HemoptysisAPPROACH

RESPIRATORY · 19 SECTIONS

⚲

522 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Wheezing, Undifferentiated Wheezing In Infants Stridor And Upper Airway Symptoms Dyspnea Aspiration Event Cough Hemoptysis Upper Respiratory Infection Symptoms Suspected Pulmonary Embolism Presentation Smoke Inhalation Concern Smoke Exposure And Inhalational Injury

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx55

Symptom characterization

›Hemoptysis features

›Hemoptysis versus pseudohemoptysis

›Nasal or oropharyngeal source

›Oral bleeding

›Hemoptysis versus hematemesis

›Nausea

›Melena

OPQRST

›Onset

›Time of first blood

›Sudden versus gradual

›Provocation and palliation

›Cough trigger

›Exertion trigger

›Relief with rest

›Quality

›Bright red blood

›Clots

›Blood streaked sputum

›Region and radiation

›Chest pain location

›Throat irritation

›Severity

›Estimated volume in mL

›Frequency of episodes

›Functional impact

›Timing

›Continuous versus intermittent

›Nocturnal predominance

Associated symptoms

›Respiratory symptoms

›Dyspnea

›Wheeze

›Pleuritic chest pain

›Fever

›Constitutional symptoms

›Weight loss

›Night sweats

›Bleeding symptoms

›Epistaxis

›Gingival bleeding

›Easy bruising

Prior episodes and baseline

›Prior hemoptysis

›Prior investigations

›Prior bronchiectasis diagnosis

›Baseline pulmonary status

›Home oxygen use

›Baseline exercise tolerance

Exposure and infection context

›Recent respiratory infection

›Viral prodrome

›Purulent sputum

›Tuberculosis exposure

›Known contact

›Prior latent TB treatment

›Aspiration risk

›Recent vomiting

›Altered mental status event

02Alarm Features/alarm26

Immediate life threats

›Life threatening hemoptysis

›Any bleeding with airway compromise

›Inability to clear secretions

›Gurgling respirations

›Any bleeding with respiratory failure

›SpO2 less than 90 percent on room air

›Rising oxygen requirement

›Any bleeding with hemodynamic instability

›SBP less than 90 mmHg

›Shock index greater than 1

High risk patterns

›High risk history features

›Anticoagulant use

›Known lung cancer

›Known pulmonary aspergilloma

›Known bronchiectasis with prior major bleeds

›High risk symptom features

›Large clots

›Rapid recurrence within hours

Escalation triggers

›Escalate to resuscitation bay

›Ongoing active bleeding

›Altered mental status

›Increased work of breathing

›Persistent tachycardia greater than 120

›Activate airway team

›Inability to protect airway

›Anticipated need for lung isolation

03Medications/meds20

Bleeding and clotting relevant

›Antithrombotic agents

›Warfarin

›Direct oral anticoagulants

›Heparin products

›Antiplatelet agents

›Recent thrombolytics

›Alteplase exposure

›Tenecteplase exposure

Pulmonary and infectious relevant

›Respiratory medications

›Inhaled corticosteroids

›Bronchodilators

›Antibiotics

›Recent courses

›Treatment failure history

Medication change and adherence

›Recent changes

›Dose increases

›New prescriptions within 30 days

›Adherence and access

›Missed doses

›Overuse of NSAIDs

04Diet/diet9

Recent intake and exposures

›Intake patterns

›Poor oral intake

›Dehydration symptoms

›Caffeine and stimulants

›Energy drinks

›High caffeine intake

›Alcohol exposure

›Recent binge drinking

›Chronic heavy use

05Review of Systems/ros23

Pulmonary and cardiac

›Cardiopulmonary symptoms

›Dyspnea

›Orthopnea

›Chest pain

›Palpitations

Infectious and inflammatory

›Systemic symptoms

›Fever

›Chills

›Night sweats

›Weight loss

Thromboembolic and vascular

›PE symptoms

›Pleuritic chest pain

›Syncope

›Unilateral leg swelling

ENT and GI clues

›Upper airway and GI symptoms

›Epistaxis

›Gum bleeding

›Nausea

›Melena

Autoimmune and renal

›Vasculitis and pulmonary renal symptoms

›Hematuria

›Rash

›Arthralgia

06Collateral History and Family History/chafh10

Collateral source and reliability

›Collateral

›Source availability

›Reliability

Family history

›Familial risk conditions

›Hereditary hemorrhagic telangiectasia (I78.0)

