Name:
A 19-Year-Old with Hemoptysis
Description:
A 19-Year-Old with Hemoptysis
Thumbnail URL:
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Duration:
T00H05M20S
Embed URL:
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Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/63504beb-a0e2-46f8-9043-ca956cf4eefb/16461977.mp3?sv=2019-02-02&sr=c&sig=s0I46BbtGYdqOsfwJ1XShASSDam%2B01enAEqJ9Zqxv50%3D&st=2024-05-05T04%3A59%3A18Z&se=2024-05-05T07%3A04%3A18Z&sp=r
Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
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CATHY: Hi, welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy. And I'm Charlie Wiener and we're coming to you from the Johns Hopkins School of Medicine. Welcome to Harrison's Podclass. Today's case is a 19 year old with hemoptysis. I'll read the question. Mr. Boyle is a 19-year-old college student who has a known history of cystic fibrosis.
CATHY: While studying for midterm examinations, he suddenly begins coughing up large volumes of bright red blood. Emergency medical personnel are called rapidly and they transfer him to the nearby university hospital emergency department where you are working. His blood pressure is 70 systolic, his heart rate is 145, his oxygen saturation is 85% on room air, and he's breathing in excess of 40 times per minute.
CATHY: He's barely able to speak to the three word phrases, he appears pale and in definite respiratory distress. Auscultation of the lungs reveals diminished breath sounds on the right with good air movement on the left. An emergent chest radiograph shows dense opacification of the right lung. Cathy, what are your initial thoughts?
CATHY: So, in this case we hear about a 19-year-old with cystic fibrosis which is an autosomal recessive disorder due to a mutation in the CFTR gene. It results an abnormal transport of chloride and sodium across a secretory epithelial and is diagnosed with sweat testing and genetic testing. The major complications are respiratory problems, and usually it's infections but bronchiectasis is very common and that can also be complicated by bleeding. In this case, our patient is having large volume, life-threatening hemoptysis. He's basically in hemorrhagic shock with hypotension, tachycardia and he's hypoxic.
CATHY: The physical exam and chest radiograph also point to the right lung as being the major source of the problem.
CHARLIE: So, the question to ask what you would do for him in your initial management and we have some choices. All of these are going to be correct except for there's one incorrect answer in this set. I'll read all the options first. Option A is bronchoscopic examination of the airways and consideration of bronchoscopically directed cauterization or laser therapy. Option B is consultation with the interventional radiology team to evaluate for bronchial artery angiography and potential embolization.
CHARLIE: Option C is endotracheal intubation with a dual lumen endotracheal tube and mechanical ventilation. Option D is placement of the patient in the left lateral decubitus position. And Option E is placement of two large port peripheral intravenous catheters and aggressive admnistration of intravenous fluids in the form of crystalloids.
CATHY: Something to remember about hemoptysis in cystic fibrosis patients is that the culprit vessel is usually the bronchial artery. And it's important when you're thinking about what to do with this patient. But first things first, we need to stabilize him so we would definitely begin fluid resuscitation with two large bore IVs which means 18 gauge or larger and then start IV fluids. So answer E is definitely something that I would do. Next I'd also make sure he has a secure airway and you don't necessarily need to intubate all patients with hemoptysis but in this case, where we heard the patient was very tachypnic and unable to speak and clearly in respiratory distress, you would definitely need to intubate and mechanically ventilate this patient.
CHARLIE: A dual lumen tube can be used in patients with bronchiectasis but it requires specialized anesthesia help to place those but if they can be placed successfully, they can isolate the good lung from the bad lung and prevent bleeding into the good lung. So, we know Option C and Option E are true. What about the other options?
CATHY: So, next I would think about positioning the patient and we already heard that there's little air movement on the right side and that matches what we see on the chest radiograph. So, there's probably not much, if any gas exchange is happening on the right side of the lung because of the bleeding. So, in order to preserve the air spaces on the other side and prevent blood from getting to the left lung which is the good lung, we would want to put the bleeding side down so in this case, you would place the patient in the right lateral decubitus position.
CATHY: So, that gravity helps to keep all the blood on the right side of the thorax. And this is one of the easiest things to do to also help improve oxygenation when you're in a critical situation in an ICU. Therefore, I would not do Option D.
CHARLIE: And the adage to take home is that in the bleeding patient, you put the bad lung down, right?
CATHY: That's right. And then in just thinking about the other options, Options A and B are also both reasonable options because ultimately, the patient may need and intervention to stop the bleeding and that can be done either with bronchoscopy or angiography.
CHARLIE: So today's teaching point is that in patients with massive hemoptysis the first and most important thing is to stabilize the patient in terms of their blood pressure and their airway function. Positioning is also important in that it can minimize the involvement of the good lung and we always put the bad lung down in bleeding patients.
CATHY: To read more about this, you can check out Harrison's Internal Medicine chapter on cystic fibrosis or the chapter on cough and hemoptysis.
CHARLIE: Thanks very much.