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Ann Thorac Surg 2007;84:1373-1374
© 2007 The Society of Thoracic Surgeons

Case Reports

Successful Use of Recombinant Activated Coagulation Factor VII in a Patient with Massive Hemoptysis From a Penetrating Thoracic Injury

Homer C.N. Tien, MD, MSca,b,*, Michael R.C. Goughc,d, Robert Farrell, MD, MSce, John Macdonald, MD, MScb,f

a The Trauma Program and the Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
b Canadian Forces Health Services, Ottawa, Ontario, Canada
c St. George’s Hospital, University of London, London, United Kingdom
d Royal Army Medical Corps, British Army, London, United Kingdom
e Carbonear General Hospital, Newfoundland, Ottawa, Ontario, Canada
f Department of Critical Care Medicine, University of Ottawa, Ottawa, Ontario, Canada

Accepted for publication May 11, 2007.

* Address correspondence to Dr Tien, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Suite H186, Toronto, Ontario, M4N 3M5, Canada (Email: homer.tien{at}sunnybrook.ca).


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Acute massive hemoptysis is a rare complication of pulmonary injury and contusion, and it is particularly difficult to manage in the nontertiary care setting. Recombinant activated coagulation factor VII (rFVIIa) is a prothrombotic drug that is increasingly being used to treat coagulopathy in massively exsanguinating trauma patients. We report a case in which recombinant activated coagulation factor VII successfully controlled massive hemoptysis and improved ventilation from a severe pulmonary contusion in a noncoagulopathic patient who suffered a penetrating thoracic injury in a military setting in Afghanistan.


   Introduction
Top
 Abstract
 Introduction
Comment
 References
 
Acute massive hemoptysis is a rare complication of pulmonary injury and contusion that warrants prompt multimodal intervention because of impaired ventilation and alveolar gas exchange [1]. Managing this life-threatening condition can be particularly challenging in the nontertiary care setting [2].

Recently, recombinant activated coagulation factor VII (rFVIIa [NovoSeven, Novo Nordisk Pharmaceuticals Inc, Princeton, NJ]) has been proposed as an adjuvant therapy for exsanguinating trauma patients with coagulopathy [3]. To date, the use of rFVIIa in trauma-related hemoptysis has been limited to one case of diffuse alveolar hemorrhage from coagulopathy after blunt thoracic injury [4]. We report the successful use of rFVIIa in treating massive hemoptysis from penetrating thoracic trauma in a noncoagulopathic patient treated in a military field hospital in Afghanistan.

A 23-year-old Afghanistan man sustained a gunshot wound to his left chest and was evacuated to a Canadian Forces field hospital in Kandahar. On admission he was alert and his systolic blood pressure was 85 mm Hg; his pulse rate was 125 beats per minute, and his respiratory rate was 35 per minute. His oxygen saturation was 85%. He had a small wound in his left axilla and a large wound over his anterior chest (Fig 1). There were no retained bullets.


Figure 1
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  		Fig 1. Location of exit wound.

 
Resuscitation included endotracheal intubation, mechanical ventilation, and volume administration. Left tube thoracostomy was also performed with minimal output and no significant air leak. However the patient had massive hemoptysis develop (100 cc every 15 minutes). Consequently he became impossible to ventilate except with manual bagging. He was also hypotensive, despite blood product transfusion (4 units, type O blood). His oxygen saturation remained between 88% and 92%. Ultrasound examination showed no peritoneal fluid, but was indeterminate for pericardial fluid. Portable supine chest roentgenogram was performed (Fig 2). The patient was not overtly coagulopathic at this time; hemoglobin, platelets, activated partial thromboplastin time, and international normalized ratio were all within their normal limits.


Figure 2
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  		Fig 2. Chest x-ray film showing left contusion.

 
A double-lumen endotracheal tube was placed. Standard therapy for massive hemoptysis was instituted. A left anterolateral thoracotomy with a clamshell extension (see Fig 1) was performed to rule out cardiac and great vessel injury. Concurrently, a flexible bronchoscopy showed ongoing bleeding from the left lung with no definitive source; however significant bilateral soiling was present.

A thoracotomy revealed a severely contused left upper lobe. Otherwise there was no retained hemothorax, cardiac injury, or great vessel injury. The Canadian field hospital holds approximately 6 dosages of rFVIIa. As thoracotomy was initiated, 4,800 mcg of rFVIIa (approximately 90 mcg/kg) was administered on the belief that the patient had an exsanguinating thoracic hemorrhage. Within 1 minute the hemoptysis was controlled and the patient’s ventilation improved, such that he was placed on the mechanical ventilator. We then terminated the operation without performing a left upper lobectomy as the patient did not have a significant air leak and had no further hemorrhage. The patient remained ventilated for 7 days, and he was discharged home within 2 weeks.


