Localized bleeding: ulcerated wound, fungating tumor, bleeding from vessel in hollow organ
Generalized: from platelet dysfunction, thrombocytopenia or coagulation disorder
Localized Bleeding:
Exclude systemic causes that could be contributing: NSAIDS (stop), Vitamin K deficiency due to liver failure (Vitamin K 5-10mg s.c. or p.o.)
Visible vessel: clamp and ligate or cauterize
Multiple sites of vascular bed:
- Pressure dressings:
- Topical hemostatic agents:
- Tranexamic acid: 5% solution in saline, soaked in gauze and applied with pressure and packing e.g. nose
- epinephrine 1:1000: apply to site with gauze and pressure
- Radiotherapy if ongoing and not accessible e.g. cervix
Bleeding from large vessel in hollow organ (bladder, rectum, lung): treatment specific to organ or systemic measures as below if inaccessible
Generalized Bleeding:
Severe bleeding: intervention depends on clinical situation, illness trajectory and patient goals of care. If high risk, prepare ahead: discuss with patient/family, dark towels, warm blankets, midazolam 5-10mg subcutaneous. If bleed happens, use midazolam 5-10mg subcutaneous every 10minutes prn to achieve calm unawareness.
Systemic measures:
Vitamin K 5-10mg s.c. or p.o. if INR elevated
Tranexamic acid: 1.5gm stat then 500-1000 tid. Discontinue 1 week after bleeding stopped or reduce to 500mg tid.
Platelet transfusion if appropriate
Patient on DOAC: Reversal agents expensive and take time for prep. Only consider if major bleed and other measures (IV access, blood products, volume resuscitation) not working. Consider time last dose and half-life. Apixaban 7-15 hrs