Assessment hints

Mr. Fare’s vital signs are stable: blood pressure (BP) is 120/60 mm Hg; pulse rate (PR), 98 beats/minute; and respiratory rate (RR), 21 breaths/minute. His oxygen saturation (Sao2) is 96%. His lab values are as follows: hemoglobin level, 11.4 g/dL; hematocrit, 35%; prothrombin time (PT), 21.2 seconds; International Normalized Ratio (INR), 2.4 seconds; and activated partial thromboplastin time (APTT), 42.7 seconds. He is alert, oriented, and able to talk to you.

Forty-five minutes later, Mr. Fare is pale and restless. His BP is 80/30; PR, 130; RR, 34; and Sao2, 86%. You recognize that restlessness with a decreased BP and elevated PR and RR indicates active bleeding, so you immediately notify the physician of the change in the patient’s condition. Despite Mr. Fare’s coughing and hemoptysis, he isn’t experiencing nausea and vomiting, which typically result from GI bleeding, so you suspect the bleeding originates outside the GI tract.

On the scene

The physician arrives as Mr. Fare starts spewing blood from his mouth. All color drains from his face, and he thrashes about as you place him on his left side. The situation is now a medical emergency, and the physician orders a transfer to the medical-surgical intensive care unit (MSICU).

In the MSICU, Mr. Fare’s BP is 70/30; PR, 150; RR, 40; and Sao2, 80%. His airway is so severely compromised that each inspiratory effort produces audible gurgling sounds. Placing an endotracheal (ET) tube for mechanical ventilation takes both a respiratory therapist and a physician.

To prevent aspiration, Jocelyn, an MSICU nurse, places a nasogastric tube and notes that the drainage is clear. Then, she runs I.V. fluids wide open to expand volume, hangs a bag of fresh frozen plasma (FFP) to expand volume and reduce the elevated INR, and administers vitamin K to reduce the INR.

A central line is inserted, and the patient has an echocardiogram. Endoscopy rules out GI bleeding, and Mr. Fare’s condition seems stable. His BP is 130/72; PR, 110; RR, 24; and Sao2, 100%. He has received 10 mg of vitamin K and 7 units of FFP.

Suddenly, the monitor alarms go off: The patient’s Sao2 is 9%, and his PR is 30. Using an Ambu bag, Jocelyn gives 100% fraction of inspired oxygen through the ET tube. Another nurse auscultates his chest, noting no breath sounds on the right side. Suddenly, a large clot appears in the ET tube, followed by smaller clots. As Jocelyn suctions the ET tube, Sao2 and PR return to baseline, and she realizes the hemorrhage is from the lungs. Mr. Fare’s BP is now 128/68, and his RR is 24.

Education and follow-up

The primary care physician will discuss the episode with Mr. Fare, determine whether to restart warfarin therapy, and advise the patient about the risks and benefits of having the temporary filter replaced with a permanent one. The patient may also undergo follow-up bronchoscopy and a proton emission tomography.

A ruptured right bronchial artery is a rare medical emergency that’s often fatal. Mr. Fare can be thankful that a quick, skillful response by a dedicated team kept him alive.

Brenda A. Kifer is a staff nurse in the MSICU at Winchester Medical Center in Virginia and at City Hospital in Martinsburg, West Virginia.