No universally agreed definition regarding major haemorrhage – the Palliative Care Network of Wisonsin describes this as ” Terminal haemorrhage is defined as a major haemorrhage that is likely to rapidly result in a patient’s death due to a massive lost of circulating volume “ Dylan G Harris et al in The Journal of Pain and Symptom Management in 2009 described terminal haemorrhage as ” a major haemorrhage from an artery which is likely to result in death within a period of time that may be as short as minutes because of the rapid internal or external loss of circulating blood volume ”
Relatively rare Several other terms are used interchangeably as ○ catastrophic bleed ○ major bleed ○ haemorrhagic complications in patients with advanced cancer ○ terms ” crisis” or ’emergency” medication is a term used to describe medication given urgently once a haemorrhage has started Sentinel or Herald bleed is used to indicate a small or prodromal bleeding 24-48 hrs before the the rupture of an artery that that resolves spontaneously or with packing or pressure Seen more commonly in patients with ○ head and neck cancer ○ lung ○ upper GI Overall the current literature suggests that haemorrhage or bleeding is likely to occur in 6 % to 10 % of patients with advanced cancer.
Internal -erosion of thoracic or abdominal vessels External – rupture of an artery Local insult as a result of cancer , surgery, radiotherapy , tumour invasion Systemic process as coagulopathy , thrombocytopenia , disseminate intravascular coagulation , bone marrow involvement , liver disease Anti-tumour treatments ( e.g prior radiation therapy or chemotherapy ) Immunotherapies as bevacizumab Infections – which may cause haemoptysis , haematuria , vaginal bleeding , fungating wounds NSAIDs , anticoagulants
Head and neck cancer patients may show ballooning or visible pulsatile arterial vasculature Sentinel bleeding Bruising Petechiae Epistaxis Haemoptysis Haematemesis Haematochezia Melena Haematuria Vaginal bleeding
Vitals Haemoglobin ( if recent bloods available ) Site of bleeding if visible ○ Head and neck ○ vascular ○ GI- upper / lower ○ pulmonary ○ skin ( fungating or ulcerating ) ○ gynae ○ urinary tract Review drugs Patient condition Any advance directives / wishes / family preference or plans in place.
left lateral position apply pressure compression dressing call for help
Anatomical -Fungating wound Recurrent sentinel bleeds Site of the lesion is close to a major vessel
Systemic disease- bone marrow failure coagulation disorders DIC infection at the site of the lesion malabsorption / ↓↓ Vit K severe liver disease uraemia.
Infection of a fungating wound low platelet count radiotherapy to a post-operative site.
chemotherapy causing mucositis Heparin NSAIDs Anticoagulants.
Stop any drug / agents which may exacerbate bleeding ( risk / benefit ) Modify risk factors when and where appropriate.
discuss the possibility with the patient / family provide emergency contact numbers anticipatory prescribing for e.g sedatives for prn use ( e. crisis pack ) discuss resuscitation / DNR and document supply equipment’s as gloves , aprons, plastic sheet , clinical waste bag , dark coloured towels communicate the plan to all stakeholders for e.g OOH/ DN’s
This aide memoir tries to simplify a situation which can be stressful for both the carers and clinicians Where possible use of sedative as midazolam / opioid A healthcare professional may not be present when this happens and the relatives may find it helpful to dial 999 to obtain acute support.
reduces mortality in about 1/3 rd of cases have minimal side effects and studies have not shown an ↑ thrombotic risk can be used as inj , soaked gauze packing , powdered TA mouthwash , paste Scottish palliative care guideline recommends that TA 5 % solution can be made by crushing and dispersing a 500 mg tablet in 10 ml of water or diluting the contents of one 500 mg / 5 ml ampoule to a final volume of 10 ml dose can be for e.g 500 mg 8 hrly orally , up to 1 gm every 6-8 hrs.
silver nitrate sticks to cauterize bleeding points Kaltostat ( haemostatic aliginate dressing ) Nasal tampons or Rapid rhino nasal packs for epistaxis Sucralfate suspension as ○mouthwash or for oesophageal lesions ○ rectally for rectal lesions Systemic – synthetic hemostatic drug ethamsylate ( if available )
- Bleeding Scottish Palliative Care Guidelines Scottish Palliative Care Guidelines – Bleeding
- Bleeding in cancer patients and its treatment: a review Annals of Palliative Medicine Bleeding in cancer patients and its treatment: a review – Johnstone – Annals of Palliative Medicine (amegroups.com)
- Guidelines for the assessment and management of major haemorrhage in palliative care Major_Haemorrhage.pdf (nwcscnsenate.nhs.uk)
- Grippsland Region Palliative Care Consortium – Palliative care emergencies Palliative Care Service Access & Management Flow Chart for General Practitioners (grpcc.com.au)