Transcript Extern conference 20 sep 2007

EXTERN CONFERENCE
20 SEP 2007
HEMOPTYSIS
History
Admit september 6 ,2007
14-year-old Thai boy
 CC: hemoptysis for 2 hours
 PI :
2 hr. PTA, after school, the patient felt like something caught
in his throat so he went into the bathroom and cough up a
large amount of bright red blood (about 1 cola can) , no air
bubble, food particles, sputum or clotted blood was seen
 He continued to have hemoptysis since then, the total amount
was about 3 cola cans
 1 hr. PTA , he started to have nose bleeding
 He had palpitation but no fainting or dizziness

History : Present illness


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
He never had unexplained bleeding, petechiae,
epistaxis, hemoptysis, hematemesis, hematuria,
melena
He denied history of chronic cough, recurrent
pneumonia, jaundice, weight loss, low grade fever,
anorexia
None of his family member or friends have similar
symptoms
No history of trauma
History

PMI:

Underlying disease :

asthma



Personal history





No history of hematologic disease
No history of tuberculosis
Medication


No smoking, no alcohol drinking, no IVDU
Family history


for 10 years, last attack 3 years ago
No current medication
No history of drug allergy
No current medication
Developmental history: normal
Vaccination

Complete EPI programme
History : Present illness


First, his mother took him to Srivichai hospital
At Srivichai hospital
Massive hemoptysis with epistaxis
 Physical examination

V/S : BP 140/80 mmHg., T 38.3oC, RR 40/min,
 GA : dyspnea
 HEENT : Epistaxis in nasal cavity, Bloody discharge at posterior
pharynx
 RS : wheezing both lungs with transmitted sounds form upper tract :
after ventolin NB –> crepitation RML field
 CVS, Abdomen : WNL
 Cervical lymph node : not palpable


Management

Ventolin & adrenaline aerosol – wheezing improved but hemoptysis
continued.
History : Present illness

At ER Siriraj

Physical examination
V/S : BP 121/75 mmHg., T 37oC, PR 108/min, RR 32/min
 O2 sat. 86%
 HEENT :
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nose : blood clot in Rt. Nasal canal, normal Lt. side, pale mucosa
Pharynx : not injected
Oropharynx : mild injected
ENT : TM- no erythema, bleeding
CVS : normal S1 & S2, no murmur
 RS : mild dyspnea, substernal retraction, decreased breathsounds
RLL, crepitation RML, wheezing both lungs, secretion sounds
 LN : no superficial lymphadenopathy

Investigations

CBC (6/9/07)
 Hb
11.6 mg/dl., Hct 37.2%
 WBC 12,770/mm3 (N 82.5%, L 13.4%, Mo 3%)
 Platelet 275,000/mm3

Blood chemistry (6/9/07)
 Na
141 mmol/l
 K 4.1 mmol/l
 Cl 106 mmol/l
 HCO3 26 mmol/l
 BUN : Cr = 10 : 0.6

Rt. Middle lobe
silhouette to Rt.
heart border, no
perihilar
lymphadenopathy,
reticulonodular
infiltration Rt. lower
lung field

Right lateral
decubitous: no
pleural effusion
was seen
Problem lists
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

Massive Hemoptysis for 2 hours
Bleeding per nose for 1 hours
Underlying disease : asthma for 10 years
Differential diagnosis

Infectious cause : most likely
 Atypical
pneumonia
 Pulmonary tuberculosis

Pulmonary hypertention:
 congenital
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
heart disease
Trauma: lung contusion
Tumor:
 pulmonary
adenoma
 Adenoid tumor
Hemoptysis


Hemoptysis : the coughing up of blood derived from the lungs or
bronchial tubes as a result of pulmonary or bronchial hemorrhage.
Classification
 Non-massive : blood vol. < 200 ml./day
 Massive : usually from bronchial system (systolic pressure)
First step :
hemoptysis VS.
pseudohemoptysis
or hematemesis
Massive hemoptysis

Common
 Tuberculosis
 Bronchiectasis
(including cystic fibrosis)
 Nontuberculous mycobacteria
 Lung abscess
 Mycetoma (aspergilloma, or fungus ball)
 Pulmonary contusion or trauma
Management

