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Hematuria may result from one of two mech-
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anisms: rupture or perforation of vessels in the
renal system or urinary tract, or impaired
glomerular filtration, which allows RBCs to seep
into the urine. The color of the bloody urine
provides a clue to the source of the bleeding.
Generally, dark or brownish blood indicates renal or upper urinary tract bleeding, whereas
bright red blood indicates lower urinary tract
bleeding.
Although hematuria usually results from renal and urinary tract disorders, it may also result from certain GI, prostate, vaginal, or coagulation disorders or from the effects of certain
drugs. Invasive therapy and diagnostic tests that
involve manipulative instrumentation of the renal and urologic systems may also cause hematuria. Nonpathologic hematuria may result from
fever and hypercatabolic states. Transient
hematuria may follow strenuous exercise. (See
Hematuria: Causes and associated findings, pages
362 to 365.)
H
ISTORY AND PHYSICAL
EXAMINATION
After detecting hematuria, take a pertinent
health history. If hematuria is macroscopic, ask
the patient when he first noticed blood in his
urine. Does it vary in severity between voidings? Is it worse at the beginning, middle, or
end of urination? Has it occurred before? Is the
patient passing any clots? To rule out artifactual
hematuria, ask about bleeding hemorrhoids or
the onset of menses, if appropriate. Ask if pain
or burning accompanies the episodes of hematuria.
Ask about recent abdominal or flank trauma.
Has the patient been exercising strenuously?
Note a history of renal, urinary, prostatic, or coagulation disorders. Then obtain a drug history,
noting the use of anticoagulants or aspirin.
Begin the physical examination by palpating
and percussing the abdomen and flanks. Next,
percuss the costovertebral angle (CVA) to elicit
tenderness. Check the urinary meatus for bleeding or other abnormalities. Using a chemical
reagent strip, test a urine specimen for protein.
A vaginal or digital rectal examination may be
necessary.
M
EDICAL CAUSES
◆ Appendicitis. About 15% of patients with ap-
pendicitis have either microscopic or macroscopic hematuria accompanied by bladder tenderness, dysuria, and urinary urgency. More
HEMATURIA
361
Confirming hematuria
If the patient’s urine appears blood tinged,
be sure to rule out pseudohematuria, red or
pink urine caused by urinary pigments.
First, carefully observe the urine specimen.
If it contains a red sediment, it’s probably
true hematuria.
Then check the patient’s history for use of
drugs associated with pseudohematuria, including rifampin, chlorzoxazone,
phenazopyridine, phenothiazines, doxorubicin, phenytoin, and laxatives containing
phenolphthalein.
Ask about the patient’s intake of beets,
berries, or foods with red dyes that may color the urine red. Be aware that porphyrinuria and excess urate excretion can also
cause pseudohematuria.
Finally, test the urine using a chemical
reagent strip. This test can confirm even microscopic hematuria and can also estimate
the amount of blood present.
typical findings include constant right-lowerquadrant pain (especially over McBurney’s
point), nausea and vomiting, anorexia, abdominal rigidity, rebound tenderness, constipation,
tachycardia, and low-grade fever.
◆ Bladder cancer. A primary cause of gross
hematuria in men, bladder cancer may also produce pain in the bladder, rectum, pelvis, flank,
back, or leg. Other common features are nocturia, dysuria, urinary frequency and urgency,
vomiting, diarrhea, and insomnia.
◆ Bladder trauma. A characteristic finding in
traumatic rupture or perforation of the bladder,
gross hematuria is typically accompanied by lower abdominal pain. The patient may also develop
anuria despite a strong urge to void; swelling of
the scrotum, buttocks, or perineum; and signs of
shock, such as tachycardia and hypotension.
◆ Calculi. Both bladder and renal calculi pro-
duce hematuria, which may be associated with
signs of urinary tract infection, such as dysuria
and urinary frequency and urgency. Bladder calculi may also cause gross hematuria, referred
pain to the lower back or penile or vulvar area
and, occasionally, bladder distention.
Renal calculi may produce microscopic or
gross hematuria. The cardinal symptom,
though, is colicky pain that travels from the CVA
to the flank, suprapubic region, and external
(Text continues on page 366.)