   Comment
Top
 Abstract
 Introduction
 Comment
References
 
Very little has been written about the management of massive hemoptysis from penetrating thoracic injury. Massive hemoptysis is more likely to be secondary to chronic inflammatory conditions or neoplastic disease [5]. In these cases, emergency pulmonary resection is associated with substantial mortality and is usually reserved for cases of localized bleeding that are refractory to other modalities, such as embolization [5]. In contrast, unstable patients with penetrating thoracic injury usually require emergency thoracotomy to exclude injuries to the heart or great vessels. For that reason, any associated massive hemoptysis is usually treated with emergency pulmonary resection at the time of trauma thoracotomy [1].

We report a case in which rFVIIa successfully controlled massive hemoptysis related to a pulmonary contusion from a gunshot wound to the left chest. The rFVIIa becomes active after forming a complex with tissue factor, which is only exposed to circulating blood at the site of injury. Formation of the tissue factor-rFVIIa complex then initiates activation of factors IX and X, inducing a thrombin burst and faster formation of the fibrin clot [3]. In our patient, administration of rFVIIa may have accelerated thrombosis within ruptured arterioles in the macerated left upper lobe of lung, stopping the intra-alveolar hemorrhage and the resulting hemoptysis.

The rFVIIa may have a role in treating massive hemoptysis in the military setting. Military surgeons may see relatively high volumes of penetrating thoracic trauma while deployed, and yet may not have the expertise of experienced thoracic surgeons for performing anatomical pulmonary resections [6]. In addition, military field hospitals usually do not have interventional radiologic capabilities to perform embolization.

Recombinant activated coagulation factor VII (rFVIIa) is approved to treat hemorrhage in hemophiliacs, but it is increasingly being used in massively exsanguinating, coagulopathic trauma patients. However, rFVIIa has not been shown to improve survival in these patients [7]. One explanation is that any reduction in bleeding achieved by administering rFVIIa may have been overshadowed by the severity of their physiologic derangements.

The rFVIIa may be beneficial in cases where adverse outcomes are less related to the absolute volume of bleeding, but to its location. For example, the "off-label" use of rFVIIa has improved survival in noncoagulopathic patients suffering from spontaneous, nontraumatic intracerebral hemorrhage [8]. Certainly, the volume reduction achieved by using rFVIIa for this indication was extremely modest, but was shown to be associated with a profound survival benefit. Likewise, rFVIIa use should be considered in traumatic hemoptysis cases where physiologic consequences of intra-alveolar hemorrhage predominate. In these cases the danger from hemorrhage is primarily to ventilation and impaired gas exchange, which may be improved by relatively modest reductions in intra-alveolar bleeding. Future studies on rFVIIa use in trauma patients should also focus on ventilatory and oxygenation measurements as intermediate outcomes, especially in patients with documented pulmonary injury.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Wilson RF, Soullier GW, Wiencek RG. Hemoptysis in trauma J Trauma 1987;27:1123-1126.[Medline]
  2. Jean-Baptiste E. Clinical assessment and management of massive hemoptysis Crit Care Med 2000;28:1642-1647.[Medline]
  3. Rizoli SB, Nascimento Jr B, Osman F, et al. Recombinant activated coagulation factor VII and bleeding trauma patients J Trauma 2006;61:1419-1425.[Medline]
  4. O’Connor JV, Stein DM, Dutton RP, Scalea TM. Traumatic hemoptysis treated with recombinant human factor VIIa Ann Thorac Surg 2006;81:1485-1487.[Abstract/Free Full Text]
  5. Jougon J, Ballester M, Delcambre F, et al. Massive hemoptysis: what place for medical and surgical treatment Eur J Cardiothorac Surg 2002;22:345-351.[Abstract/Free Full Text]
  6. Tien HC, Farrell R, Macdonald J. Preparing Canadian military surgeons for Afghanistan CMAJ 2006;175:1365.[Free Full Text]
  7. Boffard KD, Riou B, Warren B, et al. NovoSeven Trauma Study Group Recombinant factor VIIa as adjunctive therapy for bleeding control in severely injured trauma patients: two parallel randomized, placebo-controlled, double-blind clinical trials J Trauma 2005;59:8-15discussion 15–8.[Medline]
  8. Mayer SA, Brun NC, Begtrup K, et al. Recombinant Activated Factor VII Intracerebral Hemorrhage Trial Investigators Recombinant activated factor VII for acute intracerebral hemorrhage N Engl J Med 2005;352:777-785.[Abstract/Free Full Text]



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