Based on 2 important issues
 The
underlying cause
 The severity of bleeding
Management
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
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To protect airway, maintain oxygenation(ET
tube/rigid bronchoscopy in case of severe
respiratory distress)
Maintain sufficient blood volume
Stop hemorrhage
Treat the underlying cause
How to approach
Progress note
Progress note
Management 6 september 2007

To protect airway, maintain oxygenation
 NPO
 On
oxygen canula 3 LMP
 Position: lying right side down
 Arterial blood gas stat

Maintain sufficient blood volume
 5%D/N/2
(1000ml) iv drip 100cc/hr
 recordV/S q 2 hr
 G/M PRC 550 cc
Management 6 september 2007

Observe bleeding
 Serial

Hct q 6 hr
Treatment the underlying cause
 CXR
lateral decubitous stat,then F/U again tomorrow
 Claforan 100 MKD> sig 1 gm IV q 6 hr
 Paracetamol (500mg) 1 tab oral prn
Progress note 7 Sep 2007 1.30am


V/S: T 37.5 P 98/min, BP 124/64 mmHg,
RR 32/min
RS: decreased breath sound RLL, coarse crepitation
RML, Dullness on percussion & Decreased vocal
resonance at RLL, trachea in midline, decreased
chest movement on Rt. side


Opacity area at
RLL silhouette to
Rt. Diaphragm
and Rt heart
border
minimal
mediastinal shift
to the right
Progress note 7 Sep 2005 1.30am

DDX: (film)
-
Atelectasis
 - Consolidation from pneumonia
 - Hemorrhage
 - Pleural effusion
Film right lateral
decubitus
-Minimal pleural
effusion,
-pneumothorax,
-haziness at RLL&lateral
side of Rt.lung
suspected atelectasis
Progress note 7 September 2007
A&P
-5% D/N/2 1000 cc IV drip rate 100 cc/hr
- Oxygen cannula 3 LPM
-Pleural fluid gram stain, AFB,modified AFB, fresh smear
,culture for bacteria fungus ,LDH,sugar

(Pleural fluid gram stain ,AFB,modified AFB : neg )
Progress note 7 September 2007
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CXR all members of the family
 Result:
All negative
Management 7 September 2007
-ATB:
- Claforan
- Azithromycin(250mg)sig 2 tab oral OD
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Blood for Clamydia Ab, Mycoplasma Ab titer
Tuberculine skin test
Sputum for AFB x 3 days
Progress note 8 September 2007
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Lab sputum AFB (8 sep 07) not found
Progress note 9 September 2007
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Lab sputum AFB (9 sep 07) : positive 5 cells/slide
Tuberculin skin test results:
48 hr.: 13 mm.
 72 hr.: 18 mm.

Question for medical student !!!
Progress note 10 September 2007
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S: dyspnea , no fever
Massive pneumothorax
at right lung
Massive loss of lung
volume right side
Blunt costophrenic
angle
Progress note 10 September 2007
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
Right lateral
decubitous
Fluid level was
seen
Atelectasis
Progress note 10 September 2007
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Consult CVT for applied ICD
 After
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
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ICD insertion: Air + pleural effusion
CXR after ICD insertion
Applied intermittent suction 20 mmH2O
CXR again after applied suction
Sputum AFB day 3 : negative
Progress note 10 September 2007
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Oxygen 8 LPM keep Oxygen > 95 %
CXR tomorrow
Pleural fluid for cell count, cell diff, gram stain, AFB,
modified AFB, fresh smear ,Culture for bacteria ,
fungus, mycobacteria, LDH, sugar, protien, pH, ADA
, PCR, pleural fluid cytology
H/C
serum LDH, protein
Progress note 10 September 2007
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Off Azithromycin
INH(100mg)(6mg/kg/day) sig 3 tab oral hs
Rifampicin(600mg)sig 1 tab oral hs
Pyrazinamide (500mg) sig 2 tab oral hs
Ethambutol (500mg) sig 2 tab oral hs
Vitamin B6 sig 1tab oral OD
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After
applied ICD
Haziness at
right lung
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After ICD
insertion with
intermittent
suction
Increase lung
expansion
Progress note 10 September 2007
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-
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ICD content : 50 mL.
lab investigation
sputum AFB not found
Pleural effusion gram stain (10sep07)
: moderate PMN , no bacteria seen
Progress note 10 September 2007
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-
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Pleural effusion modifiedAFB(10sep07)
:moderate PMN ,not found modified acid fast
baccili
Pleural effusion : total protein 3.8 g/dl , glucose
74 mg/dl
LDH 1880 u/litre
Blood chemistry :total protein 6.8 g/dl ,LDH 254
u/litre
Conclusion: pleural fluid is exudate
Progress note 11 September 2007
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Asymmetrical CXR
Rt. Main bronchus
was not seen
Airway trapping
Diff Dx – atelectasis
or pleural effusion
Progress note 11 September 2007

