A 21 y.o. male arrives from a motor vehicle collision . He is unresponsive, being bagged. He is hypotensive and hypoxic.
The pt is emergently intubated with large amounts of blood in the airway
What do you think happened.?
he has an abrasion on the L forehead; do you notice anything on his head CT?
On arrival our patient had bradycardia and was peri-arrest with sats in the 60’s. During intubation copious amounts of blood continued to fill the airway. The presumed cause for this patient’s presentation was anoxia from both blood in the airway and bilateral pneumothoraces.
He received MTP for a splenic injury with extravasation. Chest tubes were placed and the bp rose but the bleeding in the airway continued. The pt was taken to the ICU and bronched. His sats remained low. He had bilateral bronchial lacerations with contusions, hemorrhages and lacerations of both lungs. His head CT showed no grey white differentiation and global cerebral edema. His injuries were determined to be non survivable and pressors were withdrawn. He expired.
A Rasmussen’s aneusym caused by Tbc can cause massive hemoptysis.
HOW MUCH BLOOD IN THE AIRWAY IS TOO MUCH?
In the ED, blood in the airway can come from either the lower airways as in hemoptysis or the upper airway as in a post-tonsillar surgery bleed. The differentiation of mild and massive hemoptysis is urgent because they are treated differently. Massive bleeding fills the airways and leads to death from asphyxia. It is estimated that 150-200 cc of blood in the airway is all that it takes to cause a hypoxic arrest.
Massive hemoptysis is thought to be in the range of 300-600ml. Conservatively treated massive hemoptysis has a mortality of 50-100%. The volume of the tracheobronchial tree is 150-200 ml so massive hemoptysis rapidly impairs gas exchange. The most frequent cause of massive hemoptysis world-wide is tuberculosis because of bleeding from a Rasmussen’s aneurysm ( a pseudo aneurysm of a branch of the pulmonary artery near a tuberculous cavity).
The lungs have a dual blood supply with 99% of perfusion being from the pulmonary arteries. While on 1% of the blood supply comes from the bronchial arteries, they are the cause of 90% of hemotysis since they are thin-walled and carry a systemic arterial pressure load.
In addition to blood obstructing the airway, many objects have been reported in the airways including beads, toys, nuts, hot dogs, grapes and even Ascaris worms,leeches and fish.
Fun fact; multiple cases of fisherman aspirating live fish have been reported. In the image below a fisherman died from aspirating a tilapia which lodged at the bifurcation causing anoxia.
Ittrich H, Bockhorn M, Klose H, Simon M. The diagnosis and treatment of hemoptysisDeutc\sxhes Arzteblatt International 2017;114:371-81.
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Yoon W, Kim J, Kim Y et al. Bronchial and nonbronchial systemic artery embolization for life threatening hemoptysis : a comprehensive review. Eur Radial 1997;7:1221-7
Rizwan S, Mehta A. Alive in the Airways. Liveendobronchial foreign bodies. Chest 2017;151(2):481-491. doi: http://dx.doi.org/10.1016/J.chest. 2016.10.041
Grey-white differentiation refers to the interface between white matter and grey matter on CT. It is most often used in differentiating cytotoxic from vasogenic edema. In hypoxic insults there is an inability to distinguish white matter from grey matter and in tumors or abscesses the differentiation is accentuated.
