The classic definition of massive hemoptysis (coughing up >600 mL fresh blood every 24 hours) has limited utility in the ED, so there has been a shift to a clinical definition: hemoptysis with clinical deterioration (e.g., hypoxia and respiratory distress).
If the decision is made to intubate, use at least an 8.0 endotracheal tube (an 8.5 is often recommended for men), if possible, to allow subsequent bronchoscopy and use of bronchial blockers. (Am J Emerg Med. 2021;50:148; J Thorac Dis. 2021;13:5139; https://bit.ly/3ztiVuI.) If a chest x-ray reveals a unilateral source of bleeding (e.g., malignancy), intubate the mainstem bronchus on the other (i.e., nonbleeding) side and then cut tidal volume in half. Placing the patient in the lateral decubitus position with the affected lung down can prevent aspiration of blood into the unaffected lung. (J Clin Med. 2022;11:633; https://bit.ly/3zsgQzh.) TXA has been shown to be effective in nonmassive hemoptysis. (J Thorac Dis. 2021;13:5139; https://bit.ly/3ztiVuI.) It is reasonable to give for massive hemoptysis while awaiting other interventions and tests.
Case reports and small randomized controlled trials have studied nebulized and IV TXA separately. (J Thorac Dis. 2021;13:5139; https://bit.ly/3ztiVuI.) For nebulized TXA, give 500 mg every eight hours. First, draw up 500 mg of TXA, then add it to 10 mL saline and nebulize. For IV TXA, give a 1000 mg load followed by 1000 mg over eight hours. Expert opinion says to administer nebulized and IV TXA for a patient with massive hemoptysis, recognizing that no RCTs have studied the combination and that increased thrombotic complications are a theoretical risk.
Obtain a CTA as soon as the patient is stable enough (e.g., a nonintubated patient can lie flat). The CTA is to delineate the source and etiology of the hemoptysis in preparation for possibly allowing interventional radiology to perform bronchial artery embolization. (J Clin Med. 2022;11:633; https://bit.ly/3zsgQzh; Am J Emerg Med. 2021;50:148; J Thorac Dis. 2021;13:5139; https://bit.ly/3ztiVuI.) It is important to understand that the CTA is timed differently from a CTPA for PE, so radiology must be aware that the indication of the CTA is massive hemoptysis.
This clinical pearl first appeared onwww.EMedHome.com, which subscribers a new clinical pearl emailed every Wednesday.
EMedHome.com on EM-News.com
Visit our website for videos from emergency medicine experts (http://bit.ly/EMN-EMedHomeVideos) and podcasts from Amal Mattu, MD, and other noted emergency physicians from EMedHome.com (http://bit.ly/MattuEMN).
This Month's Video
Jenelle Badulak, MD: Resuscitative ECMO: Defying Death in the ED: http://bit.ly/EMN-EMedHomeVideos. Dr. Badulak is an assistant professor of emergency medicine and an adjunct assistant professor of pulmonary, critical care, and sleep medicine and cardiothoracic surgery at University of Washington.
This Month's Podcast
Amal Mattu, MD, and colleagues: CAR T-Cell Therapy, Hyperkalemia Myths, Occult Abdominal Trauma, and Tubo-Ovarian Abscess: http://bit.ly/MattuEMN. Dr. Mattu is one of the premier speakers in emergency medicine, and a professor of emergency medicine and the vice chair of emergency medicine at the University of Maryland School of Medicine in Baltimore.