What is the initial approach to a 14-year-old female patient presenting with hematemesis (vomiting blood) and hemoptysis (coughing up blood)?

Approach to Hematemesis and Hemoptysis in a 14-Year-Old Female

Immediate Priority: Distinguish the Source and Stabilize

The first critical step is to determine whether the blood is truly from the lungs (hemoptysis) versus the gastrointestinal tract (hematemesis), as this fundamentally changes management—hemoptysis requires airway protection while hematemesis requires endoscopic evaluation. 1

Differentiating Hemoptysis from Hematemesis

• Hemoptysis characteristics: Bright red, frothy blood that is coughed up, often with an alkaline pH, and may contain air bubbles 2
• Hematemesis characteristics: Dark red or coffee-ground appearance, vomited (not coughed), acidic pH, may contain food particles 3
• Insert a nasogastric tube immediately to decompress the stomach, protect the airway if hematemesis is present, and help differentiate the source 3

If Hematemesis is Confirmed (Upper GI Bleeding)

Resuscitation Protocol

• Establish large-bore IV access (ideally 8-Fr central line) and begin fluid resuscitation to normalize blood pressure and heart rate 3, 1
• Transfuse packed red blood cells to maintain hemoglobin above 7 g/dL (threshold of 9 g/dL if massive bleeding or cardiovascular compromise) 3
• Obtain baseline labs: Complete blood count, PT/aPTT, fibrinogen (Clauss method), type and cross-match 1

Diagnostic and Therapeutic Approach

• Perform gastroscopy once hemodynamically stable to identify and potentially treat the bleeding source 3
• In a 14-year-old, common causes include gastritis, peptic ulcer disease, esophageal varices (if portal hypertension), or Mallory-Weiss tears 3
• If lower GI source suspected after ruling out upper GI bleeding, consider sigmoidoscopy or colonoscopy 3

If Hemoptysis is Confirmed (Lower Respiratory Tract Bleeding)

Severity Assessment (Critical for Management Pathway)

• Scant hemoptysis (<5 mL/24h): May not require hospital admission 4
• Mild-to-moderate (5-240 mL/24h): Requires admission and workup 4
• Massive hemoptysis (>240 mL/24h or causing respiratory compromise): Immediate life-threatening emergency with mortality up to 59-100% if untreated 4
• The rate of bleeding matters more than total volume—rapid bleeding of 50 mL is more dangerous than slow bleeding of 100 mL over 24 hours 5

Immediate Airway Management for Massive Hemoptysis

• Intubate immediately with a single-lumen cuffed endotracheal tube to allow bronchoscopic suctioning and clot removal (success rate 73-99%) 1, 4
• Consider selective right or left mainstem intubation to protect the non-bleeding lung if the bleeding side is identified 1, 4
• Never use BiPAP or double-lumen tubes—positive pressure worsens bleeding and double-lumen tubes prevent effective clot removal 1, 4
• Stop all airway clearance therapies immediately to allow clot formation 1

Definitive Management for Massive Hemoptysis

• Proceed directly to bronchial artery embolization (BAE) without bronchoscopy in clinically unstable patients, as over 90% of massive hemoptysis originates from bronchial arteries, with immediate hemostasis achieved in 73-99% of cases 1, 4
• Delaying BAE in unstable patients significantly increases mortality 1
• Admit to intensive care for monitoring of coagulation parameters, hemoglobin, blood gases, and ongoing bleeding 1, 4

Management for Mild-to-Moderate Hemoptysis

• Admit to hospital for any hemoptysis ≥5 mL 4
• Start antibiotics immediately for any hemoptysis ≥5 mL, as bleeding may represent pulmonary infection or exacerbation 4, 5
• Stop all NSAIDs immediately due to their effect on platelet function that worsens bleeding 4, 5
• Consider adjunct treatment with tranexamic acid 4
• Perform bronchoscopy to identify the bleeding source (diagnostic yield 70-80%) 4

Diagnostic Imaging Strategy

• For stable patients, obtain CT chest with IV contrast as the preferred initial diagnostic test to identify cause and location of bleeding (diagnostic accuracy 77%, superior to bronchoscopy) 1, 4
• Chest radiograph is reasonable initially when confirming benign causes like acute bronchitis or pneumonia, but has limited sensitivity (26%) 1, 5
• Two or more opacified lung quadrants on chest radiograph indicate increased mortality risk 1, 4

Common Etiologies in Adolescents

In a 14-year-old female, consider:

• Respiratory infections (most common cause of mild hemoptysis) 2
• Bronchiectasis (most common cause in many series) 1
• Tuberculosis (especially in endemic areas) 1
• Foreign body aspiration (if history of choking) 5
• Pulmonary arteriovenous malformations 2
• Coagulopathy or platelet disorders 2

Critical Pitfalls to Avoid

• Never delay airway protection in favor of diagnostic procedures when the patient has respiratory distress 1
• Do not continue NSAIDs or anticoagulants during active bleeding, even if mild 1, 4
• Do not use derived fibrinogen levels—they are misleading; use Clauss fibrinogen instead 1
• Do not rely on single hematocrit measurements as an isolated marker for bleeding severity 1
• Avoid hyperventilation and excessive positive end-expiratory pressure in hypovolemic patients, as this worsens hemodynamics 1

Recurrent Bleeding Management

• Recurrence occurs in 10-55% of cases after initial BAE 1, 4
• Repeat BAE is the primary therapeutic option for recurrent hemoptysis, with no increased risk of morbidity or mortality 1, 4
• Surgery is reserved as a final option when BAE fails or for surgically resectable lesions 4