›Bleeding disorders

›Early lung cancer

Household and sick contacts

›Exposure history

›TB contacts

›Viral respiratory exposure

07Risk Factors/rf25

Malignancy and smoking

›Malignancy risk

›Age greater than 40

›Tobacco exposure

›Occupational exposure

›Asbestos

›Silica

Infection and structural lung disease

›Pulmonary infection risk

›Immunocompromised state

›Recent travel

›Homelessness or congregate living

›Structural lung disease

›Bronchiectasis (J47)

›COPD (J44.9)

›Cystic fibrosis (E84)

Thrombosis and bleeding

›PE risk

›Recent surgery

›Estrogen therapy

›Prior VTE

›Bleeding risk

›Anticoagulation

›Thrombocytopenia history

›Liver disease

Cardiac causes

›Pulmonary venous hypertension risk

›Mitral stenosis (I05.0)

›Heart failure (I50.9)

08Differential Diagnosis/ddx52

Life threatening

›Life threatening causes

›Lung cancer with airway bleeding (C34)

›Weight loss

›Persistent hemoptysis

›Pulmonary embolism with infarction (I26)

›Pleuritic chest pain

›Risk factors for VTE

›Tuberculosis (A15)

›Night sweats

›Exposure risk

›Diffuse alveolar hemorrhage

›Hypoxemia disproportionate to CXR

›Hematuria

›Aortobronchial fistula

›Prior thoracic aortic surgery

›Sentinel bleeding then massive event

›Massive hemoptysis leading to asphyxiation

›Inability to clear airway

›Rapid desaturation

Common

›Common causes

›Acute bronchitis (J20.9)

›Recent viral symptoms

›Mild blood streaking

›Pneumonia (J18.9)

›Fever

›Focal crackles

›Bronchiectasis (J47)

›Chronic sputum

›Recurrent infections

›COPD exacerbation (J44.1)

›Increased sputum

›Wheeze

Less common

›Less common causes

›Aspergilloma

›Prior cavitary disease

›Recurrent hemoptysis

›Pulmonary vasculitis

›Rash

›Renal involvement

›Pulmonary AVM

›Hereditary hemorrhagic telangiectasia

›Hypoxemia

›Coagulopathy related bleeding

›Elevated INR

›Thrombocytopenia

Mimics

›Mimics

›Epistaxis with swallowed blood

›Nasal bleeding

›Blood in nares

›Hematemesis

›Coffee ground emesis

›Melena

09Past Medical History/pmh20

Pulmonary history

›Chronic lung disease

›Bronchiectasis (J47)

›COPD (J44.9)

›Asthma (J45.909)

›Prior TB (Z86.11)

Vascular and thrombotic history

›Thromboembolism history

›Prior PE (Z86.711)

›Prior DVT (Z86.718)

Bleeding and hematologic history

›Bleeding disorders

›Thrombocytopenia history

›Known coagulopathy

Cardiac history

›Cardiac conditions

›Heart failure (I50.9)

›Mitral stenosis (I05.0)