362 HEMATURIA
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SIGNS & SYMPTOMS
Hematuria: Causes and associated findings
Major associated signs and symptoms
Common
causes
Appendicitis
Bladder cancer
Bladder trauma
Calculi (bladder)
Calculi (renal)
Coagulation
disorders
Cortical necrosis
(acute)
Cystitis (bacterial)
Cystitis (chronic
interstitial)
Cystitis (tubercular)
Cystitis (viral)
Diverticulitis
Endocarditis
(subacute infective)
Abdominal
distention
Abdominal pain
Anuria
Bladder distention
Blood pressure
increase
Bowel sounds,
hypoactive
•
••
••
•• •
••
•
Colicky pain
Costovertebral angle
tenderness
Dysuria
Edema, generalized
••
•
•
•• •
••
•
•
••
Edema of the legs
Fever
••
•
Glomerulonephritis
(acute)
Glomerulonephritis
(chronic)
Nephritis (acute
interstitial)
Nephritis (chronic
interstitial)
Nephropathy
(obstructive)
•• • • •
••
••
•
••
•
•
Flank mass
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Flank pain
Lumbar pain
Murmurs
Nausea
Nocturia
Oliguria
Perineal pain
Polyarthralgia
Polyuria
Proteinuria
Purpura
Rash
Urethral discharge
Urinary frequency
HEMATURIA 363
Urinary hesitancy
Urinary stream,
diminished
Urinary urgency
Vomiting
•••
••
•
•
•••
••
•• • ••
•
•
••
•
••
••
•••
•••
•
••
••
•
•
••• • •
•
•••
••
•
(continued)
364 HEMATURIA
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Hematuria: Causes and associated findings (continued)
Major associated signs and symptoms
Common
causes
Polycystic kidney
disease
Prostatic
hyperplasia
(benign)
Prostatitis (acute)
Prostatitis (chronic)
Pyelonephritis
(acute)
Renal cancer
Renal infarction
Renal papillary
necrosis (acute)
Renal trauma
Renal tuberculosis
Renal vein
thrombosis
Abdominal
distention
Abdominal pain
Anuria
Bladder distention
Blood pressure
increase
Bowel sounds,
hypoactive
Colicky pain
Costovertebral angle
tenderness
Dysuria
Edema, generalized
Edema of the legs
Fever
••
•
•
•
•••
••
•••••
•
•••
•
•• • • • •
•• •
••
•
•
•
•
•
••••
Schistosomiasis
Sickle cell anemia
Systemic lupus
erythematosus
Urethral trauma
Vaginitis
Vasculitis
•
•
•
•
•
••
Flank mass
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Flank pain
Lumbar pain
Murmurs
Nausea
Nocturia
Oliguria
Perineal pain
Polyarthralgia
Polyuria
Proteinuria
Purpura
Rash
Urethral discharge
Urinary frequency
HEMATURIA 365
Urinary hesitancy
Urinary stream,
diminished
Urinary urgency
Vomiting
•
••••
•
•
•••
•• •• • ••
••••
••• ••••
•• • •
••
•
•• •
•
••
•
•
•
•
•
••
•
•
•
•
•
••
•
•
•
•
•
•
•
•
••
366 HEMATURIA
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genitalia when a calculus is passed. The pain
may be excruciating at its peak. Other signs and
symptoms may include nausea and vomiting,
restlessness, fever, chills, abdominal distention
and, possibly, decreased bowel sounds.
◆ Coagulation disorders. Macroscopic hema-
turia is commonly the first sign of hemorrhage
in coagulation disorders, such as thrombocytopenia or disseminated intravascular coagulation. Among other features are epistaxis, purpura (petechiae and ecchymosis), and signs of GI
bleeding.
◆ Cortical necrosis (acute). Accompanying
gross hematuria in this renal disorder are intense flank pain, anuria, leukocytosis, and fever.
◆ Cystitis. Hematuria is a telling sign in all
types of cystitis. Bacterial cystitis usually produces macroscopic hematuria with urinary urgency and frequency, dysuria, nocturia, and
tenesmus. The patient complains of perineal
and lumbar pain, suprapubic discomfort, and fatigue and occasionally has a low-grade fever.
More common in women, chronic interstitial
cystitis occasionally causes gross hematuria. Associated features include urinary frequency, dysuria, nocturia, and tenesmus. Both microscopic
and macroscopic hematuria may occur in tuber-
cular cystitis, which may also cause urinary urgency and frequency, dysuria, tenesmus, flank
pain, fatigue, and anorexia. Viral cystitis usually
produces hematuria, urinary urgency and frequency, dysuria, nocturia, tenesmus, and fever.
