Management of accidental pulmonary artery rupture

This was asked about in Question 15 from the first paper of 2000.

In brief:

Airway management

Isolate the affected lung.

• Either insert a dual-lumen tube to isolate the affected lung, or advance the existing tube into the right main bronchus (if this is an option).This should protect the unaffected lung from contamination with blood and clots.

Support of ventilation and oxygenation

If the lung is not isolated:

• crank up the PEEP. This may decrease the rate of haemorrhage by putting up a resistance to pulmonary blood flow.
• Position the patient affected-side down. This way, only one lung fills up with blood.

If the lung is isolated:

• Increase the FiO2. If a DLT is in position, the pulmonary vasodilation should encourage blood flow into the good lung.
• Position the patient affected-side up. This way, the affected lung will have decreased blood flow.

Circulatory control

Attempt temporary haemostasis.

• One may try to wedge the balloon in the affected pulmonary artery, thereby preventing further blood loss.

Establish definitive haemostasis

• Cardiothoracic surgical repair will be the only way this situation can be salvaged.
• Case reports have demonstrated that angioembolisation is also a viable option if urgent surgery is impossible or undesirable.

Lastly;

Family conference and full disclosure.

The historical mortality rate from these is about 70%.