The first priority in a patient coughing up 200 ml of fresh blood (massive hemoptysis) is to protect the airway to prevent aspiration, airway obstruction, and respiratory failure. Securing the airway minimizes the risk of asphyxiation from blood flooding the trachea and bronchi. This may involve positioning, suctioning, or even intubation if necessary. Once the airway is secured, further diagnostic and therapeutic interventions can be safely performed. Immediate stabilization takes precedence over interventions such as antibiotics or vitamin K administration.

Reference: Bailey & Love’s Short Practice of Surgery, Norman S. Williams, 27th Edition.