Procedures and devices

›Prior thoracic procedures

›Lung resection

›Bronchoscopy history

›Implanted devices

›Tracheostomy history

›Vascular graft history

10Physical Exam/exam31

General and vital signs

›Initial appearance

›Distress level

›Ability to speak full sentences

›Vital sign patterns

›Hypoxemia

›Tachypnea

›Fever

›Hypotension

Airway and ENT

›Upper airway findings

›Blood in nares

›Oropharyngeal bleeding

›Gingival bleeding

Respiratory

›Lung exam

›Focal crackles

›Wheeze

›Asymmetric breath sounds

›Signs of consolidation

Cardiovascular and volume

›Hemodynamic assessment

›Capillary refill

›JVP elevation

›Peripheral edema

Skin and mucosa

›Bleeding and vasculitis signs

›Petechiae

›Purpura

›Telangiectasias

Extremities

›DVT exam

›Unilateral swelling

›Calf tenderness

Neurologic

›Perfusion and airway protection

›Mental status changes

›Fatigue from respiratory effort

11Lab Studies/labs40

Initial ED labs

›Hemorrhage and infection evaluation

›CBC

›Hemoglobin trend

›Platelet count

›Coagulation profile

›INR

›aPTT

›Type and screen

›Crossmatch if ongoing bleeding

›Massive transfusion protocol local protocol dependent

›Basic metabolic panel

›Creatinine for contrast planning

›Electrolytes for arrhythmia risk

Targeted labs by scenario

›Etiology directed testing

›D dimer

›Use only if low pretest probability for PE

›False positives common with infection and malignancy

›ABG or VBG

›Hypercapnia assessment

›Severe hypoxemia assessment

›Lactate

›Shock marker

›Trend with resuscitation

Infection studies

›Microbiology when indicated

›Sputum culture

›Purulent sputum

›Failure of outpatient antibiotics

›AFB smear and culture

›TB risk factors

›Cavitary disease on imaging

Autoimmune and renal hemorrhage workup

›Suspected diffuse alveolar hemorrhage

›Urinalysis

›Hematuria

›Proteinuria

›ANCA testing

›GPA suspicion

›MPA suspicion

›Anti GBM antibodies

›Pulmonary renal syndrome

›Rapidly progressive renal failure

12Imaging/img36

Scoring Systems

›PE probability tools

›Wells score

›Use to guide D dimer versus CT pulmonary angiography

›Not validated for massive hemoptysis decision making alone

›PERC

›Use only in very low risk patients

›Not for patients with hemoptysis and additional risk features

MRI

›MRI roles

›Vascular malformation characterization when CT contraindicated

›Contrast limitations and availability

›Usually not first line in acute bleeding

›Cardiac MRI for selected structural etiologies

›Outpatient context typical

›Limited utility in unstable patients

›CT chest with contrast

›Localization and etiology

›Tumor

›Bronchiectasis

›Infection

›CT angiography planning for bronchial artery embolization

›Early imaging improves localization yield

›Use renal function and contrast allergy precautions

›CT pulmonary angiography

›Suspected PE with moderate to high pretest probability

›Not a substitute for bronchial artery source evaluation

›Consider dual phase protocols local protocol dependent

Ultrasound

›POCUS applications

›DVT ultrasound

›Adjunct in suspected PE

›Positive study increases PE probability

›Lung ultrasound

›Focal consolidation

›Pleural effusion

›Cardiac ultrasound

›Right heart strain features

›Volume status assessment

13Special Tests/spec24

Bronchoscopy and airway localization

›Bronchoscopy

›Indications

›Life threatening hemoptysis with airway compromise

›Need for clot extraction

›Utility

›Localization of bleeding side

›Endobronchial therapy options

›Limitations

›Visualization reduced with active heavy bleeding

›Often adjunct to CT and embolization planning

Interventional radiology procedures

›Bronchial artery angiography and embolization

›Indications

›Ongoing significant bleeding

›Recurrent bleeding with identifiable systemic arterial source

›Key complications

›Spinal cord ischemia risk

›Non target embolization

Infectious and TB specific testing

›TB evaluation tests

›AFB smear and culture

›Multiple samples may be required

›Isolation precautions local protocol dependent

›NAAT testing when available

›Faster confirmation

›Does not exclude TB if negative

14ECG/ecg9

Indications and high risk patterns

›ECG indications

›Hypoxemia with chest pain

›Suspected PE with hemodynamic compromise

›ECG findings supporting PE

›Sinus tachycardia

›Right heart strain patterns

›ECG findings affecting management

›Ischemia patterns

›Atrial fibrillation with RVR

15Assessment/ax25

Severity and stabilization category

›Hemoptysis severity category

›Life threatening hemoptysis

›Airway compromise

›Respiratory failure

›Hemodynamic instability

