Bloody, Coughing, and Bored - Review

It’s a dreary day in Brooklyn–cold and rainy with a cesspool of germs in the air–and Pod A sounds like a sweet symphony of hacking, moaning, and coughing. You pick up a patient with a chief complaint of ‘coughing up blood,’ and before you “don” you personal protective armor and face mask, you think about the different problems that can present with HEMOPTYSIS.

What is the most common cause of hemoptysis?

Bronchitis. However, worldwide TB is a major cause as well.

How would you categorize hemoptysis--clinically and officially--based on amount of blood?

-Mild: blood tinged/streaked, less than 20mL in 24 hours

-Moderate: frank blood, either clotted or bright red, 20-600mL in 24 hours (for example, a cup or two)

-Severe: Can’t talk because they are breathing blood instead of air…. or > 600mL

What do you need to do in a severe case of hemoptysis?

-In any severe hemoptysis, before a diagnosis you must worry about airway and asphyxiation. People don’t die from exanguination, they die from suffocation. Secure the airway with intubation!

Now you have chief complaint of hemoptysis in a 30yo female with a strange rash on her face, complaining of shortness of breath. What's top of your diagnosis?

Think about SLE and vasculitis and worry about diffuse alveolar hemorrhage.

What's your next step for a Russian immigrant with a history of incarceration, with fevers and night sweats? And what is a Rasmussen's aneurysm?

Yikes!!!! TB!!! First, isolation, CXR, sputum for acid-fast bacilli.

Hemoptysis in TB can be caused by a Rasmussen aneurysm, which is a false aneurysm of a tortuous pulmonary artery crossing into a TB cavitary lesion.

Hemotysis in a patient with a heart murmur? What's the murmur and how does it cause hemoptysis?

Mitral stenosis! Mitral stenosis leads to increased pulmonary pressures and damage pulmonary vasculature. Similar situation for a large PE and hemoptysis, whereas small or distal PEs lead to ischemia and death of pulmonary tissue with hemorrhage.

References

Tintinalli’s 7th ed. Young. Ch 66: Hemoptysis.

TIntinalli’s 8th ed, Sims. Ch 63: Hemoptysis.

Special Thanks to Dr Jimmy Willis!