 | Brain Food is a project to drip feed clinical knowledge (in the form of mock SAQs) to satisfy those hungry neurons. Sources are SA/NT Trial Exam 2021.2 and Monash 2022.1. Answers are prone to ageing. Leave a comment if you don't understand or something doesn't seem right... PS we don't use the mock questions uploaded to ACEMs official mocks |
A 69-year-old lady presents to your tertiary emergency department with a one-hour history of haemoptysis. She states that she has coughed up about 2 cups full of bright red blood.
She has a past medical history of breast cancer with a right sided mastectomy and on apixaban for paroxysmal atrial fibrillation.
Her observations are:
PR 100 bpm
BP 110/80 mmHg
SaO2 92% RA
RR 28 bpm
Temp afebrile
She has a past medical history of breast cancer with a right sided mastectomy and on apixaban for paroxysmal atrial fibrillation.
Her observations are:
PR 100 bpm
BP 110/80 mmHg
SaO2 92% RA
RR 28 bpm
Temp afebrile
1. State a definition of massive haemoptysis.
No accepted definition but something sensible. 150 mL of blood expectorated in a 24‐hour period or bleeding at a rate ≥100 mL/hour.
2. List your top three (3) differential diagnoses in this patient.
Most common are bronchogenic Ca, bronchiectasis, TB, fungal infections. Need Ca or max 1 mark
She has ongoing haemoptysis and a decision is made to reverse her anticoagulation.
3. State two (2) medications including route and dose that could be given.
3. State two (2) medications including route and dose that could be given.
Andexanet (not available in Australia), 25‐50/kg prothrombinex, TXA, DDAVP likely to be less useful, no evidence for FFP
4. List three (3) investigations that would assist in your management and a justification for each.
- CXR
- CT angiogram
- Laboratory Ix especially apixaban/Xa levels/coagulation/cross match
- Bedside such as ECG/echo less useful
- Bronchoscopy unlikely to occur prior to intubation
The patient continues to deteriorate with ongoing large volume haemoptysis despite your management. She is in your resuscitation bay will full NIV monitoring attached and peripheral IV access.
Observations are:
PR 140 bpm
BP 80/60 mmHg
Sao2 90 % 15 litres O2
GCS 12
Observations are:
PR 140 bpm
BP 80/60 mmHg
Sao2 90 % 15 litres O2
GCS 12
5. State three (3) treatment priorities in this patient.
- Lateral decubitus with suspected bleeding side down, prepare for intubation
- Resuscitation with blood products and correction of bleeding diathesis eg temp/Ca/plts and further prothrombinex if given 25/kg before
- Intubation, consider advancing tube into non bleeding lung for single lung ventilation or double lumen tube
- Urgent interventional radiology if bleeding source identified or balloon tamponade once intubated
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