of 1–2-mm-thick sections
obtained every 10 mm from the thoracic inlet to the lung bases, with spiral
sequences from the level of the aortic arch to just inferior to the level of
the pulmonary veins, including intravenous contrast enhancement. Abnormalities reliably diagnosed on CT include peripheral masses, alveolar
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consolidation, bronchiectasis, and abnormal enhancing vessels. CT not only
can optimize detection of many pulmonary abnormalities, it can help direct
possible surgical intervention and facilitate sampling for cytologic and
microbiologic studies. CT is quick, noninvasive, and less costly than other
modalities. The emergency physician also may arrange a followup CT when
formulating a disposition for the stable patient complaining of mild
hemoptysis and having a normal initial screening chest radiograph, particularly when the patient has a history of smoking and age greater than
40 years.
Ventilation-perfusion scans
Ventilation-perfusion (VQ) scans are important studies in patients
suspected of having hemoptysis from PE or infarct, particularly in the case
of a normal chest radiograph. The emergency physician must select the
study based on patient risk factors and symptoms consistent with this lifethreatening cause of hemoptysis. The study is performed once the clinical
scenario allows for the patient to be transported for the test.
Evidence of distinct perfusion abnormalities not matching the ventilation pattern in the patient with a high pretest probability for PE is reliably
diagnostic. The normal perfusion scan effectively rules out PE, although
almost 4% of near-normal VQ scans in the PIOPED study [14] showed
PE on pulmonary angiogram. The difficulty lies in interpreting the intermediate and low probability scans and may lead to subsequent pulmonary
angiography. Once a diagnosis is proved or disproved, appropriate further
treatment and disposition decisions can be made.
Bronchoscopy, pulmonary arteriography, and surgery
The emergency physician should know about indications regarding the
need for invasive measures of diagnosis and intervention. No absolute parameters have been formulated for their use. Aggressive use of these options, however, should be exercised for patients presenting with massive
hemoptysis and signs of respiratory or hemodynamic compromise. These
modalities all require prompt communication with pulmonary, radiologic,
and surgical consultants. The role of the emergency physician in these cases
is that of stabilizer and facilitator, as these skills typically lie beyond the
scope of their expertise. In facilitating this evaluation, it is necessary for the
emergency physician to perform endotracheal intubation using an endotracheal tube (ET) with an internal diameter of 8 mm or greater. This achieves
the result of supporting oxygenation and ventilation while allowing passage
of the bronchoscope through the ET tube. Flexible fiberoptic bronchoscopy
is used emergently to visualize the origin of bleeding and can be used to
control it also. It is a technique that is safe, can be performed at the patient’s
bedside often without general anesthesia, and can evaluate bleeding down to
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the fifth or sixth bronchial orifice. It can be used to obtain specimens by
biopsy, washing, and brushing to aid in bacteriologic, histologic, and
cytologic evaluations. The downside of using the flexible scope is that its
suctioning abilities are inferior to the larger diameter rigid scope. The
flexible bronchoscope, however, allows the introduction of balloon catheters
to tamponade sites of bleeding. The balloon at the distal tip of the catheter is
inflated into the bleeding segmental bronchus as a hemostat, known as
endobronchial tamponade, described in 1974 by Hiebert [15]. This technique
often is used as a temporizing measure until more definitive embolization
or surgical intervention can be achieved. The control of bleeding also can
be achieved by the infusion of a vasoconstricting drug, epinephrine for
example, directly through the bronchoscope channel into the bleeding
bronchus. Intrabronchial infusion of a hemostatic agent like fibrin precursors has been used also [16]. Also, precision laser photocoagulation
has been attempted with the use of fiberoptic bronchoscopy [17]. Rigid
bronchoscopy is a second modality using a larger diameter tube with resultant greater suctioning capability in the case of massive hemoptysis. It
reliably maintains a patent airway. It commonly requires general anesthesia,
although conscious sedation can be used. It has limited use in accessing the
upper lobes or peripheral airways; therefore, sites of bleeding expected in
these areas of the lungs are better evaluated with a flexible bronchoscope or
angiographic technique.
It is generally recommended that if the site of bleeding identified is limited
to one lung, that side should be kept in the dependent position while the
patient is laterally recumbent. This protects the unaffected contralateral lung
from complications arising from aspiration of blood from the affected side.
No controlled studies have tested this theory, however.
