Intern Report Case Discussion 2.7

intern-report

Presented by Daniel Seitz, MD

CC: “I’m coughing up blood”.

HPI: A 44-year-old man presents to the Emergency Department complaining of coughing up blood for two days.  The patient states that two months ago he began experiencing progressively worsening cough and fatigue.  The cough was initially non-productive, but for the past month he’s been coughing up thick yellow sputum.  One week ago he noticed that his sputum was intermittently blood streaked, and yesterday he coughed up gross blood.  Over the last 24hrs the patient reports coughing up a cup and a half of gross blood.  He describes the blood as bright red, frothy and devoid of food particles.  He also reports a history of weight loss, approximately 20lbs in the last 6 months. The patient occasionally has fevers in the afternoon, and reports night sweats over the past three weeks. The patient states that he experiences a diffuse achy pain on deep inhalation and with cough.  He denies any shortness of breath or difficulty breathing.

ROS: Negative except for as mentioned in the HPI.
PMH: Hypertension which he’s treating with diet and exercise.
PSH: Denies.
Medications: None.
Allergies: No known drug allergies.
FH: Hypertension, heart disease, and diabetes.
SH: The patient smokes 1 pack per day, has smoked for ten years, occasionally drinks alcohol, and denies any illicit drug use.  The patient lives alone and works as an actuary.  He was born in China and immigrated to the United States as a teenager.

PE:
VITAL SIGNS: BP 92/55, P 109, R 21, T 38.4, SpO2 95% on room air.
GENERAL: Patient is sitting comfortably in his stretcher and is in no apparent acute distress.
HEAD: Head is atraumatic, normocephalic, and no tenderness to palpation.
EYES:  Mild conjunctival pallor.  Pupils are 4 mm bilaterally, are equally round and reactive to light and accomodation.  No nystagmus.  No conjunctival injection, but mild conjuctival pallor.  No scleral icterus
EARS: Tympanic membranes are normal.
NOSE: No nasal drainage, no blood in nares, no swollen turbinates.
MOUTH:  Dried  blood around the patient’s mouth.  Moist mucous membranes, no tonsillar enlargment or exudates, no intraoral lesions.
NECK: Supple without lymphadenolpathy.  There is no nuchal rigidity, no tenderness to palpation, no carotid bruits, trachea is midline.
CARDIOVASCULAR: S1, S2, tachychardic rate with normal rhythm.  No murmurs, rubs or gallops.  Peripheral pulses are present , 2+, and symmetric in all four extremities.
RESPIRATORY: Good air entry bilateral.   Diffuse post-tussive rales, distant breath sounds heard over the lung apices .
GASTROINTESTINAL: Abdomen soft, non-tender, non-distended, no tenderness to palpation, no appreciable organomegaly.  Bowel sounds present in all quadrants.
MUSCULOSKELETAL: Patient is mildly cachexic.  Strength 5/5 proximally and distally in all extremities.
SKIN:  No rashes, lesions or ulcerations.  Increased pallor.
NEUROLOGIC: Patient is awake, alert and oriented to person, place and time.  Face is symmetrical.  Sensation is equal and intact throughout.  The patient walks with a normal gait and performs finger to nose examination without difficulty.

Course in the ED: While waiting to be seen in the module, the patient expectorates 700 mLs of gross blood.  The patient is rushed to resuscitation; where he’s placed on a monitor and two large bore peripheral IVs are placed.  A stat portable chest x-ray is obtained which shows a cavitary lesion at the apex of the patient’s left lung.  The patient’s vital signs in resuscitation are as follows:  T: 38.6 HR: 112 RR: 25 BP: 81/50 O2Sat: 87% on non-rebreather.