◆ Diverticulitis. When this disorder involves
the bladder, it usually causes microscopic
hematuria, urinary frequency and urgency, dysuria, and nocturia. Characteristic findings include left-lower-quadrant pain, abdominal tenderness, constipation or diarrhea and,
occasionally, a palpable, firm, fixed, and tender
abdominal mass. The patient may also develop
mild nausea, flatulence, and a low-grade fever.
◆ Endocarditis (subacute infective). Occa-
sionally, this disorder produces embolization,
resulting in renal infarction and microscopic or
gross hematuria. Common related findings are
constant fever, chills, night sweats, fatigue, pallor, anorexia, weight loss, polyarthralgia, petechiae, flank pain, severe back pain, stiff neck,
cardiac murmurs, tachycardia, and
splenomegaly.
◆ Glomerulonephritis. Acute glomerulonephri-
tis usually begins with gross hematuria that ta-
pers off to microscopic hematuria and RBC
casts, which may persist for months. It may also
produce oliguria or anuria, proteinuria, mild
fever, fatigue, flank and abdominal pain, generalized edema, increased blood pressure, nausea, vomiting, and signs of lung congestion,
such as crackles and a productive cough.
Chronic glomerulonephritis usually causes mi-
croscopic hematuria accompanied by proteinuria, generalized edema, and increased blood
pressure. Signs and symptoms of uremia may
also occur in advanced disease.
◆ Nephritis (interstitial). Typically, this infec-
tion causes microscopic hematuria. However,
some patients with acute interstitial nephritis
may develop gross hematuria. Other findings
are fever, maculopapular rash, and oliguria or
anuria. In chronic interstitial nephritis, the patient has dilute—almost colorless—urine that
may be accompanied by polyuria and increased
blood pressure.
◆ Nephropathy (obstructive). This disorder
may cause microscopic or macroscopic hematuria, but urine is rarely grossly bloody. The patient may report colicky flank and abdominal
pain, CVA tenderness, and anuria or oliguria
that alternates with polyuria.
◆ Polycystic kidney disease. This hereditary
disorder may cause recurrent microscopic or
gross hematuria. It commonly produces no
symptoms before age 40 but may cause increased blood pressure, polyuria, dull flank pain,
and signs of urinary tract infection, such as dysuria and urinary frequency and urgency. Later,
the patient develops a swollen, tender abdomen
and lumbar pain that’s aggravated by exertion
and relieved by lying down. He may also have
proteinuria and colicky abdominal pain from the
ureteral passage of clots or calculi.
◆ Prostatic hyperplasia (benign). About 20%
of patients with an enlarged prostate have
macroscopic hematuria, usually when a significant obstruction is present. The hematuria is
usually preceded by diminished urinary stream,
tenesmus, and a feeling of incomplete voiding.
It may be accompanied by urinary hesitancy,
frequency, and incontinence; nocturia; perineal
pain; and constipation. Inspection reveals a
midline mass representing the distended bladder; rectal palpation reveals an enlarged
prostate.
◆ Prostatitis. Whether acute or chronic, pro-
statitis may cause macroscopic hematuria, usually at the end of urination. It may also produce
urinary frequency and urgency and dysuria followed by visible bladder distention.
Acute prostatitis also produces fatigue,
malaise, myalgia, polyarthralgia, fever with
HEMATURIA
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367
chills, nausea, vomiting, perineal and low back
pain, and decreased libido. Rectal palpation reveals a tender, swollen, boggy, firm prostate.
Chronic prostatitis commonly follows an acute
attack. It may cause persistent urethral discharge, dull perineal pain, ejaculatory pain, and
decreased libido.
◆ Pyelonephritis (acute). This infection typi-
cally produces microscopic or macroscopic
hematuria that progresses to gross hematuria.
After the infection resolves, microscopic hematuria may persist for a few months. Related
signs and symptoms include persistent high
fever, unilateral or bilateral flank pain, CVA tenderness, shaking chills, weakness, fatigue, dysuria, urinary frequency and urgency, nocturia,
and tenesmus. The patient may also exhibit
nausea, vomiting, anorexia, and signs of paralytic ileus, such as hypoactive or absent bowel
sounds and abdominal distention.
