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MANAGEMENT OF HEMOPTYSIS IN EMERGENCY ROOM
A.N. Venkatesh1, H. Rajanna2
Apollo Hospital, Karnataka Region. India 2Apollo Hospital, Bengaluru, India
ЛЕЧЕНИЕ КРОВОХАРКАНЬЯ В ОТДЕЛЕНИИ ЭКСТРЕННОЙ МЕДИЦИНСКОЙ ПОМОЩИ
А.Н. Венкатеш1, Х. Раджанна2
1Больница Апполо, Карнатака, Индия 2Больница Аполло, Бангалор, Индия
We present a case of 21y old man who had presented to our hospital with hemoptysis and breathing difficulty. He was previously been diagnosed as having pulmonary Koch's and had received treatment for same. Now had presented with worsening hemoptysis. While he was waiting in ER for pulmonologist initial management was initiated. After being reviewed by specialty team they wanted to do bronchial arterial embolization. While team and theatre were preparing, patient was in emergency room (ER) and his hemoptysis was getting worse. This made me search for available options for management of sever haemoptysis in ER. Though the definitive (non-surgical) management is arterial embolization. We look for management option in ER while the definitive treatment is being arranged, or if patient needs to be transferred to place of definitive treatment, or if there is no option of arterial embolization. We learn from the review that ER can play its role in stabilizing these patients. They can also initiate management measure to transfer patient to specialty centre, where needed. In places and situation where no further care is available these additional measure could make a difference in helping manage patients with pulmonary Hemorrhage. Learning Points:
- The initial assessment and management of patients with severe hemoptysis in ED.
- Further steps which could be undertake in ED to stop or control sever hemoptysis.
Keywords: hemoptysis, management, emergency room.
В статье представлен случай по оказанию экстренной медицинской помощи 21-летнему мужчине, который поступил в нашу больницу с кровохарканьем и затрудненным дыханием. Ранее ему был поставлен диагноз легочной болезни Коха, он проходил лечение от этого же заболевания. Теперь поступил с усиливающимся кровохарканьем. Пока он ждал в отделении неотложной помощи пульмонолога, было начато лечение. После проведенного консилиума пациенту планировали сделать эмболизацию бронхиальной артерии. Пока команда врачей готовилась, пациент находился в отделении неотложной помощи, и его кровохарканье усиливалось. Это заставило искать доступные варианты лечения сильного кровохарканья в отделении неотложной помощи, хотя окончательным (нехирургическим) лечением является эмболизация артерий. В данной статье мы ищем вариант экстренного оказания помощи в период, пока назначается окончательное лечение, или если пациента необходимо перевести в место окончательного лечения, или если нет возможности артериальной эмболизации. Из обзора мы узнаем, что неотложная помощь может сыграть свою роль в стабилизации состояния таких пациентов. Они также могут инициировать меры по переводу пациента в специализированный центр, если это необходимо. В местах и ситуациях, когда дальнейшая помощь недоступна, эти дополнительные меры могут иметь значение в лечении пациентов с легочным кровотечением. Цель этой статьи:
- Первичная оценка и ведение пациентов с тяжелым кровохарканьем.
- Дальнейшие шаги, которые можно предпринять в отделении неотложной помощи, чтобы остановить или контролировать тяжелое кровохарканье.
Ключевые слова: кровохарканье, лечение, отделение экстренной медицинской помощи.
UDC: 616-08-039.74/24-005.1
Case Presentation
21 year old male presented with history of hemoptysis for past 3-4 days. He had been bringing up 15-20 ml of blood every day. He had presented as it was getting progressively worse. He had history of Pulmonary Tuberculosis (TB) about three years back for which he had completed six months course of anti-TB treatment. He was seen in Emergency department. He was noted to be tachycardic with HR of 130 beats/min with a BP of 110/70 mmhg, his RR was 24 with oxygen saturation of 84% on room air and requiring 8 ltr/min of oxygen to maintain a saturation of 95%. His temperature was noted to be 98F. on examination he was lean built and was noted to have crackles diffusely on right lung fields.
He did not have any high risk features in history for COVID. In view of his presentation he was treated as a high risk of COVID while in ED. He was not on any other medication and not other risk factors for bleeding.