Questions

1.  What is the patient’s most likely diagnosis?
a) Lung cancer
b) Tuberculosis
c) Aspergillosis
d) Pneumonia
e) Bronchitis

2.  Which of the following characteristics indicates hematemesis over hemoptysis?
a) Alkaline pH
b) Dark color
c) Frothy appearance
d) Presence of macrophages

3.  What is the best course of management in this patient?
a) Emergent angiography
b) Flexible Bronchoscopy
c) Intubation of the right main stem bronchus, and place patient in left lateral decubitus position
d) Rigid Bronchoscopy
e) Rush the patient to the operating room for emergent thoracotomy

4.  What vessel is most likely responsible for this patient’s massive hemoptysis?
a) Aorta
b) Bronchial artery
c) Inominate artery
c) Pulmonary artery
d) Tracheobronchial capillaries

Discussion

-Answers-

1. B (Tuberculosis)
2. B (Dark Color)
3. C (Intubate and lie on left side)
4. B (Bronchial Artery)

Hemoptysis is the expectoration of blood of any quantity, from below the larynx.  Massive hemoptysis is defined as >600 mL of blood expectorated in 24 hours.  While massive hemoptysis only comprises 5% of all reported hemoptysis, the mortality is upwards of 80%.

The most common causes of massive hemoptysis are bronchiectasis, tuberculosis, lung cancer, lung abscess, arteriotracheobronchial fistula, and pulmonary angiodysplasia.  Based upon this patient’s history (Chinese immigrant, cough that progresses from non-productive to productive to blood streaked to massive, fevers and night sweats) the etiology of this patient’s hemoptysis is tuberculosis.  Tuberculosis is the most common cause of massive hemoptysis worldwide and until the 1960s was the most common cause of massive hemoptysis in the United States.

90% of massive hemoptysis involves the bronchial arteries.  These are high-pressure branches off of the thoracic aorta.  Alternately, the majority of trace hemoptysis originates from the tracheobronchial capillaries.

When evaluating a patient with hemoptysis it is important to exclude gastrointestinal and upper airway etiologies of bleeding.  The workup for each of these conditions is very different, but the presentations can be surprisingly similar.  History is the most helpful tool in differentiating hematemesis and hemoptysis, but the following characteristics can be helpful as well:
Hemoptysis blood – alkali, bright red, frothy appearance, macrophages
Hematemesis blood – acidic, dark color, clots and food particles, coffee grounds

Approach to non-massive hemoptysis
1. Evaluate oxygenation (pulse oximetry / ABG)
2. History and physical – does anything indicate GI or upper respiratory etiology?
3. Chest radiograph
4. Are lab studies indicated? (CBC, coags, PPD, ANA, ESR?)
5. Create differential (Bronchitis?, malignancy?)
6  Bronchoscopy / HRCT

Approach to massive hemoptysis should be managed more aggressively.  Mortality with massive hemoptysis is extremely high, and these patients will inevitably need ICU admission.  The most common cause of death in these patients is asphyxiation and not exsanguination.  Intubation of the mainstem bronchus contralateral to the hemorrhage has the potential to protect the unaffected lung.  This is most easily done on the right side. In addition, it has been suggested that laying the patient on the side of the hemorrhage can keep the non-affected alveoli from flooding with blood.

Definitive management of massive hemoptysis will involve bronchoscopy, thoracotomy or angiography, depending on your institution.   Getting either Cardiothoracic Surgery, Pulmonology or Interventional Radiology involved early will expedite potentially life saving management.

FURTHER READING:

Bidwell JL, Pachner RW. Hemoptysis: diagnosis and management. Am Fam Physician. 2005 Oct 1;72(7):1253-60.

Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med. 2001 May;29(5):1098.

Rudzinski JP, delCastillo J. Massive hemoptysis. Ann Emerg Med. 1987 May;16(5):561-4.

Collard HR, Gruber MP, Weinberger SE, Saint S. Clinical problem-solving. Anatomy of a diagnosis. N Engl J Med. 2003 Sep 4;349(10):987-92.

Marx JA, Hockberger RS, Walls RM, Adams J, Rosen P. Rosen’s emergency medicine : concepts and clinical practice. 7th ed. Philadelphia: Mosby/Elsevier; 2010; 223-225.

This case discussion presented by Dr Daniel Seitz

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