The most effective nonsurgical treatment for massive hemoptysis is
bronchial artery embolization (BAE) [1]. Selective angiography is performed
initially to locate the site of bleeding. Then a substance is injected into
the bleeding bronchial artery. The embolizing materials include Gelfoam,
isobutyl-2-cyanoacrylate, and steel coils. A 24-hour success rate of 98% has
been reported, with a 1-year rate of bleeding recurrence of 16% [18]. More
recently, Swanson et al reported a 30-day success rate of 85%, rebleeding
within 30 days of 9.8%, and a 15.6% rate of rebleeding at 30 days [19].
When arterial embolization temporarily controls but does not provide definitive treatment, it serves the purpose of decreasing the risks associated
with surgical resection by stabilizing the patient.
Any time a patient presents with massive hemoptysis, a thoracic surgical
consult should be obtained. As selective angiographic and bronchoscopic
techniques improve, however, surgery is considered another option in the
treatment of massive or recurrent hemoptysis. Nonsurgical options are required in conditions in which surgery is contraindicated. Such entities
include lung carcinoma invading the parietal pleura, great vessels, heart,
mediastinum, and trachea. Surgery also is discouraged in patients with other
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conditions that render them poor candidates for surviving surgery or
tolerating life after lobe or total lung resection. These conditions include
COPD, CHF, and pulmonary fibrosis. During acute life-threatening hemoptysis, there is a 30%–40% operative mortality when treated surgically
[20]. Some investigators and clinicians believe bronchoscopic and radiologic
approaches to the management of massive life-threatening hemoptysis are
preferred to surgery. In an article by Haponik et al, results of a survey
of chest clinicians attending a respiratory emergency symposium were
published [21]. The article compared answers to questions on management
of life-threatening hemoptysis at the Annual Scientific Assembly of the
American College of Chest Physicians in 1988 and 1998. They showed that
50% of clinicians preferred interventional radiography to surgery compared
with 23% questioned in 1988 (P\0.0001). Only 14% found endobronchial
measures worthwhile. They concluded approaches other than surgery have
become more widely accepted in that span of 10 years.
Surgical treatment of massive hemoptysis remains preferred when caused
by arteriovenous malformations, chest injuries, leaking aortic aneurysm,
hydatid cyst, bronchial adenoma, fungal lesion refractory to other therapies,
and iatrogenic pulmonary rupture. The specific choice of intervention depends on many factors, including whether the emergency department has
thoracic surgery capabilities, whether angiography is readily available,
whether a pulmonary critical care specialist is a realistic resource, and
whether there is a critical care bed open. If the emergency physician is
practicing in a rural or community hospital without these resources, initial
hemodynamic and respiratory stabilization efforts may be all that is possible
to temporize the situation before transfer to another facility.
Bioterrorism
The practice of using living organisms or their toxins as weapons against
humans and domesticated animals dates back to 400 BC when arrow tips of
Scythian archers were dipped in manure, blood, and tissue of decomposing
corpses and then shot at their enemies [22]. Refinement of biologic weapons
had to wait for science to unravel the modes of transmission and microbiology of pathogens. As the effects of the September 11, 2001, attacks on
the World Trade Center and Pentagon and subsequent terrorist use of
anthrax have settled in, awareness, screening, and prevention programs have
been developed. Several suggested protocols have been written that provide
guidance to healthcare workers and public health personnel in recognizing
health patterns and illness possibly associated with the release of biologic
weapons [23]. Biologic weapon construction requires less financial and
intellectual capital than chemical or nuclear weapons [24]. As a result, the
list of countries suspected of having biologic weapons programs has grown
to 17, according to the Office of Technology Assessment’s 1995 report. The
threat of bioterrorism is real and the emergency physician must be prepared
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to recognize, appropriately triage and treat, notify appropriate agencies, and
protect unaffected individuals.
There are three agents that have been weaponized and that cause
hemoptysis as part of their symptomatology: plague, tularemia, and T2
mycotoxin. A brief introduction to these entities follows.
Plague
The organism responsible for this disease is Yersinia pestis, a gramnegative bacillus primarily infecting rodents. Its transmission to humans is
from the bite of an infected rodent flea. The bacilli multiply intracellularly
within regional lymph nodes, followed by development of fever, chills, and
painful swollen lymph nodes called buboes. These symptoms of bubonic
plague occur 2–8 days after a bite. Hematogenous spread to the lungs occurs
in 12% of patients, which causes pneumonic plague, a pneumonia with
hemoptysis, chest pain, shortness of breath, and cough. It then can spread
through aerosolized droplets from person to person. Weaponized Y pestis
has eliminated the need for the animal vector. The Soviet military reportedly
has aerosolized large amounts of Y pestis for weaponization. The World
Health Organization estimates 36,000 deaths and 150,000 cases of pneumonic plague if 50 kg of Y pestis were released over a city of 5 million
people [25]. Currently no commercially available vaccine is available to
protect against weaponized primary pulmonary plague from an aerosolized
attack; however, research is ongoing. A person suspected of being exposed
to pneumonic plague should be treated immediately. If asymptomatic, a
7-day prophylactic course of oral doxycycline should be given. Alternative
choices would be ciprofloxacin or chloramphenicol. If a person complains of
cough, fever, or hemoptysis, intravenous gentamicin or streptomycin should
be started. The same treatments are recommended for pregnant woman at
risk and children. Untreated pneumonic plague has a 100% mortality rate.
