Vomic

Specialty: Respiratory.

• sudden expectoration of pus
• emptying of the lung cavity by air

Why it occurs

• Amebic or bacterial lung abscess that abruptly fistulizes into a segmental or lobar bronchus (causing massive expulsion of pus and necrotic tissue)
• Ruptured pulmonary hydatid cyst (caused by rupture of the adventitia of the Echinococcus granulosus cyst, expelling crystalline fluid ("rock water"), germinative membranes and hooks of the parasite)
• Pleural empyema with bronchopleural fistula (accumulation of pus in the pleural space that erodes the visceral pleura and suddenly drains through the tracheobronchial tree)
• Suppurative mediastinitis fistulized to the trachea (deep infection of the mediastinum that drains its purulent contents into the airway)
• Superinfected tuberculous cavern (with massive liquefaction necrosis that is suddenly evacuated)

Initial workup

Urgent chest x-ray (where the sudden appearance of an air-fluid level in a previously opaque cavity is usually observed); Computed tomography (CT) of the chest with intravenous contrast; Immediate microscopic examination of the expelled fluid (Gram stain, Ziehl-Neelsen stain, search for hooks of Echinococcus and amoebae); Microbiological culture of vomica material; Emergency rigid or flexible bronchoscopy to secure the airway and aspirate debris.

Standard management

• Ampicillin/Sulbactam — 1.5-3 g intravenously every 6 hours to cover anaerobic and aerobic germs in the oral cavity
• Metronidazole — 500 mg intravenously every 8 hours if amoebic abscess is strongly suspected
• Hydrocortisone — 100-200 mg immediate intravenous if anaphylactic reaction occurs due to rupture of hydatid cyst
• Adrenaline (0.3 mg intramuscularly for anaphylactic shock associated with hydatid cyst).