›Non life threatening hemoptysis

›Small volume blood streaking

›Normal oxygenation and hemodynamics

Working diagnosis and rule out priorities

›Working diagnosis candidates

›Infection related hemoptysis

›Fever

›Imaging evidence of pneumonia

›Malignancy related hemoptysis

›Smoking history

›Imaging mass or lymphadenopathy

›PE related hemoptysis

›Pleuritic pain

›VTE risk factors

Complications to exclude

›Immediate complications

›Aspiration of blood

›Worsening oxygenation

›New infiltrates

›Acute anemia

›Hemoglobin drop

›Tachycardia and orthostasis

16Plan/plan61

First 5 minutes and resuscitation

›Life threatening hemoptysis pathway

›Monitoring and access

›Cardiac monitor

›Continuous pulse oximetry

›Two large bore IVs

›Oxygenation targets

›SpO2 92 to 96 percent

›SpO2 88 to 92 percent if chronic hypercapnia suspected

›Positioning

›Bleeding side down if known

›Upright positioning if tolerated

›Airway strategy

›Early airway team activation if ongoing bleeding

›Large ETT to facilitate bronchoscopy and suction

›Lung isolation options local protocol dependent

Hemorrhage control and reversal

›Coagulopathy management

›Warfarin reversal

›Vitamin K IV dosing local protocol dependent

›PCC dosing local protocol dependent

›DOAC related bleeding

›Specific reversal agents local protocol dependent

›Activated charcoal only if very recent ingestion

›Platelet transfusion considerations

›Severe thrombocytopenia

›Antiplatelet associated bleeding with planned procedure

Diagnostic sequencing

›Stable patient diagnostic sequence

›Chest radiograph

›Initial localization clues

›Pneumonia or mass screening

›CT chest with contrast or CTA

›Highest yield for etiology and localization

›Expedite before blood obscures findings

›Bronchoscopy

›If CT non diagnostic with ongoing bleeding

›If airway clearance required

Definitive therapy by cause

›Etiology specific treatment

›Suspected pneumonia

›Antibiotics per local guideline

›Consider aspiration coverage if risk present

›Suspected TB

›Airborne isolation local protocol dependent

›Infectious diseases consultation

›Suspected PE

›Anticoagulation decisions balance bleeding severity

›Thrombolysis avoided if active significant bleeding unless life saving and local protocol dependent

Consultation plan

›Specialty involvement

›Interventional radiology

›Ongoing bleeding with CT localized arterial source

›Recurrent hemoptysis with bronchiectasis

›Pulmonology

›Bronchoscopy need

›Diffuse alveolar hemorrhage concern

›Thoracic surgery

›Failed embolization

›Surgical lesion requiring resection

Reassessment loop

›Reassessment timing

›Repeat vitals every 15 to 30 minutes in active bleeding

›Repeat hemoglobin based on bleeding and initial value

›Escalation based on trend

›Rising oxygen requirement triggers ICU consideration

›Recurrent large volume bleeding triggers IR activation

17Disposition/dispo22

ICU and high acuity criteria

›ICU criteria

›Intubation requirement

›Ongoing active bleeding

›High flow oxygen or noninvasive ventilation requirement

›Hemodynamic instability

Inpatient admission criteria

›Admission criteria

›Moderate bleeding with unclear source

›Significant comorbidity

›COPD with hypoxemia

›Heart failure

›High risk imaging findings

›Mass lesion

›Cavitary disease

Observation pathway criteria

›Observation suitable

›Small volume bleeding with stable vitals

›Completed CT and initial labs without high risk features

Discharge criteria

›Discharge criteria

›Minimal blood streaking only

›Normal oxygenation on room air

›No recurrent bleeding in ED

›Benign cause identified and treated

›Reliable follow up within 24 to 72 hours

18Discharge Instructions/di19

Copy discharge instructions

›Summary

›Seen for coughing up blood

›Your vital signs and oxygen levels were stable today

›Medications

›Take prescribed medications exactly as directed

›Avoid NSAIDs unless instructed

›Activity

›Avoid heavy exertion for 24 to 48 hours

›Avoid smoking and inhaled irritants

›Follow up

›Primary care or pulmonology within 24 to 72 hours

›Earlier follow up if imaging abnormality was found

›Return to emergency

›Any large amount of blood

›Trouble breathing

›Chest pain

›Fainting

›Fever with worsening symptoms

›Recurrent bleeding after discharge

19References/r15

Guidelines and key reviews

›CIRSE Standards of Practice on Bronchial Artery Embolisation for Haemoptysis 2022

›Best practice procedural guidance for BAE

›Complications and safety considerations

›Society of Chest Imaging and Interventions consensus recommendations for management of hemoptysis 2023