He was having bouts of cough bringing up 15-20 ml of blood with each bout. It was noted an approximalty 150-200 ml of blood loss in 30 mins of his arrival. An intravenous cannula was secured and bloods sent to lab. He was given codeine 45 mg (15 ml of corex-T) as antitussive. 1G of Tranaxamic acid [1, 11, 28] was given as slow injection over 15-20 mins. He was also started on ringers lactate 100 ml/hour. His Chest x-ray showed - right upper lobe fibrosis and bilateral diffuse ground glass appearance.
Patient seemed to be settling with his coughing bouts and thus his hemoptysis. But he still had been having bouts of cough and hemoptysis. Hence we prepared for intubation if symptoms continued as he had lost almost about 400 ml of blood in 90 mins. In view of blood loss, blood transfusion was of one unit was started. On discussing with Pulmonology team, they advised CT chest with contrast to evaluate the feasibility of Bronchial artery embolization (BAE). Patient underwent CT scan and was back in ED. While we wait for report and for further plan, we had a young patient with ongoing cough and hemoptysis (much less severe than from arrival) we had run out of further interventions and were waiting for further advice from Pulmonology team.
This made me ask myself is that all we can do in emergency for patients with hemoptysis?
Patients CT images
Patient was shifted to ICU waiting further management plan. As the CT reports was available and on review by interventional radiologist patient underwent BAE on the same evening. He continued to maintain his own airway and breathing, was hemodynamically stable and tolerated procedure well. He continued to have good recovery. He was noted to have HB of 9.9 which had dropped to 7.4 on day two of admission. He had received a further two units of blood transfusion. The next day he underwent a bronchoscopy for evaluation which showed clots in right bronchus which was cleared. No active bleed was noted. His CO-VID tests were negative. Patient was discharged on day 6 of his admission in a stable condition.
Learning Points:
• The aim of this article is to emphasize on;
• The initial assessment and management of patients with severe hemoptysis in ED
Further steps which could be undertake in ED to stop or control sever hemoptysis
Review:
Hemoptysis is a worrying presentation for both the doctor and patients. It can be due to a wide spectrum of cause from infective to inflammatory, from vascular to malignancy [8, 9]. Hemoptysis was associated with a high mortality of 70% [10], which has been reduced to 6.5% to 38% [10].
Etiology: Pulmonary TB is the most common cause for presentation of hemoptysis in India [2, 3, 4] followed by Pneumonia and bronchiacta-sis. TB is said to be cause in 27-78% in various studies across the country. This is different to presentation in European countries [5, 6] where pulmonary malignancy is a leading cause along with cryptogenic causes. In a report in 2019 WHO [7] has reported the total number of cases in India as of August 2018 was 2 690 000 which would be about 199 cases per 100,000. The incidence of TB in India is reducing by the year but in recent years there has been an increase in new and relapse cases of TB. Most cases of sever hemoptysis are due to TB [4].
Etiologies of hemoptysis: [12-21]
Pulmonary-airway
Neoplasm* Bronchitis* Bronchiectasis* Airway trauma Foreign body Bronchovascular fistula
Pulmonary vascular
Pulmonary- Pneumonia*
parenchyma| Tuberculosis*
Mycetomas* (aspergillosis)/ fungal infections
Lung abcess
Parasitic diseases
Leptospirosis
Cocaine inhalation
Lung contusion
Vasculitis (Wegener, etc.)
Systemic lupus erythematosus
Behcet's disease
Goodpasture syndrome
Idiopathic pulmonary hemosiderosis
Pulmonary embolism*
Arteriovenous malformation
Pulmonary artery pseudoaneurysm
Dieulafoy's disease
Pulmonary veno-occlusive disease
Bronchial telangiectasia
Cardiac Heart failure*
Mitral stenosis
Congenital heart disease
Iatrogenic Anticoagulant and antiplatelet
medications
Pulmonary artery catheter Biopsy
Bronchoscopy Airway stent
Endotracheal tube erosion
Bevacizumab treatment
Others Idiopathic*
Disorders of coagulation
Thoracic endometriosis (catamenial hemoptysis)
* The most common etiologies.
In the case presented above CT scan of chest was suggestive of aspergilloma. He did have history of pulmonary TB for which he had been treated 3 years ago. There was no evidence of recurrence.
