A patient on the respiratory ward coughs up 250ml of blood. Manage.

Question

A 58-year-old man being investigated for a cavitating lung lesion coughs up an estimated 300ml of bright red blood. He becomes hypoxic and tachycardic. You are the first doctor on scene.

Accepted Answer

Massive haemoptysis is life-threatening and the immediate risk is airway compromise, not blood loss. ABCDE with crash call and senior anaesthetic input. Airway: sit the patient up if alert, but if they cannot protect the airway position them bleeding-side down to protect the contralateral lung — anaesthetics for early intubation with a large-bore tube and possible bronchial blocker. Breathing: high-flow O₂, consider selective intubation. Circulation: two large-bore cannulae, crossmatch, send FBC, U&E, clotting, group and save; reverse any anticoagulant (vitamin K, PCC for warfarin; idarucizumab/andexanet for DOACs), give IV tranexamic acid 1g and transfuse with major haemorrhage protocol if shocked. Disability and exposure as standard. Once stabilised, urgent CT angiography to localise the bleeding source, then bronchial artery embolisation via interventional radiology as definitive treatment in most cases. I would involve thoracic surgery and ITU early. Throughout I would update the family clearly, explaining this is a life-threatening complication and what we are doing, and document carefully.

Massive haemoptysis on the ward

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