›Imaging and IR centered algorithms

›Recurrence and follow up considerations

›AAFP Hemoptysis evaluation and management 2022

›Primary care and ED evaluation framework

›Role of CT angiography and embolization

›CHEST Managing Massive Hemoptysis 2020

›Stepwise approach to life threatening hemoptysis

›Airway and definitive therapy priorities

›ATS Scholar ABCDE Approach for Massive Hemoptysis 2022

›Cognitive aid for acute management

›Emphasis on asphyxiation risk

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

HemoptysisAPPROACH

RESPIRATORY · 19 SECTIONS

⚲

522 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx55

Symptom characterization

›Hemoptysis features

›Hemoptysis versus pseudohemoptysis

›Nasal or oropharyngeal source

›Oral bleeding

›Hemoptysis versus hematemesis

›Nausea

›Melena

OPQRST

›Onset

›Time of first blood

›Sudden versus gradual

›Provocation and palliation

›Cough trigger

›Exertion trigger

›Relief with rest

›Quality

›Bright red blood

›Clots

›Blood streaked sputum

›Region and radiation

›Chest pain location

›Throat irritation

›Severity

›Estimated volume in mL

›Frequency of episodes

›Functional impact

›Timing

›Continuous versus intermittent

›Nocturnal predominance

Associated symptoms

›Respiratory symptoms

›Dyspnea

›Wheeze

›Pleuritic chest pain

›Fever

›Constitutional symptoms

›Weight loss

›Night sweats

›Bleeding symptoms

›Epistaxis

›Gingival bleeding

›Easy bruising

Prior episodes and baseline

›Prior hemoptysis

›Prior investigations

›Prior bronchiectasis diagnosis

›Baseline pulmonary status

›Home oxygen use

›Baseline exercise tolerance

Exposure and infection context

›Recent respiratory infection

›Viral prodrome

›Purulent sputum

›Tuberculosis exposure

›Known contact

›Prior latent TB treatment

›Aspiration risk

›Recent vomiting

›Altered mental status event

02Alarm Features/alarm26

Immediate life threats

›Life threatening hemoptysis

›Any bleeding with airway compromise

›Inability to clear secretions

›Gurgling respirations

›Any bleeding with respiratory failure

›SpO2 less than 90 percent on room air

›Rising oxygen requirement

›Any bleeding with hemodynamic instability

›SBP less than 90 mmHg

›Shock index greater than 1

High risk patterns

›High risk history features

›Anticoagulant use

›Known lung cancer

›Known pulmonary aspergilloma

›Known bronchiectasis with prior major bleeds

›High risk symptom features

›Large clots

›Rapid recurrence within hours

Escalation triggers

›Escalate to resuscitation bay

›Ongoing active bleeding

›Altered mental status

›Increased work of breathing

›Persistent tachycardia greater than 120

›Activate airway team

›Inability to protect airway

›Anticipated need for lung isolation

03Medications/meds20

Bleeding and clotting relevant

›Antithrombotic agents

›Warfarin

›Direct oral anticoagulants

›Heparin products

›Antiplatelet agents

›Recent thrombolytics

›Alteplase exposure

›Tenecteplase exposure

Pulmonary and infectious relevant

›Respiratory medications

›Inhaled corticosteroids

›Bronchodilators

›Antibiotics

›Recent courses

›Treatment failure history

Medication change and adherence

›Recent changes

›Dose increases

›New prescriptions within 30 days

›Adherence and access

›Missed doses

›Overuse of NSAIDs

04Diet/diet9

Recent intake and exposures

›Intake patterns

›Poor oral intake

›Dehydration symptoms

›Caffeine and stimulants

›Energy drinks

›High caffeine intake

›Alcohol exposure

›Recent binge drinking

›Chronic heavy use

05Review of Systems/ros23

Pulmonary and cardiac

›Cardiopulmonary symptoms

›Dyspnea

›Orthopnea

›Chest pain

›Palpitations

Infectious and inflammatory

›Systemic symptoms

›Fever

›Chills

›Night sweats

›Weight loss

Thromboembolic and vascular

›PE symptoms

›Pleuritic chest pain

›Syncope

›Unilateral leg swelling

ENT and GI clues

›Upper airway and GI symptoms

›Epistaxis

›Gum bleeding

›Nausea

›Melena

Autoimmune and renal

›Vasculitis and pulmonary renal symptoms

›Hematuria

›Rash

›Arthralgia

06Collateral History and Family History/chafh10

Collateral source and reliability

›Collateral

›Source availability

›Reliability

Family history

›Familial risk conditions

›Hereditary hemorrhagic telangiectasia (I78.0)