◆ Renal cancer. The classic triad of signs and
symptoms includes gross hematuria; dull,
aching flank pain; and a smooth, firm, palpable
flank mass. Colicky pain may accompany the
passage of clots. Other findings include fever,
CVA tenderness, and increased blood pressure.
In advanced disease, the patient may develop
weight loss, nausea and vomiting, and leg edema with varicoceles.
◆ Renal infarction. Typically, this disorder pro-
duces gross hematuria. The patient may complain
of constant, severe flank and upper abdominal
pain accompanied by CVA tenderness, anorexia,
and nausea and vomiting. Other findings include
oliguria or anuria, proteinuria, hypoactive bowel
sounds and, a day or two after the infarction,
fever and increased blood pressure.
◆ Renal papillary necrosis (acute). This dis-
order usually produces gross hematuria, which
may be accompanied by intense flank pain, CVA
tenderness, abdominal rigidity and colicky pain,
oliguria or anuria, pyuria, fever, chills, vomiting,
and hypoactive bowel sounds. Arthralgia and
hypertension are common.
◆ Renal trauma. About 80% of patients with
renal trauma have microscopic or gross hematuria. Accompanying signs and symptoms may
include flank pain, a palpable flank mass, oliguria, hematoma or ecchymosis over the upper
abdomen or flank, nausea and vomiting, and
hypoactive bowel sounds. Severe trauma may
precipitate signs of shock, such as tachycardia
and hypotension.
◆ Renal tuberculosis. Gross hematuria is of-
ten the first sign of this disorder. It may be ac-
companied by urinary frequency, dysuria,
pyuria, tenesmus, colicky abdominal pain, lumbar pain, and proteinuria.
◆ Renal vein thrombosis. Gross hematuria
usually occurs in this type of thrombosis. In an
abrupt venous obstruction, the patient experiences severe flank and lumbar pain as well as
epigastric and CVA tenderness. Other features
include fever, pallor, proteinuria, peripheral
edema and, when the obstruction is bilateral,
oliguria or anuria and other uremic signs. The
kidneys are easily palpable. Gradual venous obstruction causes signs of nephrotic syndrome,
proteinuria and, occasionally, peripheral edema.
◆ Schistosomiasis. This infection usually
causes intermittent hematuria at the end of urination. It may be accompanied by dysuria, colicky renal and bladder pain, and palpable lower
abdominal masses.
◆ Sickle cell anemia. In this hereditary disor-
der, gross hematuria may result from congestion of the renal papillae. Associated signs and
symptoms may include pallor, dehydration,
chronic fatigue, polyarthralgia, leg ulcers, dyspnea, chest pain, impaired growth and development, hepatomegaly and, possibly, jaundice.
Auscultation reveals tachycardia and systolic
and diastolic murmurs.
◆ Systemic lupus erythematosus. Gross
hematuria and proteinuria may occur when this
disorder involves the kidneys. Cardinal features
include nondeforming joint pain and stiffness, a
butterfly rash, photosensitivity, Raynaud’s phenomenon, seizures or psychoses, recurrent
fever, lymphadenopathy, oral or nasopharyngeal
ulcers, anorexia, and weight loss.
◆ Urethral trauma. Hematuria may occur ini-
tially, possibly with blood at the urinary meatus,
local pain, and penile or vulvar ecchymosis.
◆ Vaginitis. When this infection spreads to the
urinary tract, it may produce macroscopic
hematuria. Related signs and symptoms may include urinary frequency and urgency, dysuria,
nocturia, perineal pain, pruritus, and a malodorous vaginal discharge.
◆ Vasculitis. Hematuria is usually microscopic
in this disorder. Associated signs and symptoms
include malaise, myalgia, polyarthralgia, fever,
increased blood pressure, pallor and, occasionally, anuria. Other features, such as urticaria and
purpura, may reflect the etiology of vasculitis.
O
THER CAUSES
◆ Diagnostic tests. Renal biopsy is the diag-
nostic test most often associated with hematuria.
368 HEMIANOPSIA
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This sign may also result from biopsy or manipulative instrumentation of the urinary tract, as
in cystoscopy.
◆ Drugs. Drugs that commonly cause hema-
turia are anticoagulants, aspirin (toxicity), analgesics, cyclophosphamide, metyrosine, penicillin, rifampin, and thiabendazole.