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pleural fluid (11 sep 07) :serosanguinous fluid,
negative for malignancy ,reactive cellular changes
associated with inflammation
H/C : NG
Plan: Treat pulmonary TB at least 2 weeks then F/U
CXR
Progress note 12 September 2007

Increased lung
expansion
Management 12 September 2007

Plan:
 after
improvement of Rt. Lung atelectasis
off ICD
 Pleural effusion will improve after starting anti-TB
drugs
 Lung expansion therapy: suck triflow 4 times a day
 Start
pc
steroid: Prednisolone (2mg/kg/day)3 tab oral tid
Progress note 13 September 2007
 S&O:
He got exhausted after going to the bathroom
 O2 sat. 77%
on O2 mask with bag 15 LPM
O2 sat 95%
 ICD content(13/9/07): 20 ml.
 The 3rd ICD bottle was wrong connection
correct ICD connection
Progress note 14 September 2007
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ICD(14/9/07) 70 ml.
O2 mask with bag 10 LPM keep O2 >95%
Progress note 15 September 2007
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Rt. pneumothorax
Progress note 15 Sep 2007
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ICD content: (15 Sep 2007)no content
 On
oxygen mask with bag 10 LPM.
Progress note 16 Sep 2007
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ICD content: (16 Sep 2007)20 mL
Continue O2 mask with bag 10 LPM
 (for
improvement pneumothorax)
Progress note 17 Sep 2007
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Mild dyspnea, No hemoptysis or epistaxis
PE:
 V/S:T
37.2 C, BP 122/84 mmHg, RR 18/min. PR
86/min
 RS: Equal chest movement, Decreased breath sound
Rt.lung, dullness on purcussion.

Plan: Clamp ICD tomorrow,if no dyspnea
off ICD
Progress note 18 Sep 2007
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S : no dyspnea, no fever
O : v/s : stable
RS : Equal chest movement, Decreased breath
sound Rt.lung, dullness on purcussion.
A&P : F/U CXR
Off ICD
Progress note 18 Sep 2007
No pneumothorax seen
RLL atelectasis
Mediastinum shift to
the right
Progress note 19 Sep 2007
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S : No fever, no dyspnea, no cough
O : v/s : T 36.5, PR 76, RR 20, BP 109/64, O2sat
(mask with bag 10 LPM) 98 %
RS : Decrease breath sound at Rt. Lung, dullness on
percussion, no air leakage when cough
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P : Clamp ICD 4 hour if no dyspnea then off ICD
Progress note 19 Sep 2007
Reference
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Robert C. Stern,Nelson textbook of pediatrics
16th,Hemoptysis p1307-1308
Simon Godfrey, MD, Hemoptysis in Children,
Pediatric Pulmonology, Supplement 26:177–179
(2004)
Simon Godfrey, MD, Pulmonary Hemorrhage/
Hemoptysis in Children, Pediatric Pulmonology
37:476–484 (2004)


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Freixinet J et al, Role of surgery in pulmonary
tuberculosis, Med Sci Monit, 2002; 8(12): CR782786
T.W. Noseworthy,MD,MSc,FRCPC,FACP, B.J.Anderson,
RN, BSc, Massive hemoptysis, CMAJ, VOL. 135,
NOVEMBER 15, 1986
Kin-sun Wong, Reyin Lien and Shao-Hsuan Hsia,
Major Hemoptysis in Adolescents, Indian Journal
of Pediatrics, Volume 72—June, 2005


Stefan Goldberg, MD, TUBERCULOSIS, CLINICS IN
FAMILY PRACTICE Volume 6 Number 1 March
2004,
Takeshi HISADA, Massive Hemoptysis Due to
Pulmonary Tuberculosis, Internal Medicine Vol. 44,
No. 2 (February 2005)
Special thanks
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

A. Kulkanya Chokphaiboolkit, Pediatrics
A. Kriengkrai, Radiologist
Chest pediatrics fellow