Hypoxia in a Patient With Hemoptysis

Vital Signs

• Temperature: 100.4 °F, axillary

• Blood Pressure: 90/50 mmHg

• Heart Rate: 120 beats per min (bpm) – sinus tachycardia on the monitor

• Respiratory Rate: 35 breaths per min

• Oxygen Saturation: 70% on room air, 90% on 12 L/min (LPM) high flow nasal cannula

Focused Physical Examination

A quick exam showed an older adult who appeared visibly dyspneic and was using accessory muscles of respiration. Crackles were present in the left lower lung field. Heart auscultation was normal except for tachycardia, and his abdomen was soft, non-tender, and non-distended. The remaining examination was unremarkable.

Interventions

A cardiac monitor and pads were attached to the patient. Fifteen LPM oxygen was administered through a non-rebreather mask, which improved oxygen saturation to 96%. Due to concerns for airway protection, and the patient’s continued hemoptysis, he was intubated by the anesthesiologist on call. He was started on intravenous (IV) fluid resuscitation. Stat arterial blood gas was ordered, which showed pH 7.25, pO ₂ 92 mmHg, pCO ₂ 60 mmHg, lactate 4.9 mmol/L. Stat chest X-ray, complete blood count (CBC), prothrombin time, and partial thromboplastin time were done. The patient was on warfarin for his atrial fibrillation, which led to an international normalized ratio of 2.9; this was reversed acutely with 4-factor prothrombin complex concentrate (Kcentra) and 5 mg of IV vitamin K. His chest X-ray revealed multiple opacities in the left lung ( Fig. 31.1 ). The patient was placed in the left lateral position (diseased lung down to prevent the gravity-guided blood pooling in the healthy right lung) and was transferred to the intensive care unit (ICU) for further management and intervention.