Clinical suspicion of plague in the context of a bioterrorist attack may be
based on presentation of many patients with rapidly progressive pneumonia with hemoptysis. Sputum, blood, cerebrospinal fluid (CSF), and lymph
nodes should be obtained as indicated for Gram, Wright, Wayson, or
Giemsa stain and culture. The laboratory should be notified of the suspicion
for plague so culture temperatures are maximized for rapid growth and
identification of the capsular antigen. These tests should be ordered with
the knowledge and assistance of the public health service, state health
department, Centers for Disease Control (CDC), or military laboratory.
Tularemia
The organism responsible for the disease is Francisella tularensis, an
aerobic, gram-negative coccobacillus. Natural transmission of disease is
from contact with skin or mucous membrane of a carcass or body fluid of an
infected animal. Onset of disease typically is 3–5 days after inoculation.
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Clinical manifestations depend on route of exposure. As an aerosolized
weapon, F tularensis likely would take the typhoidal form and 80% of cases
would be complicated by pneumonia. Symptoms would be influenza-like,
with complaints of fever, chills, myalgias, arthralgias, dyspnea, pleural pain,
and hemoptysis. The diagnosis might be suspected when a large number of
patients present with similar influenza-like illnesses and atypical pneumonia.
The diagnosis is difficult. Chest radiographs and complete blood count
(CBC) may be normal. Samples from sputum, pharyngeal exudates, gastric
aspirates, and blood should be obtained. The organism grows only on
special media, and because it is hazardous to work with, cultures must be
sent to a biosafety level 3 laboratory (ie, double door entry, inward airflow,
nonrecirculating air) [26]. Blood should be sent for PCR, ELISA, and pulse
field gel electrophoresis. Serology has limited use, as 2 weeks must pass for
antibody titers to reach diagnostic levels. For postexposure prophylaxis,
doxycycline should be given for 14 days. Treatment of choice for disease is
intravenous gentamicin. A live attenuated vaccine is commercially available.
If left untreated, typhoidal tularemia has a mortality rate of approximately
35%.
T2 mycotoxin
Tricothecene mycotoxin is extracted from filamentous fungi like
Fusarium, Trichoderma, and Stachybotrys. The toxin’s mechanism of injury
is through inhibiting protein synthesis in rapidly dividing cells of bone
marrow, skin, and mucosa. The toxin is heat stable, and when aerosolized it
is known as ‘‘yellow rain.’’ Symptoms after exposure include hemoptysis,
sore throat, cough, and burning of skin that progresses to necrosis.
Diagnosis should be considered in the setting of possible biologic attack,
the presence of the mentioned symptoms, and observation of a pigmented oily
residue on patients and surrounding environment. Samples of blood, tissue,
and from the physical surroundings can be sent for gas liquid chromatography
for confirmation. No rapid assay or test is available. Supportive treatment is
recommended, including removal of clothing, skin decontamination, administration of activated charcoal if exposure is through ingestion, and saline
irrigation for eye exposure. The other causes to consider are mustard gas
exposure or other chemical blistering agents. There is no vaccine or antitoxin
available.
The role of the emergency physician in the event of terrorism has been well
demonstrated. The importance of their ability to consider bioterrorism in the
differential diagnosis depends on the context of the surrounding events. A
system of triage, decontamination, obtaining specimens, notifying appropriate local, state, and federal agencies, and treatment should be implemented in
the emergency department. The emergency physician performs a central role
in the event of bioterrorism, and the need for familiarity with the possibilities
cannot be overstated.
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Management
Hemoptysis is a common complaint with a spectrum of causes. The amount
of bleeding and its effect on the patient’s respiratory and cardiovascular
system dictates initial assessment and management decisions. The following
outline for the treatment of hemoptysis provides a framework based on
stability and estimated blood loss. Respiratory and circulatory considerations
are similar to other patients whose organ systems are being affected by other
disease process. Decisions on the use of specific diagnostic and radiographic
modalities are predicated on known diagnostic and therapeutic yields.