HERB ALERT When taken with an antico-
agulant, herbal medicines such as garlic and
ginkgo biloba can cause excessive bleeding and
hematuria.
◆ Treatments. Any therapy that involves ma-
nipulative instrumentation of the urinary tract,
such as transurethral prostatectomy, may cause
microscopic or macroscopic hematuria. After a
kidney transplant, a patient may experience
hematuria with or without clots, which may require indwelling urinary catheter irrigation.
S
PECIAL CONSIDERATIONS
Because hematuria may frighten and upset the
patient, be sure to provide emotional support.
Check his vital signs at least every 4 hours and
monitor intake and output, including the
amount and pattern of hematuria. If the patient
has an indwelling urinary catheter in place, ensure its patency and irrigate it if necessary to remove clots and tissue that may impede urine
drainage. Administer prescribed analgesics, and
enforce bed rest as indicated. Prepare the patient for diagnostic tests, such as blood and
urine studies, cystoscopy, and renal X-rays or
biopsy.
P
EDIATRIC POINTERS
Many of the causes described above also produce hematuria in children. However, cyclophosphamide is more likely to cause hematuria in children than in adults.
Common causes of hematuria that chiefly affect children include congenital anomalies, such
as obstructive uropathy and renal dysplasia;
birth trauma; hematologic disorders, such as vitamin K deficiency, hemophilia, and hemolyticuremic syndrome; certain neoplasms, such as
Wilms’ tumor, bladder cancer, and rhabdomyosarcoma; allergies; and foreign bodies in the
urinary tract. Artifactual hematuria may result
from recent circumcision.
G
ERIATRIC POINTERS
Evaluation of hematuria in elderly patients
should include a urine culture, excretory urography or sonography, and consultation with a
urologist.
P
ATIENT COUNSELING
Teach the patient how to collect serial urine
specimens using the three-glass technique. This
technique helps determine whether hematuria
marks the beginning, end, or entire course of
urination.
Hemianopsia
Hemianopsia is loss of vision in one-half the
normal visual field (usually the right or left half)
of one or both eyes. However, if the visual field
defects are identical in both eyes but affect less
than half the field of vision in each eye (incomplete homonymous hemianopsia), the lesion
may be in the occipital lobe; otherwise, it probably involves the parietal or temporal lobe. (See
Recognizing types of hemianopsia.)
Hemianopsia is caused by a lesion affecting
the optic chiasm, the optic tract, or the optic radiation. Defects in visual perception due to
cerebral lesions are usually associated with impaired color vision.
H
ISTORY AND PHYSICAL
EXAMINATION
Suspect a visual field defect if the patient seems
startled when you approach him from one side
or if he fails to see objects placed directly in
front of him. To help determine the type of defect, compare the patient’s visual fields with
your own—assuming that yours are normal.
First, ask the patient to cover his right eye while
you cover your left eye. Then move a pen or
similarly shaped object from the periphery of his
(and your) uncovered eye into his field of vision.
Ask the patient to indicate when he first sees
the object. Does he see it at the same time you
do? After you do? Repeat this test in each quadrant of both eyes. Then, for each eye, plot the
defect by shading the area of a circle that corresponds to the area of vision loss.
Next, evaluate the patient’s level of consciousness (LOC), take his vital signs, and check
his pupillary reaction and motor response. Ask
if he has recently experienced headache,
dysarthria, or seizures. Does he have ptosis or
facial or extremity weakness? Hallucinations or
loss of color vision? When did his neurologic
symptoms start? Obtain a medical history, noting especially eye disorders, hypertension, diabetes mellitus, and recent head trauma.
HEMIANOPSIA 369
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Recognizing types of hemianopsia
Lesions of the optic pathways cause visual field defects. The lesion’s site determines the type of
defect. For example, a lesion of the optic chiasm involving only those fibers that cross over to the
opposite side causes bitemporal hemianopsia, vision loss in the temporal half of each field. However, a lesion of the optic tract or a complete lesion of the optic radiation produces vision loss in
the same half of each field—either left or right homonymous hemianopsia.
