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 . 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 . 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 R. Corder / Emerg Med Clin N Am 21 (2003) 421–435 422 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 . 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 ) R. Corder / Emerg Med Clin N Am 21 (2003) 421–435 423 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 . 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% . 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 . 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 . 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. 424 R. Corder / Emerg Med Clin N Am 21 (2003) 421–435 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 . 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. R. Corder / Emerg Med Clin N Am 21 (2003) 421–435 425 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 . 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. 426 R. Corder / Emerg Med Clin N Am 21 (2003) 421–435 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 . In cases of hemoptysis with normal chest radiographs, the CT has proven to be helpful. In a study by Millar et al , 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  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 R. Corder / Emerg Med Clin N Am 21 (2003) 421–435 427 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  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 428 R. Corder / Emerg Med Clin N Am 21 (2003) 421–435 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 . 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 . Also, precision laser photocoagulation has been attempted with the use of ﬁberoptic bronchoscopy . 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) . 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% . 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 . 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 R. Corder / Emerg Med Clin N Am 21 (2003) 421–435 429 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 . 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 . 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 . 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 . Biologic weapon construction requires less ﬁnancial and intellectual capital than chemical or nuclear weapons . 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 430 R. Corder / Emerg Med Clin N Am 21 (2003) 421–435 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 . 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. R. Corder / Emerg Med Clin N Am 21 (2003) 421–435 431 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) . 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. 432 R. Corder / Emerg Med Clin N Am 21 (2003) 421–435 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 R. Corder / Emerg Med Clin N Am 21 (2003) 421–435 433 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, 434 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. References  Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med 2000;28(5):1642–7.  Szidon JP, Fishman AP. Approach to the pulmonary patient with respiratory signs and symptoms. 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