What is the management for a patient with hemoptysis after receiving streptokinase (thrombolytic therapy)?

Management of Hemoptysis Post-Streptokinase

Immediately discontinue streptokinase infusion if hemoptysis develops, as this represents a serious bleeding complication requiring urgent intervention. 1, 2

Immediate Actions

Stop the Bleeding Source

• Discontinue streptokinase immediately upon recognition of hemoptysis, as continued thrombolytic therapy significantly increases bleeding risk and mortality 1, 2
• Do not restart thrombolytic therapy after a significant bleeding episode 1

Airway Protection and Stabilization

• For massive hemoptysis (>240 mL/24h or causing respiratory compromise), intubate immediately with a single-lumen cuffed endotracheal tube to allow bronchoscopic suctioning and clot removal 3, 4, 5
• Establish high-flow oxygen and large-bore IV access (ideally 8-Fr central line) for volume resuscitation 3, 4
• Avoid BiPAP entirely in massive hemoptysis, as positive pressure ventilation worsens bleeding 3

Laboratory Assessment

• Obtain urgent complete blood count with platelets, PT/INR, aPTT, and Clauss fibrinogen (not derived fibrinogen, as it is misleading) 1, 3
• Type and cross-match blood products 1
• Monitor arterial blood gas if concern exists for metabolic or respiratory acidosis 4

Pharmacological Reversal

Antifibrinolytic Therapy

• Administer tranexamic acid 1000 mg IV infused over 10 minutes for active bleeding 1
• Alternative: ε-aminocaproic acid 4-5 g over 1 hour, followed by 1 g IV until bleeding is controlled 1

Blood Product Support

• For severe bleeding with hemodynamic compromise, administer 6-8 units of cryoprecipitate containing factor VIII or 6-8 units of platelets 1
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 3, 4

Adjunctive Medications

• Stop all NSAIDs immediately, as they impair platelet function and worsen bleeding 3, 4
• If patient was receiving vitamin K antagonists, consider vitamin K 5-10 mg by slow IV injection 1

Definitive Management Based on Severity

For Massive Hemoptysis (Life-Threatening)

• Proceed directly to bronchial artery embolization (BAE) without delay in clinically unstable patients, as this achieves immediate hemostasis in 73-99% of cases 3, 4, 5
• Do not perform bronchoscopy before BAE in unstable patients, as delaying BAE significantly increases mortality 3, 4
• Over 90% of massive hemoptysis originates from bronchial arteries, making BAE the first-line therapy 3

For Mild-to-Moderate Hemoptysis (≥5 mL but not life-threatening)

• Admit to hospital for monitoring and treatment 3
• Perform flexible bronchoscopy to identify the source and side of bleeding 3, 6
• CT chest with IV contrast is the preferred diagnostic test to identify cause and location of bleeding once patient is stable 3, 6
• Administer antibiotics for any hemoptysis ≥5 mL, as bleeding may represent pulmonary exacerbation or superimposed bacterial infection 3

Bronchoscopic Interventions (if available and patient stable enough)

• Tamponade by wedging the bronchoscope tip into the bleeding bronchus 3
• Instillation of iced saline solution to constrict blood vessels 3
• Bronchial blockade balloons for temporary control 3
• Topical hemostatic tamponade with oxidized regenerated cellulose mesh (98% success rate) 3
• Thermal ablation using argon plasma coagulation, Nd:YAG laser, or electrocautery for visible central airway lesions 3

Monitoring and Supportive Care

Intensive Care Management

• Admit all patients with significant hemoptysis to intensive care for monitoring of coagulation parameters, hemoglobin, blood gases, and ongoing bleeding 3, 4
• Monitor vital signs closely, with special attention to blood pressure and heart rate 1
• Two or more opacified lung quadrants on chest radiograph correlate with increased mortality risk 3, 4

Airway Management Considerations

• Stop all airway clearance therapies immediately in massive hemoptysis to allow clot formation 3
• Stop aerosolized hypertonic saline, as it can exacerbate bleeding 3
• Avoid hyperventilation and excessive positive end-expiratory pressure in hypovolemic patients 3

Urinary Considerations (if hematuria also present)

• Maintain adequate hydration to promote urinary flow and prevent clot formation 1
• Consider urinary catheterization with gentle irrigation if clots are causing obstruction, but use caution as this may exacerbate bleeding 1

Prevention of Further Complications

Avoid Invasive Procedures

• Avoid unnecessary invasive procedures for at least 24 hours after thrombolysis to prevent additional bleeding sites 1
• Avoid arterial punctures or insertion of catheters for at least 24 hours 1
• Avoid automatic blood pressure cuffs on the same arm as venous access to prevent hematoma formation 1

Anticoagulation Management

• After resolution of hemoptysis, if continued anticoagulation is necessary, consider switching to unfractionated heparin with careful aPTT monitoring (target 1.5-2.0 times control) 1
• For long-term anticoagulation in high-risk patients, consider low molecular weight heparin at 75-80% of the initial dose rather than vitamin K antagonists 1

Investigation of Underlying Pathology

Post-Stabilization Workup

• Investigate underlying pathology once the patient is stable, as up to 25% of patients presenting with gross hemoptysis while on anticoagulant therapy may have underlying neoplastic disease 1
• Obtain chest radiograph (preferably posteroanterior and lateral) to define severity and presence of complications such as effusions or cavitation 4
• CT chest with IV contrast provides 77% diagnostic accuracy for determining etiology 3
• Consider urological evaluation with cystoscopy after stabilization if hematuria also occurred and persists 1

Recurrence Risk

• Recurrence of bleeding occurs in 10-55% of cases after BAE, requiring close follow-up 3
• Higher recurrent hemoptysis rates are associated with chronic pulmonary aspergillomas (55% recurrence rate), malignancy, and sarcoidosis 3

Common Pitfalls to Avoid

• Do not continue streptokinase after hemoptysis develops—this is the single most important intervention 1, 2
• Do not delay airway protection in favor of diagnostic procedures when the patient has respiratory distress 3
• Do not use double-lumen endotracheal tubes as initial airway management—single-lumen tubes allow better suctioning and clot removal 3, 4
• Do not rely on single hematocrit measurements as an isolated marker for bleeding severity 3
• Do not use derived fibrinogen levels, as they are misleading—use Clauss fibrinogen instead 3
• Do not overlook the possibility of underlying pulmonary pathology (pneumonia, bronchiectasis, malignancy) as a contributor to hemoptysis, particularly in patients with recent respiratory symptoms 7, 8, 9

Special Considerations

Diffuse Alveolar Hemorrhage

• Streptokinase can cause diffuse alveolar hemorrhage presenting with hemoptysis, drop in hematocrit, hypoxemia, and new bilateral alveolar infiltrates 7, 9
• Markedly increased carbon monoxide diffusion capacity suggests alveolar hemorrhage 7
• Patients with congestive heart failure are at particular risk for this complication 7
• Most cases recover with conservative treatment within 7 days if streptokinase is discontinued promptly 7

Elderly Patients

• Elderly patients (>75 years) have a higher risk of bleeding complications with thrombolytic therapy and may require more aggressive management 1