The charge nurse grabs your arm and pulls you into the resuscitation bay, where EMS have just unloaded a 45 year old guy in obvious distress, coughing up a significant amount of blood. The paramedic tells you, “He doesn’t speak English, so we don’t know a lot about him. My guess is that he has already coughed up about 250ml of blood on route. He still sating OK, and his pressure is holding, but I’m just glad we got here. He’s all yours doc…”
Call for help: Thoracic surgery, interventional radiology, and respirology are all required (and sadly, none are available at my shop.) Unfortunately, this is one of the scenarios that an ED doc cannot handle alone. The patient will require at least one of bronchoscopy, angiographic intervention, or surgery.
Protect yourself and your team. Everyone gets PPE on. There is no excuse for anyone getting an eyeful of blood.
Monitors and two large bore IVs. Preoxygenate the patient with a NRB to the best of your ability.
Reverse any coagulopathy. Yes, usually airway comes first, but as little as 200 ml of blood can completely fill the bronchial tree, so you need to control the bleeding early.
- Give PCC immediately if any coagulopathy
- Tranexamic acid 1 gram IV over 10 minutes
- DDAVP 0.3mcg/kg IV if any platelet disorder
Control the airway. Inform everyone in the room that you are anticipating a difficult airway. State the plan, and ensure everyone understands (and will remind you) that you will only make two attempts before moving down the difficult airway algorithm.
Mark the cricothyroid membrane. Have the cricothyrotomy kit open.
The best approach to intubation here is certainly debatable. My plan is to stick with what I am most comfortable with and perform a classic RSI. The modifications I would make are:
- Intubate with the head of the bed up, hoping to keep blood down and out of my field of view. (Some sources recommend Trendelenberg to keep the blood out of the lungs, but I want the best view for first pass success.)
- Make sure you have at least 2 working suctions
- Use the largest diameter ETT possible to facilitate bronchoscopy
- I would start with direct laryngoscopy, as blood doesn’t mix well with fiberoptics.
- If lots of blood, I would attach a meconium aspirator, so the ETT can be used as a large suction as you go (suggestion from EMCrit.)
Maintain oxygenation. First, try positioning the patient with the bleeding lung down.
If bleeding and oxygenation is not managed with simple suction and positioning, you need to attempt mainstem intubation.
Right mainstem intubation should be easy.
Left mainstem intubation
- Ideally, the bronchoscope will be in the ED at the point
- If not, Right lateral decubitus to shift mediastinum right
- Angulate the ETT towards the left and use the coude tip of the bougie to attempt to direct the ETT towards the left
Localize the bleeding and get someone to stop it. Get the patient into the combined hands of interventional radiology and thoracic surgery for bronchial artery embolization, or if that fails surgery.
Blind attempts at intubating the correct mainstem bronchus by directing the ETT were successful 95% of the time on the right and 73% of the time on the left. (See Bair et al 2003 paper)
There is an emphasis on the largest possible ETT, but in a truly sick patient, when immediate bronchoscopy is not going to be possible, I wonder if getting a larger ETT to turn the corner in the left mainstem might be more difficult. (I will need to experiment if I ever get into a cadaver lab.)
There is a lot of talk about double lumen ETTs, and opinions vary from ‘they are life saving’ to ‘they are inherently evil’. They seem to be placed incorrectly a large percentage of the time, and I have no training in their use, so they do not make it onto my algorithm.
The title image is an adaptation of an image from http://classroomclipart.com/
Other FOAMed Resources
RE the meconium aspirator and intubation: EMCrit Podcast 5 – Intubating the Critical GI Bleeder and A novel set-up to allow suctioning during direct endotracheal and fiberoptic intubation from EMCrit
Young W. Chapter 66. Hemoptysis. In: Tintinalli JE et al. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York: McGraw-Hill; 2011.http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381532.
Brown CA and Raja AS. Chapter 24. Hemoptysis. In: Marx JA et al. eds. Rosen’s Emergency Medicine, 8e. Philadelphia: Elsevier Saunders; 2014.
Zimmerman JL and Sanchez R. Chapter 46. Massive Hemoptysis. In: Parrillo JE and Dellinger RP, eds. Critical Care Medicine: Principles of Diagnosis and Management in the Adult, 4e. Philadelphia: Elsevier Saunders; 2014.
Bair AE et al. An evaluation of a blind rotational technique for selective mainstem intubation. Acad Emerg Med. 2004;11(10):1105-7. PMID: 15466157
Sakr L and Dutau H. Massive Hemoptysis: An Update on the Role of Bronchoscopy in Diagnosis and Management. Respiration 2010;80:38-58. PMID: 20090288
Lordan JL et al. The pulmonary physician in critical care c Illustrative case 7: Assessment and management of massive haemoptysis. Thorax 2003;58:814-819. PMID: 12947147
Sakkour A and Susanto I. Airway management in massive hemoptysis. Emergency Med & Crit Care Rev 2006.