LEFT VISUAL FIELD RIGHT VISUAL FIELD
Bitemporal
hemianopsia
Right homonymous
hemianopsia
Optic tract
Optic
chiasm
Optic
radiation
BRAIN
Left homonymous
hemianopsia
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M
EDICAL CAUSES
◆ Carotid artery aneurysm. An aneurysm in
the internal carotid artery can cause contralateral or bilateral defects in the visual fields. It can
also cause hemiplegia, decreased LOC,
headache, aphasia, behavior disturbances, and
unilateral hypoesthesia.
◆ Occipital lobe lesion. The most common
symptoms arising from a lesion of one occipital
lobe are incomplete homonymous hemianopsia,
scotomas, and impaired color vision. The patient may also experience visual hallucinations:
flashes of light or color, or visions of objects,
people, animals, or geometric forms. These may
appear in the defective field or may move toward it from the intact field.
◆ Parietal lobe lesion. This disorder produces
homonymous hemianopsia and sensory deficits,
such as an inability to perceive body position or
passive movement or to localize tactile, thermal, or vibratory stimuli. It may also cause
apraxia and visual or tactile agnosia.
◆ Pituitary tumor. A tumor that compresses
nerve fibers supplying the nasal half of both retinas causes complete or partial bitemporal
hemianopsia that first occurs in the upper visual
fields but later can progress to blindness. Related findings include blurred vision, diplopia,
headache, and (rarely) somnolence, hypothermia, and seizures.
◆ Stroke. Hemianopsia can result when a he-
morrhagic, thrombotic, or embolic stroke affects
any part of the optic pathway. Associated signs
and symptoms vary according to the location
and size of the stroke but may include decreased LOC; intellectual deficits, such as memory loss and poor judgment; personality
changes; emotional lability; headache; and
seizures. The patient may also develop contralateral hemiplegia, dysarthria, dysphagia,
ataxia, unilateral sensory loss, apraxia, agnosia,
aphasia, blurred vision, decreased visual acuity,
and diplopia as well as urine retention or incontinence, constipation, and vomiting.
S
PECIAL CONSIDERATIONS
If the patient’s visual field defect is significant,
further visual field testing, such as perimetry or a
tangent screen examination, may be indicated.
To avoid startling the patient, approach from
the unaffected side and position his bed so that
his unaffected side faces the door. If he’s ambulatory, remove objects that could cause falls,
and alert him to other possible hazards. Place
his clock and other objects within his field of
vision, and avoid putting dangerous objects
(such as hot dishes) where he can’t see them.
P
EDIATRIC POINTERS
A brain tumor is the most common cause of
hemianopsia in children. To help detect this
sign, look for nonverbal clues, such as the child
reaching for a toy but missing it. To help the
child compensate for hemianopsia, place objects within his visual field; teach his parents to
do this as well.
P
ATIENT COUNSELING
Explain to the patient the extent of his defect so
that he can learn to compensate for it. Advise
him to scan his surroundings frequently, turning
his head in the direction of the defective visual
field so that he can directly view objects he
would normally notice only peripherally.
Hemoptysis
Frightening to the patient and often ominous,
hemoptysis is the expectoration of blood or
bloody sputum from the lungs or tracheobronchial tree. It’s sometimes confused with
bleeding from the mouth, throat, nasopharynx,
or GI tract. (See Identifying hemoptysis.) Expectoration of 200 ml of blood in a single episode
suggests severe bleeding; expectoration of
400 ml in 3 hours or more than 600 ml in
16 hours signals a life-threatening crisis.
Hemoptysis usually results from chronic
bronchitis, lung cancer, or bronchiectasis. However, it may also result from inflammatory, infectious, cardiovascular, or coagulation disorders and, rarely, from a ruptured aortic
aneurysm. In up to 15% of patients, the cause is
unknown. The most common causes of massive
hemoptysis are lung cancer, bronchiectasis, active tuberculosis, and cavitary pulmonary disease from necrotic infections or tuberculosis.
A number of pathophysiologic processes can
cause hemoptysis. (See What happens in hemop-
tysis, page 372.)
EMERGENCY INTERVENTIONS If the pa-
tient coughs up copious amounts of blood,
endotracheal intubation may be required. Suction
frequently to remove blood. Lavage may be necessary to loosen tenacious secretions or clots. Massive hemoptysis can cause airway obstruction and
asphyxiation. Insert an I.V. catheter to allow fluid
replacement, drug administration, and blood transfusions if needed. An emergency bronchoscopy
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