›Bleeding disorders

›Early lung cancer

Household and sick contacts

›Exposure history

›TB contacts

›Viral respiratory exposure

07Risk Factors/rf25

Malignancy and smoking

›Malignancy risk

›Age greater than 40

›Tobacco exposure

›Occupational exposure

›Asbestos

›Silica

Infection and structural lung disease

›Pulmonary infection risk

›Immunocompromised state

›Recent travel

›Homelessness or congregate living

›Structural lung disease

›Bronchiectasis (J47)

›COPD (J44.9)

›Cystic fibrosis (E84)

Thrombosis and bleeding

›PE risk

›Recent surgery

›Estrogen therapy

›Prior VTE

›Bleeding risk

›Anticoagulation

›Thrombocytopenia history

›Liver disease

Cardiac causes

›Pulmonary venous hypertension risk

›Mitral stenosis (I05.0)

›Heart failure (I50.9)

08Differential Diagnosis/ddx52

Life threatening

›Life threatening causes

›Lung cancer with airway bleeding (C34)

›Weight loss

›Persistent hemoptysis

›Pulmonary embolism with infarction (I26)

›Pleuritic chest pain

›Risk factors for VTE

›Tuberculosis (A15)

›Night sweats

›Exposure risk

›Diffuse alveolar hemorrhage

›Hypoxemia disproportionate to CXR

›Hematuria

›Aortobronchial fistula

›Prior thoracic aortic surgery

›Sentinel bleeding then massive event

›Massive hemoptysis leading to asphyxiation

›Inability to clear airway

›Rapid desaturation

Common

›Common causes

›Acute bronchitis (J20.9)

›Recent viral symptoms

›Mild blood streaking

›Pneumonia (J18.9)

›Fever

›Focal crackles

›Bronchiectasis (J47)

›Chronic sputum

›Recurrent infections

›COPD exacerbation (J44.1)

›Increased sputum

›Wheeze

Less common

›Less common causes

›Aspergilloma

›Prior cavitary disease

›Recurrent hemoptysis

›Pulmonary vasculitis

›Rash

›Renal involvement

›Pulmonary AVM

›Hereditary hemorrhagic telangiectasia

›Hypoxemia

›Coagulopathy related bleeding

›Elevated INR

›Thrombocytopenia

Mimics

›Mimics

›Epistaxis with swallowed blood

›Nasal bleeding

›Blood in nares

›Hematemesis

›Coffee ground emesis

›Melena

09Past Medical History/pmh20

Pulmonary history

›Chronic lung disease

›Bronchiectasis (J47)

›COPD (J44.9)

›Asthma (J45.909)

›Prior TB (Z86.11)

Vascular and thrombotic history

›Thromboembolism history

›Prior PE (Z86.711)

›Prior DVT (Z86.718)

Bleeding and hematologic history

›Bleeding disorders

›Thrombocytopenia history

›Known coagulopathy

Cardiac history

›Cardiac conditions

›Heart failure (I50.9)

›Mitral stenosis (I05.0)