Massive hemoptysis
When patients report hemoptysis estimated at 400–600 mL/24 hr or if
they are observed to cough up > 100 mL/hr in the emergency department
and have signs of tachypnea, hypoxia, or respiratory distress, they are at risk
for death. Obtain the best history and initial physical assessment that time
and the patient’s condition allow.
Maintain ventilation and oxygenation
1. Provide oxygen as needed: 2–10 L/min by way of nasal cannula or
mask.
2. Provide suction.
3. Secure airway with endotracheal intubation with size 8 mm inner
diameter ET tube or greater if clinically indicated.
4. Chest radiograph to confirm ET tube placement and screen for
affected side of bleeding and other lung pathology. Consider placing
affected side in dependent recumbent position.
5. Monitor using continuous pulse oximetry, ventilator parameters, and
arterial blood gas measurements as needed.
Maintain circulation
1. Place two intravenous catheters adequate for resuscitation and infusion of blood products.
2. Obtain blood for CBC, coagulation studies, type, and cross-matching
for appropriate number of units of packed red blood cells and fresh
frozen plasma if correction of coagulopathy is indicated. Other blood
work is sent, depending on clinical scenario.
3. Begin resuscitation with infusion of crystalloid solutions adequate for
the hemodynamic state of the patient, a total of 2–3 L of rapid
infusion for shock or hypotension followed by blood.
4. Monitor hemodynamics by frequent measurement of blood pressure
and pulse, follow urine output; may require central venous pressure or
arterial line assessment.
Perform a more extensive physical examination and obtain history of the
hemoptysis and possible contributing factors from family, friends, EMS
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personnel, or other observers. Early pulmonary, interventional radiology,
nuclear medicine, and surgical consultation are required. Admission to
an intensive care unit must be arranged. If appropriate specialists are
unavailable at the particular institution, communication with a referral
center and transfer by way of ACLS is indicated.
Moderate active hemoptysis
A less urgent scenario, but one possibly requiring a broader approach to
diagnosis and treatment, is one in which the patient has active but smaller
amounts of bleeding in the emergency department. A more complete history
and physical examination are possible. A pulmonary parenchymal versus
extrapulmonary etiology to the hemoptysis must be determined. The
breadth of the differential diagnosis, the urgency of the situation, and the
specifics of the medical history guide the assessment and management.
Maintain ventilation
1. Provide oxygen as needed: 2–10 L/min by nasal cannula or mask.
2. Provide suction.
3. Monitor response with continuous pulse oximetry and titrate oxygen
as needed.
Circulation
1. Place intravenous catheter large enough for resuscitation and transfusion of blood products.
2. Begin maintenance infusion of crystalloid solutions adequate for the
hemodynamic situation.
3. Obtain blood for CBC, coagulation panel, type, and screen or crossmatch. Additional culture, serology, and chemistries are sent based on
differential diagnosis.
Other underlying or associated conditions should be treated, including
congestive heart failure and epistaxis. A chest radiograph is required. The need
for antibiotics, further diagnostic radiographs, admission with respiratory
isolation, or diuresis may depend on its result. Many patients with active
hemoptysis require hospitalization for treatment of the underlying condition
or further evaluation using nonemergent computed tomography or bronchoscopy. In this case, consultation with the appropriate services should be
placed.
If proper followup can be arranged within 3–7 days, however, some
patients can be discharged to home, with cough suppressants for 2–3 days
and instructions to return for recurrence or worsening of symptoms.
Minor or historical hemoptysis
The same assessment and diagnostic approach is taken for these patients
as with patients having moderate active bleeding. Emergent intervention,
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R. Corder / Emerg Med Clin N Am 21 (2003) 421–435
however, is typically unnecessary. The most common causes are infectious
and are treated with antibiotics and cough suppressants. If cancer is suspected but initial screening chest radiograph is unremarkable, communication with the patient’s primary physician regarding the need for
a subsequent CT should occur. Return for further evaluation should be
encouraged for recurrence or worsening of hemoptysis.
Summary
Hemoptysis is a common complaint the emergency physician encounters.
Most cases are minor and treatable or self-limited. In many cases a cause is
never determined. Massive hemoptysis is an occasional occurrence that must
be assessed and managed swiftly. The initial approach is no different than
that for any bleeding or respiratory or hemodynamically unstable patient.
The emergency physician must stabilize, localize, and stop bleeding, and
include required specialists to achieve that purpose. The management
suggestions presented in this article are simplistic. The emergence of improved CT technology and new bronchoscopic and angiographic techniques has provided safe and effective alternatives to surgery for many
causes of hemoptysis. Surgery, however, continues to be the treatment of
choice for some. Being familiar with the broad list of causes is imperative to
keeping an approach organized.
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