There is still lack of consensus on severity of hemoptysis and no uniform management guidelines for management of hemoptysis. With more patients being admitted to hospitals through ED there is increased need for guidelines for management of hemoptysis. Most classification of severity noted have classified as volume of blood loss per day or over 24 hours.
For practical purposes in ED we can adopt the following classification;
Mild - specs of blood in phlegm or <50 ml in last 24 hours;
Moderate - blood noted on each bout of cough or 50-200 ml in last 24 hours;
Sever - frequent recurrent bouts of cough with hemoptysis with loss of >200 ml in last 24 hours or >50 ml blood/hour during last consecutive hours;
Life threating - interactable cough with hemoptysis with > 100 ml/hr blood loss in last two consecutive hours or moderate to severe hemoptysis with hemodynamic instability.
Applying this classification Patient described earlier would be life threating group.
Management in ED
Since early 20th century it has been recognized the management of hemoptysis has to be based on severity [22] and there is no one size fits all. Patients presenting with mild to moderate symptoms can be managed conservatively [23] and referred to speciality teams for further management. Patients presenting with severe or life threating hemoptysis needs stabilization and further management in ED [24]. The Patient described above was having life threating hemoptysis. He was managed according to principles of resuscitation guidelines.
On assessment of airway, our patient was talking comfortably and airway was clear. It should be noted that even though it is clear at time of assessment, there is a potential for impending blockage of airway with clots and hence wide bore suction should be at hand and endotrache-al intubation tray should be ready to hand.
In case presented, patient was breathing spontaneously. His RR was 24-28 and he was maintaining a SaO2 of 88-90 on RA and was requiring 2-4 ltrs O2 to maintain SaO2>95%. We avoided Hudson mask as he was having recurrent bouts out hemoptysis and managed on nasal cannula. This is one case where even if are able to main-
tain a clear airway patients breathing can deteriorate due to bleed into lungs. Important learning point from this is, what are the measure we can take in ED to stop or prevent further bleed.
Assessing his circulation, he was noted to be hemodynamically stable on presentation but in class 1 shock. He continued to have hemoptysis >200 ml of blood in first hour. We gained two IV line in both cubital fossa and sent bloods for cross matching 4 units. We noted we have O-ve as standby. We were ready to volume replace with blood if patient had any signs of worsening shock. We had started on ringer lactate at 100 ml/hour.
We used the other line for medications; he had been given ondesetron 4mg, Pantoprazo-le 40mg, cefoperanzone+sulbactam 1.5 gm. He was also given 1 gm Tranaxamic acid. We gave syp codeine 10 mg and repeated 10mg after 20 mins to help suppress cough.
Patient was shifted for CT chest to radiology and had returned to ED. His trip to CT scan was uneventful.
Pulmonology team were in Department and reviewed the patient and advised the patient to be shifted to ICU for further management. Patient was planned for BAE which has been effective in treating with hemoptysis [11, 24, 26]. While waiting for ICU bed or while waiting patient being shifted to cath-lab for BAE are there any further measures which could be done in ED to address the problem?
In patients who are on anticoagulants, it is important to reverse where possible.
Adrenaline nebulization - it has been reported that topical endobronchial use of adrenaline in various concentration has shown to stop bleeding during bronchoscopy and lung biopsy [24, 29]. This is on the understanding of vasoconstrictor effect of adrenaline and hence helping halt the bleeding process. In the absence of bronchoscopy nebulized adrenaline could have vascular constricting effect and causing broncho-dilatation which could help in halting the bleeding process. Breuer et. al [30] have reported that nebulized 8 mg adrenaline is not inferior to 0.3 mg intramuscular route. Hence nebulized adrenaline can be used in patients with hemoptysis to help stop the bleed.
Cold saline bronchial lavage-application of cold to cause vaso-spasm to arrest bleed is tried in cases of epistaxis. On the same principle applying cold compresses on bronchial vessels can
reduce or halt hemoptysis. AA Conlan et. al [27] has reported in 1980 a case series of 12 patients who had undergone rigid bronchoscopy and cold saline bronchial lavage as an emergency. Four had TB and another five of them had bronchi-actasis with secondary fungal infections. All the patients were reported to have stopped bleed. Two of them had re-bleed which was controlled by second cold saline lavage. There was no mortality in study group and all patients were discharged in stable condition.
