Pediatric emergency medicine trisk 2790 2790

pneumothorax is resolved Timing for reimplementation of therapies is based on resolution of pneumothorax and discussion with the patient’s CF team Hemoptysis Blood streaking of the sputum is common in CF patients The CFF’s Guidelines define hemoptysis as mild (less than 60 cm3 daily), moderate (more than 60 and less than 240 cm3 daily), and severe (more than 240 cm3 daily or more than 100 cm3 per day for more than days) Hemoptysis should be distinguished from epistaxis or hematemesis Mild Hemoptysis Mild hemoptysis requires no specific treatment other than observation Persistent streaking may indicate a pulmonary exacerbation requiring antibiotic treatment Other factors such as chronic use of medications with antiplatelet function activity (e.g., aspirin) or coagulopathy secondary to decreased vitamin K levels should be ruled out and treated accordingly Moderate/Severe Hemoptysis Severe episodes can be life threatening due to asphyxiation from airway obstruction, hemorrhagic shock, and/or chemical pneumonitis Approximately 1% of CF patients experience an episode of major bleeding per year, the majority of patients being 16 years or older The bleeding usually originates from enlarged and tortuous bronchial arteries, two-thirds of which arise from the ventral surface of the aorta The remaining third come from the internal mammary and intercostal arteries Onset is often abrupt Some patients may report localized gurgling or sensation in the specific area of lung involved Physical examination may reveal new, localized pulmonary findings Placing a nasogastric tube or performing endoscopy may become necessary to differentiate GI from pulmonary sources A CXR should be obtained, though the specific area of bleeding is not often visualized IV access must be established and laboratory tests obtained including CBC with differential, coagulation studies, liver function tests, blood gas analysis, and emergency type and cross match Sputum culture should also be obtained Emergency bronchoscopy to localize and treat the site of bleeding should be discussed with the primary CF team In some cases, bronchoscopy may not be helpful either because the patient has stopped bleeding or massive hemorrhage obscures visualization Most cases of severe hemoptysis are self-limited and can be managed using vitamin K, blood products, and antibiotics in an ICU setting Surgery or local vascular therapy with arterial embolization may be necessary for refractory bleeding In that situation, both rigid and flexible bronchoscopy should be available during the procedure in the operating room or ICU