Abstract Introduction A previously healthy 37-year-old male developed catastrophic massive hemoptysis from necrotizing pseudomonal pneumonia, resulting in fatal exsanguination despite maximal life-saving interventions, all within four hours of presentation. Massive hemoptysis is a rare, life-threatening emergency caused by infection, malignancy, vascular anomalies, or coagulopathy. Rapid airway compromise, refractory hypoxemia, and hemodynamic collapse demand urgent multidisciplinary management, yet mortality remains high even with aggressive intervention. Case Presentation The patient presented with one day of dyspnea and right shoulder pain. On arrival, he was mildly tachypneic, hypoxic and tachycardic. Exam revealed tripoding, inability to speak full sentences, and diminished right upper-lobe breath sounds. Arterial blood gas showed mixed metabolic and respiratory acidosis. Initial BIPAP provided transient improvement, but rapid deterioration necessitated intubation. Post-intubation chest imaging revealed progressive right-sided opacification culminating in complete lung white-out. He became hypotensive, requiring four vasopressors and methylene blue. Repeat blood gas demonstrated worsening severe acidosis. A massive transfusion protocol was initiated. Suctioning revealed massive hemoptysis exceeding eight suction cannisters. Emergent bronchoscopy with endobronchial blockade and topical tranexamic acid was unsuccessful due to profuse bleeding. Trauma and ECMO teams were consulted. Despite maximal interventions, the patient experienced three cardiopulmonary arrests, and care was withdrawn per family’s decision. Autopsy revealed necrotizing pseudomonal infection involving all five lobes, with extensive alveolar hemorrhage and parenchymal necrosis. Discussion Massive hemoptysis due to necrotizing bacterial pneumonia is rare, rapidly progressive, and often fatal, even in previously healthy adults. Management requires immediate airway stabilization, aggressive hemodynamic support, transfusion, and consideration of lung isolation or bronchial artery embolization, or even thoracotomy and VV ECMO. In hemodynamically unstable patients, definitive interventions may be impossible. This case highlights the extraordinary speed at which infection-mediated massive hemoptysis can unfold, demonstrates the extreme ICU measures sometimes required, and underscores the limitations of current interventions. Clinicians must maintain high suspicion in rapidly deteriorating patients, and early, aggressive multidisciplinary care remains essential to optimize survival. This abstract is funded by: None
Husaini et al. (Fri,) studied this question.