As these patients would need intubation for further management of hemoptysis, They could be electively intubated in ED and use a rigid bronchoscopy for cold saline lavage.
Tamponade by pneumothorax - The principle of halting the bleed by Tamponade effect was written by William MacLennan in 1908 [22]. He had written that by inducing a iatrogenic pneumothorax with oxygen we can cause tamponade effect and on affected lung. The oxygen would be gradually absorbed as the lung re-expands. There is no case reports of studies reported about this procedure. FH Young [31] has described same and has also stated that inducing a pneumoperitonium can also be beneficial in managing sever hemoptysis.
In centers where BAE or cardio-thoracic surgeons are readily available these additional me-
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Conclusion
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The aim of this article is to emphasize on;
The initial assessment and management of patients with severe hemoptysis in ED
Further steps which could be undertake in ED to stop or control sever hemoptysis
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ШОШИЛИНЧ ТИББИИ ЕРДАМ БУЛИМИДА ^ОН ТУФЛАШНИ ДАВОЛАШ
А.Н. Венкатеш1, Х. Раджанна2
хАпполо шифохонаси, Карнатака, Х,индистон 2Аполло шифохонаси, Бангалор, Х,индистон
Кон туфлаш ва нафас олиш кийинлашуви билан шифохонамизга ёткизилган 21 ёшли эркак бемор-га курсатилган шошилинч тиббий ёрдам жараёни келтирилган. Беморга аввал Кох упка касалли-ги диагнози куйилган булиб, ушбу касаллик буйича даволаниб юрган. Кон туфлаш билан бизнинг шифохонага мурожаат килган. Шошилинч тиббий ёрдам булимида пульмонологнинг маслахатини кутиш давридаёк даво муолажалари бошлаб юборилган. Беморга тегишли консилиум утказилгач, бронхиал артериянинг эмболизациясини утказиш режалаштирилган эди. Эмболизацияга тайёрлаш жараёнида бемор шошилинч тиббий ёрдам булимида булган ва бу ерда кон туфлаш кучайиб бор-ган. Бу холатда тиг тегизмасдан даволашнинг охирги чораси артериялар эмболизацияси булишига карамай, кон туфлашнинг кескин кучайиши шошилинч тиббий ёрдам булимида мавжуд булган даволаш усулларини куллашга тугри келди. Ушбу маколада эмболизация утказилгунча ёки ши-фохонада эмболизация утказиш имкони булмаган такдирда беморни бошка шифохонага кучириш зарурияти тугилганда шошилинч тиббий ёрдам курсатиш вариантлари куриб чикилган. Окилона бажарилган шошилинч тиббий ёрдам чоралари бундай тахликали беморларнинг ахволини стабил-лаштиришга ёрдам бериши муаллифлар томонидан утказилган адабиёт шархидан маълум булади. Шошилинч тиббий ёрдам булимида беморнинг ахволи яхшилангач, беморни ихтисослаштирилган булимга ёки шифохонага утказилиниши масаласи куйилади. Ихтисослаштирилган ёрдам курсатиш иложи булмаган холатларда ва жойларда шошилинч тиббий ёрдам курсатиш чоралари асосий ахамият касб этиши таъкидланган.
Шошилинч тиббий ёрдам булимидаги даво чораларининг максадлари:
- кучли кон туфлашларда беморнинг ахволига бирламчи бахо бериш ва бирламчи ёрдамни курсатиш;
- огир кон туфлашни тухтатишга ва назорат килишга йуналтирилган шошилинч тиббий ёрдам булимида курсатилиниши мумкин булган кейинги даво чораларини белгилаш.
Калит сузлар: цон туфлаш, даволаш, шошилинч тиббий ёрдам булими.
Information about authors:
Dr. A.N. Venkatesh - Senior Consultant & Head, Emergency Medicine, Apollo Hospitals, Karnataka Region, India.
Сведения об авторах:
А.Н. Венкатеш - старший консультант и руководитель отделения экстренной медицины, больница Аполло - Карнатака, Индия
Dr. H. Rajanna - Consultant Emergency room, Apollo Hospital, Bengaluru, India
Х. Раджанна - консультант по экстренной медицинской помощи, больница Аполло, Бангалор, Индия.
Поступила в редакцию 02.01.2021
