BLEEDING

Management of bleeding depends in its site and severity.

Management options may include:

1. Topical adrenaline and/or aliginate dressings.

2. Palliative radiotherapy

3. Tranexamic acid

4. Reversal of warfarin

5. Transfusion

6. Laser

7. Alum solution

8. Radiation menopause

9. Sedation in severe bleeding

1. Liberal use of topical adrenaline (1 in 1,000) on a dressing, applied with firm local pressure, is a good first aid measure for surface bleeding. If infection is contributing to bleeding give a broad spectrum antibiotic. Alginate dressings are hemostatic and can be useful for surface bleeding. (see Pressure Sores)

2. Palliative radiotherapy can dry up surface bleeding from fungating breast cancer or malignant nodes and is often effective for hemoptysis. It cannot be given if the area has already received radical doses of radiation.

3. Oral tranexamic acid 1g per day can stop capillary bleeding. It is an anti-fibrinolytic and acts by stabilizing the fibrin plug. It can cause nausea. Anti-fibrinolytics are said to increase the risk of clots forming in the bladder in patients with hematuria. Clots in the bladder can be lysed by citrate bladder washouts.

4. If the patient is taking warfarin the effect can be reversed by giving Vitamin K, phytonadione 10mg orally (which reverses warfarin in 4 hours), or 10mg IV by slow injection to avoid nausea (which has immediate effect). Warfarin should be reversed in the terminal phase of illness to prevent the distressing bleeding that can occur as the patient dies, causing altered blood to trickle from the mouth. If warfarin overdosage has caused hypothrombinemia and bleeding, fresh frozen plasma replaces clotting factors immediately.

5. Blood transfusion is not usually considered for active bleeding in terminal illness, unless the bleeding is controlled and the patient is left with symptomatic anemia. (In fact, transfusion can make bleeding heavier for a time.)

6. Laser therapy can coagulate bleeding tumors in the bronchus and rectum. It can be performed through an endoscope and has the advantages of immediate relief of symptoms without systemic side effects. It usually has to be repeated.

Standard (no-touch) laser techniques may not control heavy bleeding from large, friable cancers. Such bleeding has been controlled in gastric cancers using low-power interstitial laser coagulation. (see Lasers)

7. A 1% alum solution (100mg alum dissolved in 1,000ml sterile water, then diluted x 10 with normal saline) is the best styptic solution for bladder washouts to control bladder hemorrhage, and on ribbon gauze to control hemorrhage from carcinoma of the rectum.

8. Heavy menstrual bleeding can be troublesome for a disabled patient (with ALS, for example) and can be stopped by inducing a radiation menopause.

9. If severe bleeding and shock occurs, the patient should be sedated (with an injection of morphine, scopolamine and chlorpromazine). If a sudden massive hemorrhage is a strong possibility, these drugs should be kept ready in a syringe. A red blanket should also be readily available to reduce the visual effects of massive hemorrhage. (see Terminal Phase)

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.