6. Search for underlying cause or source of bleeding with imaging

Chest x-ray can localize the side of bleeding in patients with massive hemoptysis in approximately 50 percent of patients and suggest an etiology in about 33 percent. However, the sensitivity is poor with up to 50 percent of patients with normal chest x-ray having positive findings on CT.21 CT should be obtained in high-risk patients even with mild hemoptysis, and all patients with moderate to severe bleeding, even if the chest x-ray is unremarkable. The diagnostic yield of CT is superior to that of bronchoscopy while the yield in localizing the lesion is comparable at 75 percent.⁷ CT is generally recommended prior to bronchoscopy for this reason. The mnemonic BATTLECAMP may be used to recall the important causes of hemoptysis: Bronchiectasis, Aspergilloma/AV malformation, Tuberculosis, Tracheo-innominate fistula, Lung cancer or abscess, Pulmonary embolism, Cocaine/Coagulopathy/Catemenial/Cystic Fibrosis, Autoimmune (vasculitis, systemic lupus erythematosus), Alveolar hemorrhage, Mitral stenosis, Pneumonia.

7. Arrange for definitive management

Depending on the underlying cause, definitive management may include bronchial artery embolization, a bronchial blocker, surgical resection, or even heparinization or embolectomy in the case of pulmonary embolism. So next time you are faced with a patient with massive hemoptysis heading for respiratory failure in your ED, take an organized approach such as this seven-step one to maximize your patient’s chance of survival with good neurologic outcome.

A special thanks to Drs. Bourke Tillmann and Scott Weingart for their expertise on the EM Cases podcast that inspired this column.

Dr. Helman is an emergency physician at North York General Hospital in Toronto. He is an assistant professor at the University of Toronto, division of emergency medicine, and the education innovation lead at the Schwartz/Reisman Emergency Medicine Institute. He is the founder and host of Emergency Medicine Cases podcast and website.

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