Lecture topic:
"ACUTE AND EMERGENCY
CONDITIONS."
Lecturer: M.D. Babayeva I. Y.
PULMONARY HEMORRHAGE (hemopnoea) is the outpouring of a significant amount of
blood into the lumen of the bronchi. The difference between pulmonary bleeding and hemoptysis is mainly quantitative.
Pulmonary bleeding is a condition in which a patient loses between 200 and 1000 ml of
blood within 24 hours. In pulmonary hemorrhage, blood is coughed up in significant amounts at one time, continuously or intermittently.
BLOOD CHARCANGE (HEMOFTIS) is the presence of streaks of scarlet blood in sputum or saliva, and the discharge of individual spits of liquid or partially coagulated blood. It is more often caused by diapedesis of red blood cells, but may be a precursor to pulmonary hemorrhage. Bleeding of more than 100 ml within 24 hours should be considered potentially life- threatening.
Classification of pulmonary bleedings (Strukov V.I. et al., 1982):
1.1st degree: blood loss up to 100 ml (small), respiratory rate 22 - 24, pulse 80 - 86, normal systolic blood pressure, normal hemoglobin.
2.2nd degree: blood loss up to 100 - 500 ml (medium, moderate), respiration rate 24 - 26, pulse 90 - 96, some decrease of systolic blood pressure, hemoglobin 10 - 15% below the initial one. Lethality reaches 7 - 30%.
3.3rd degree: blood loss over 500 ml (severe, major), respiration rate 28 - 30, pulse 110 - 115, systolic blood pressure below 90 mm Hg, hemoglobin 20 - 25% below the initial. Large or profuse bleeding is very dangerous
and can lead to death. Lethality reaches 80%. Causes of death are asphyxia, collapse, acute posthemorrhagic anemia, aspiration pneumonia, progression of tuberculosis, pulmonary and cardiac failure.
THREE FACTORS PREDISPOSE TO THE OCCURRENCE OF PULMONARY BLEEDING:
1.Morphological changes in lung tissue. In the zones of pneumofibrosis there occurs a pronounced rearrangement of the vascular bed.
2.Hemodynamic factor is the increase of pressure in the pulmonary artery system up to 32-40 mm Hg and more. Chronic pulmonary hypertension contributes to aneurysmal vasodilation.
3.Blood coagulation disorders - hypocoagulation, activation of local fibrinolysis. In tuberculosis, fibrinolytic action of MBT cytolysis products is important. Some drugs can cause thrombocytopenia (rifampicin, PASC, thiacetasone).
CLINICAL picture of pulmonary hemorrhage:
1.It occurs more frequently in middle-aged and elderly men.There is a history of pulmonary pathology, and respiratory distress and pulmonary hypoxemia are common.
2.Pulmonary hemorrhage begins with hemoptysis, but can occur suddenly, against the background of good condition.
3.Scarlet (if coming from the bronchial arteries) or dark (if coming from the pulmonary artery system) blood is coughed up through the mouth (can also be excreted through the nose) either pure or with sputum.
4.The blood is frothy and does not clot, and has a neutral or alkaline reaction (pH>7.42, checked with litmus paper).
5.Blood streaks continue to come out with the sputum for several days after the pulmonary bleeding has stopped, and anemia is usually absent.
5.The onset of pulmonary bleeding is a sensation of pain in the chest, warmth, burning, flowing "warm stream", "boiling" in the chest.
6.Feathering, tickling in the throat, a brackish taste of blood appears. Patients are frightened, excited, restrained in their movements.
7.Pallor, dyspnea, and tachycardia are noted. The lungs may have abundant multi-caliber rales on the affected side, crepitations, and then - with blood aspiration - on both sides. Quiet percussion is used, techniques with forced breathing are not indicated.
DIAGNOSTIC MEASURES:
1.Blood group, Rh factor, general blood analysis in dynamics, determination of hematocrit, blood gases, coagulogram.
2.Measurement of blood pressure. Consultation of an otorhinolaryngologist (examination of the nasopharynx).
3.Chest radiography in two projections (preferably digital). Most informative computed tomography and bronchial arteriography.
4.Bronchoscopy. It is performed in almost all patients at the height of bleeding or immediately after its stoppage.
5.Additional studies (usually performed after stopping pulmonary bleeding): tomography, bronchography, angiography of bronchial arteries.
PREHOSPITAL STAGE:
1.Rest. The patient should be in a semi-sitting position, with the legs down (provide support for them). Periodic turns are advisable to improve expectoration of sputum.
2.Warm the lower extremities with heating pad, or lowering into a basin of hot water.
3.You can drink in small sips a strong solution of table salt (1 tablespoon per 1 cup of water) - this diverts blood to the abdominal organs.
4.Do not suppress coughing, as it leads to accumulation of blood in the lower regions and increases the likelihood of aspiration pneumonia. Therefore, drug administration is contraindicated. Only with a very severe cough small doses of codeine.
5.It is necessary to calm the patient. Psychotherapy, small doses of sedatives are possible, so as not to suppress the cough reflex.
HOSPITAL STAGE:
1.Be sure to admit the patient to a specialized hospital.
2.Place the patient on the side where the source of bleeding in the lung is located.
3.Conservative methods (drugs):
Compensation of blood loss at profuse LC (500 - 1000 ml or more) with hemodynamic disorders: erythrocyte suspension, native plasma, fresh frozen plasma, gelatinol, albumin, fibrinogen, platelet mass.
Increasing blood clotting (hemostatic agents): dicinone (etamsilate), vicasol.
Decrease in proteolytic activity and blood protease levels: E- aminocaproic acid, contrical.
Reduction of vascular wall permeability: calcium chloride or gluconate, ascorbic acid.
Reduction of pulmonary artery pressure: atropine sulfate, eufylline, papaverine hydrochloride, nostropa.
Oxygen therapy under control of blood gases.
Artificial controlled hypotension: ganglioblockers (pentamine, arfonad, azamethonium bromide, trimethophane camsilate, clonidine).
Broad spectrum antibiotics.