Sunday, May 21, 2017

Approach To A Patient Presenting With Haemoptysis (Blood In Sputum)



Haemoptysis (Blood In Sputum) may be the chief or sole complaint of patients presenting to the emergency department or their family doctors. . It always warrants investigation.

Causes of haemoptysis:

Respiratory causes;
• Infection (URTI, pneumonia, TB, lung abscess)
• Carcinoma (bronchial or laryngeal)
• Bronchiectasis

Cardiovascular causes:
• Pulmonary oedema
• PE
• Ruptured aortic aneurysm (aorto-bronchial fistula)

Coagulation disorder:
• Drugs (eg warfarin, heparin)
• Inherited (eg Haemophilia, Christmas disease)

Trauma:
• Penetrating or blunt

Others:
• Goodpasture’s, Wegener’s granulomatosis


Clinical History :
Ascertain the exact nature and volume (eg ‘bright red streaks’ or ‘dark brown granules’). Patients sometimes have surprising difficulty distinguishing vomited blood from that coughed up. Enquire about weight loss, and take a drug history and smoking history.

Investigation
• Send blood for CBC, coagulation screen, U&E, LFTs.
• Request Group and Save if evidence of significant haemorrhage.
• If SpO 2 <94 % on air, or the patient has COPD, check ABG.
• Obtain CXR and ECG.
• Perform urinalysis — if shocked, insert catheter and monitor output.
• Collect sputum samples. Send for microscopy, culture, and sensitivity.
• Initiate further investigations according to the likely diagnosis.

Treatment
• Airway : clear and secure (coughing/suction). Put on a face mask and shield if maintaining the airway or intubating. Ensure nearby high flow suction. Massive haemorrhage may require tracheal intubation. Whilst preparing for this, tilt trolley so that the patient is head-down.
• Breathing : provide O 2 to maintain saturations at 94–98 % . If ventilation is inadequate, assist with bag and mask or tracheal tube.
• Circulation : insert a large bore (14G) IV cannula (use 2 if hypovolaemic). Give IV fluids/blood/clotting factors as clinically indicated

Further treatment

  • Commence specific treatment measures aimed at life-threatening underlying cause (eg LVF, PE, infection, coagulopathy). 
  • In cases of large haemoptysis, it is appropriate to admit for further investigation and treatment.
  • If the patient is stable and has only had a small amount of blood stained sputum, urgent outpatient investigation may be appropriate.

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