Hemoptysis....Double Lumen Left sided Endotracheal tubes Exist.... Really
Amazing the lack of Hemoptysis talk during Emergent airways.
I have done some research.
Other than hoping the left lung has the pathology causing the MASSIVE HEMOPTYSIS and my knowing that with a recent cxr or mri or ct scan lung or from my patient since we don't have universal access to patient's medical records in another hospital or state or country. Then I can hope to intubate the right mainstem and bring the bad lung down to prevent aspiration of the good lung if I keep the patient in left lateral decubitus position.
MASSIVE HEMOPTYSIS: equal to or more than 600 ml of blood (full kidney emesis basin) over first 24 hrs.
This can manifest sooner. Realize your bp with drop or rise, and heart rate will definitely rise before you freak out and syncopize.
Good talk from the People in IOWA.
Know I can do something else. Use a left sided DOUBLE LUMEN endotracheal tube. We are using French standard measurements to distinguish from 7.5 and 35 French endotracheal tubes to be used for this MASSIVE HEMOPTYSIS scenario. I hope to improve on the video database that exists on the internet on improved EMERGENCY AIRWAY MANAGEMENT.
There must be logic in this case.
I notice Upper Blood loss/Hemorrhage from top half of the human as one of 3 causes that must be ruled out.
Upper GIB from prior hx and workup, or from recent hx.
Hemoptysis from prior hx and workup or from recent hx and electronic medical records or rare paper charts.
Or the one you need to think of then is Epistaxis from Posterior Bleed.
Unresponsive patient who can't give a history is the perfect case on why you need a strategy.
Intubate for Airway Protection to prevent aspiration possibly. Suction before the oropharynx and place orogastric tube to decompress the stomach. Or newer students of AIRWAY then if iNTUBATION via Gastric Diversion you will figure out if patient with active hemorrhage from upper gi tract or not.
You should always suction for what possibly could have been aspirated into the trachea. Then look for acute bright red blood that is voluminous and continuous.
If the bleeding is negative from the endotracheal tube and orogastric tube from suctioning but the blood keeps re-accumulating, then the bleeding is from the Hose Called the Nose.
Do this for every patient? think of this for the unresponsive patient in hypotension or near death everytime.
You will be prepared.
Double Lumen Endotracheal tubes can be used more than for elective lung resection.
I don't have a fiberoptic scope/bronchoscope. I need to call the ICU attending/fellow to bring one down to my ED if I think of using this device electively or confirm correct placement of the double lumen endotracheal tube. But in MASSIVE HEMOPTYSIS, good luck. I will place it blindly.
Man up. and Proceed. Biggest secret, as the distal cuff passes into the glottic opening (passing the vocal cords) with blue side upwards to the sky, rotate the plastic more than 90 degrees, turn it counterclockwise, to make sure the distal tip curves left pass the carina. DO NOT straighten out the endotracheal tube with its inherently shaped device from the package it comes in. Leave the stylet be until you have placed the tube inside correctly.
It will buy you time before calling Interventional Radiology who can ligate/embolize the bleeding source if available, likely bronchial artery embolization. Cardiothoracic Surgeon to resect the diseased lung that is hemorrhaging. Or call Pulmonary consult who will verify what the Emergency Medicine physician thinks is wrong with the patient. with bronchoscopy. After securing the airway, get the stat portable cxr and ct angio of the lung please. Do it to clarify to everyone in the room what is wrong with the patient. Your presentation on the phone won't be honored as much as the reading of ct scan for some reason. Don't believe me. Suffer the consequence when calling a consult without the ct scan done.
Blood work may or not tell you that the patient is supratherapeutic on heparin or Coumadin. Or you may be evolved enough to be using a TEG device to figure out and rule out other pathology that could be leading to this patient bleeding like he is.
This if of course if DIC is not suspected, but then every orifice would be bleeding including from foleys and iv sites peripheral or central.
I welcome you on this endeavor on learning more.
AVOIDING THE PROBLEM OR PRAYING FOR A MIRACLE OR MAKING THE CASE THE OTHER ATTENDING'S IS NOT APPROPRIATE. MAN UP. GET READY.
This patient below wasn't.