Procedures and devices

›Prior thoracic procedures

›Lung resection

›Bronchoscopy history

›Implanted devices

›Tracheostomy history

›Vascular graft history

10Physical Exam/exam31

General and vital signs

›Initial appearance

›Distress level

›Ability to speak full sentences

›Vital sign patterns

›Hypoxemia

›Tachypnea

›Fever

›Hypotension

Airway and ENT

›Upper airway findings

›Blood in nares

›Oropharyngeal bleeding

›Gingival bleeding

Respiratory

›Lung exam

›Focal crackles

›Wheeze

›Asymmetric breath sounds

›Signs of consolidation

Cardiovascular and volume

›Hemodynamic assessment

›Capillary refill

›JVP elevation

›Peripheral edema

Skin and mucosa

›Bleeding and vasculitis signs

›Petechiae

›Purpura

›Telangiectasias

Extremities

›DVT exam

›Unilateral swelling

›Calf tenderness

Neurologic

›Perfusion and airway protection

›Mental status changes

›Fatigue from respiratory effort

11Lab Studies/labs40

Initial ED labs

›Hemorrhage and infection evaluation

›CBC

›Hemoglobin trend

›Platelet count

›Coagulation profile

›INR

›aPTT

›Type and screen

›Crossmatch if ongoing bleeding

›Massive transfusion protocol local protocol dependent

›Basic metabolic panel

›Creatinine for contrast planning

›Electrolytes for arrhythmia risk

Targeted labs by scenario

›Etiology directed testing

›D dimer

›Use only if low pretest probability for PE

›False positives common with infection and malignancy

›ABG or VBG

›Hypercapnia assessment

›Severe hypoxemia assessment

›Lactate

›Shock marker

›Trend with resuscitation

Infection studies

›Microbiology when indicated

›Sputum culture

›Purulent sputum

›Failure of outpatient antibiotics

›AFB smear and culture

›TB risk factors

›Cavitary disease on imaging

Autoimmune and renal hemorrhage workup

›Suspected diffuse alveolar hemorrhage

›Urinalysis

›Hematuria

›Proteinuria

›ANCA testing

›GPA suspicion

›MPA suspicion

›Anti GBM antibodies

›Pulmonary renal syndrome

›Rapidly progressive renal failure

12Imaging/img36

Scoring Systems

›PE probability tools

›Wells score

›Use to guide D dimer versus CT pulmonary angiography

›Not validated for massive hemoptysis decision making alone

›PERC

›Use only in very low risk patients

›Not for patients with hemoptysis and additional risk features

MRI

›MRI roles

›Vascular malformation characterization when CT contraindicated

›Contrast limitations and availability

›Usually not first line in acute bleeding

›Cardiac MRI for selected structural etiologies

›Outpatient context typical

›Limited utility in unstable patients

›CT chest with contrast

›Localization and etiology

›Tumor

›Bronchiectasis

›Infection

›CT angiography planning for bronchial artery embolization

›Early imaging improves localization yield

›Use renal function and contrast allergy precautions

›CT pulmonary angiography

›Suspected PE with moderate to high pretest probability

›Not a substitute for bronchial artery source evaluation

›Consider dual phase protocols local protocol dependent

Ultrasound

›POCUS applications

›DVT ultrasound

›Adjunct in suspected PE

›Positive study increases PE probability

›Lung ultrasound

›Focal consolidation

›Pleural effusion

›Cardiac ultrasound

›Right heart strain features

›Volume status assessment

13Special Tests/spec24

Bronchoscopy and airway localization

›Bronchoscopy

›Indications

›Life threatening hemoptysis with airway compromise

›Need for clot extraction

›Utility

›Localization of bleeding side

›Endobronchial therapy options

›Limitations

›Visualization reduced with active heavy bleeding

›Often adjunct to CT and embolization planning

Interventional radiology procedures

›Bronchial artery angiography and embolization

›Indications

›Ongoing significant bleeding

›Recurrent bleeding with identifiable systemic arterial source

›Key complications

›Spinal cord ischemia risk

›Non target embolization

Infectious and TB specific testing

›TB evaluation tests

›AFB smear and culture

›Multiple samples may be required

›Isolation precautions local protocol dependent

›NAAT testing when available

›Faster confirmation

›Does not exclude TB if negative

14ECG/ecg9

Indications and high risk patterns

›ECG indications

›Hypoxemia with chest pain

›Suspected PE with hemodynamic compromise

›ECG findings supporting PE

›Sinus tachycardia

›Right heart strain patterns

›ECG findings affecting management

›Ischemia patterns

›Atrial fibrillation with RVR

15Assessment/ax25

Severity and stabilization category

›Hemoptysis severity category

›Life threatening hemoptysis

›Airway compromise

›Respiratory failure

›Hemodynamic instability

›Non life threatening hemoptysis

›Small volume blood streaking

›Normal oxygenation and hemodynamics

Working diagnosis and rule out priorities

›Working diagnosis candidates

›Infection related hemoptysis

›Fever

›Imaging evidence of pneumonia

›Malignancy related hemoptysis

›Smoking history

›Imaging mass or lymphadenopathy

›PE related hemoptysis

›Pleuritic pain

›VTE risk factors

Complications to exclude

›Immediate complications

›Aspiration of blood

›Worsening oxygenation

›New infiltrates

›Acute anemia

›Hemoglobin drop

›Tachycardia and orthostasis

16Plan/plan61

First 5 minutes and resuscitation

›Life threatening hemoptysis pathway

›Monitoring and access

›Cardiac monitor

›Continuous pulse oximetry

›Two large bore IVs

›Oxygenation targets

›SpO2 92 to 96 percent

›SpO2 88 to 92 percent if chronic hypercapnia suspected

›Positioning

›Bleeding side down if known

›Upright positioning if tolerated

›Airway strategy

›Early airway team activation if ongoing bleeding

›Large ETT to facilitate bronchoscopy and suction

›Lung isolation options local protocol dependent

Hemorrhage control and reversal

›Coagulopathy management

›Warfarin reversal

›Vitamin K IV dosing local protocol dependent

›PCC dosing local protocol dependent

›DOAC related bleeding

›Specific reversal agents local protocol dependent

›Activated charcoal only if very recent ingestion

›Platelet transfusion considerations

›Severe thrombocytopenia

›Antiplatelet associated bleeding with planned procedure

Diagnostic sequencing

›Stable patient diagnostic sequence

›Chest radiograph

›Initial localization clues

›Pneumonia or mass screening

›CT chest with contrast or CTA

›Highest yield for etiology and localization

›Expedite before blood obscures findings

›Bronchoscopy

›If CT non diagnostic with ongoing bleeding

›If airway clearance required

Definitive therapy by cause

›Etiology specific treatment

›Suspected pneumonia

›Antibiotics per local guideline

›Consider aspiration coverage if risk present

›Suspected TB

›Airborne isolation local protocol dependent

›Infectious diseases consultation

›Suspected PE

›Anticoagulation decisions balance bleeding severity

›Thrombolysis avoided if active significant bleeding unless life saving and local protocol dependent

Consultation plan

›Specialty involvement

›Interventional radiology

›Ongoing bleeding with CT localized arterial source

›Recurrent hemoptysis with bronchiectasis

›Pulmonology

›Bronchoscopy need

›Diffuse alveolar hemorrhage concern

›Thoracic surgery

›Failed embolization

›Surgical lesion requiring resection

Reassessment loop

›Reassessment timing

›Repeat vitals every 15 to 30 minutes in active bleeding

›Repeat hemoglobin based on bleeding and initial value

›Escalation based on trend

›Rising oxygen requirement triggers ICU consideration

›Recurrent large volume bleeding triggers IR activation

17Disposition/dispo22

ICU and high acuity criteria

›ICU criteria

›Intubation requirement

›Ongoing active bleeding

›High flow oxygen or noninvasive ventilation requirement

›Hemodynamic instability

Inpatient admission criteria

›Admission criteria

›Moderate bleeding with unclear source

›Significant comorbidity

›COPD with hypoxemia

›Heart failure

›High risk imaging findings

›Mass lesion

›Cavitary disease

Observation pathway criteria

›Observation suitable

›Small volume bleeding with stable vitals

›Completed CT and initial labs without high risk features

Discharge criteria

›Discharge criteria

›Minimal blood streaking only

›Normal oxygenation on room air

›No recurrent bleeding in ED

›Benign cause identified and treated

›Reliable follow up within 24 to 72 hours

18Discharge Instructions/di19

Copy discharge instructions

›Summary

›Seen for coughing up blood

›Your vital signs and oxygen levels were stable today

›Medications

›Take prescribed medications exactly as directed

›Avoid NSAIDs unless instructed

›Activity

›Avoid heavy exertion for 24 to 48 hours

›Avoid smoking and inhaled irritants

›Follow up

›Primary care or pulmonology within 24 to 72 hours

›Earlier follow up if imaging abnormality was found

›Return to emergency

›Any large amount of blood

›Trouble breathing

›Chest pain

›Fainting

›Fever with worsening symptoms

›Recurrent bleeding after discharge

19References/r15

Guidelines and key reviews

›CIRSE Standards of Practice on Bronchial Artery Embolisation for Haemoptysis 2022

›Best practice procedural guidance for BAE

›Complications and safety considerations

›Society of Chest Imaging and Interventions consensus recommendations for management of hemoptysis 2023

›Imaging and IR centered algorithms

›Recurrence and follow up considerations

›AAFP Hemoptysis evaluation and management 2022

›Primary care and ED evaluation framework

›Role of CT angiography and embolization

›CHEST Managing Massive Hemoptysis 2020

›Stepwise approach to life threatening hemoptysis

›Airway and definitive therapy priorities

›ATS Scholar ABCDE Approach for Massive Hemoptysis 2022

›Cognitive aid for acute management

›Emphasis on asphyxiation risk

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.