Major haemorrhage planning

01Purpose and principlesWhat the treatment does and how it fits into care.

Major bleeding risk arises when tumour invades a large vessel or ulcerates into airway, gut, bladder or skin; when treatment causes necrosis; or when platelet failure, liver disease, disseminated coagulation or antithrombotic medicines remove haemostatic reserve. Head-and-neck, lung, upper-gastrointestinal, pelvic and fungating tumours are important contexts, but only a subset will experience catastrophic haemorrhage.

Assess risk without alarming everyone. Clarify previous small bleeds, increasing frequency, site, volume, triggers and imaging that shows vessel proximity, pseudoaneurysm or fistula. Examine accessible wounds and review full blood count, clotting, fibrinogen, renal and liver function and antiplatelet or anticoagulant exposure when results can change treatment. A sentinel bleed may stop spontaneously before a later fatal event and should never be dismissed.

Prevention is mechanism based. Interventional radiology may embolise an arterial source or place a covered stent; endoscopy can inject, clip, thermally treat or stent; surgery may ligate or resect; radiotherapy can reduce tumour bleeding; topical haemostatic dressing, sucralfate, tranexamic acid or cautery may control selected surface or mucosal sites. Reverse anticoagulation and transfuse components only when the likely benefit, timing and goal justify them.

Planning begins with preferences. Ask whether the person wants a detailed explanation, a brief practical plan or for information to be shared mainly with a chosen family member while respecting consent. State that preparation does not mean the event is certain. Explore fears about choking, pain, being alone and family exposure. Agree place of care, emergency calls, resuscitation scope and who will support dependants or children.

Prepare an immediately usable kit where a catastrophic terminal bleed is plausible: dark absorbent towels, gloves, disposable apron, waste bags, a charged telephone and prescribed rapid anxiolytic with route-specific administration instructions. Equipment must be acceptable in the home and checked without making the room feel medicalised. Carers should not be made responsible for invasive administration they have not freely agreed and been trained to provide.

The response diverges by goal. If active rescue is appropriate, call emergency services or the hospital major-haemorrhage team, use ABCDE care, direct pressure or tourniquet for compressible bleeding, secure appropriate access, activate laboratory and blood-component pathways and obtain urgent procedural haemostasis. If death is expected and comfort is the agreed goal, avoid futile transfer, repeated observations or aggressive suction that separates the person from supportive presence.

During a terminal event, remain nearby, speak simply and apply dark towels over visible blood while maintaining a safe position. Midazolam can reduce panic when the person remains conscious long enough, but the event may progress within minutes. After death or stabilisation, support witnesses, offer debrief and explain what happened in plain language; staff also need opportunity for reflection and incident learning without blame.

Key points

Catastrophic haemorrhage is rapid, life-threatening bleeding from tumour erosion, vessel fistula, ulceration, thrombocytopenia, coagulopathy or anticoagulant effect; risk must be individualised rather than assumed from diagnosis alone.
Sentinel bleeds, pulsatile tumour, threatened carotid or major vessel on imaging, recurrent haemoptysis or haematemesis and worsening thrombocytopenia demand urgent specialist review.
First-line prevention treats an achievable source: local pressure or dressing, radiotherapy, endoscopy, embolisation, surgery, antifibrinolytic or correction of anticoagulant and haematological factors as appropriate.
Ask how much the patient and family want to know, explain uncertainty and distinguish a preparedness plan from a prediction that bleeding will occur.
Record whether an actual event should trigger full resuscitation and major-haemorrhage protocol, limited hospital treatment or comfort-only care; DNACPR alone does not answer this.
At a terminal catastrophic bleed, stay with the person, call for help, use calm voice and touch, position safely, apply pressure when feasible and use dark towels to reduce visual distress.
Do not leave a conscious frightened patient to search for medicine. Human presence and reassurance are the immediate treatment, because death may occur before a sedative can act.
When distress persists long enough, give the locally authorised rapid midazolam rescue by the fastest feasible route; route, dose and access must be prescribed and prepared in advance.
Protect carers and staff with gloves and a post-event debrief, practical cleaning support and bereavement follow-up; witnessing a bleed can be traumatic.
The gold-standard plan is short, visible and operational: who to call, what to do, where equipment and medicine are, what not to attempt and how the team supports survivors.

02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.

Sentinel warning bleed

A new small haemoptysis, haematemesis, oral bleed or wound bleed may temporarily stop before recurrent major vessel haemorrhage.

Anatomically threatened vessel

Tumour encasing, ulcerating or fistulating into a carotid, pulmonary, aortic, gastrointestinal or pelvic vessel creates high-consequence risk.

Haemostatic failure

Falling platelets, prolonged coagulation, low fibrinogen, liver failure, renal dysfunction or antithrombotic exposure increases otherwise controllable bleeding.

External tumour bleeding

A fungating wound with increasing ooze, pulsation, malodour or tissue slough requires careful dressing and specialist haemostasis review.

Internal major bleeding

Large haemoptysis, haematemesis, melaena, rectal or vaginal bleeding with shock, breathlessness or collapse indicates urgent internal blood loss.

Catastrophic terminal eventRed flag

Uncontrollable high-volume bleeding with rapid loss of consciousness may leave only minutes for presence, pressure and preplanned comfort treatment.

Red flags requiring action

Any sentinel bleed from a tumour close to a major vessel warrants urgent review even if observations recover.
Pulsatile bleeding or a new bruit in an ulcerated neck or groin tumour suggests arterial involvement.
Haemoptysis with airway compromise, falling oxygenation or inability to clear blood requires immediate airway and respiratory support.
Haematemesis, melaena, abdominal pain or collapse may indicate arterial gastrointestinal bleeding or aorto-enteric fistula.
Tachycardia, hypotension, mottling, confusion or syncope indicates clinically important loss despite uncertain measured volume.
A rapidly falling platelet count, fibrinogen or haemoglobin can precede overt bleeding in marrow failure or disseminated coagulation.
A DNACPR form does not establish whether transfusion, embolisation, endoscopy or emergency transfer is wanted.

03Assessment before treatmentTests and checks that guide safe selection.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
First-line bleeding history and source examinationFirst stepFirst line
Why
Define site, volume, tempo, sentinel episodes, triggers, accessible pressure points, tumour anatomy and current antithrombotic treatment.
Interpretation and limitations
An identifiable compressible or focal source directs immediate haemostasis; recurrent warning bleeds raise urgency even with stable observations.
02
Blood count and coagulation profile
Why
Measure haemoglobin, platelets, prothrombin time, activated partial thromboplastin time and fibrinogen when active treatment is contemplated.
Interpretation and limitations
Results guide component support and reversal but may lag acute loss and should not delay control of life-threatening bleeding.
03
Renal, hepatic and transfusion baseline
Why
Check organ function, group and save or crossmatch and relevant drug levels or timing when intervention or transfusion is intended.
Interpretation and limitations
These data guide anticoagulant reversal, contrast and component selection; tests add no value when a settled comfort plan excludes intervention.
04
Cause-directed endoscopy or bronchoscopy
Why
Visualise gastrointestinal or airway sources when the person can tolerate the procedure and endoscopic haemostasis is feasible.
Interpretation and limitations
Direct visualisation is the procedural gold standard for many luminal sources but must not destabilise a threatened airway or delay embolisation.
05
CT angiography
Why
Map active extravasation, pseudoaneurysm, tumour-vessel relation and access for embolisation or stent treatment.
Interpretation and limitations
A positive arterial target can enable interventional control; a negative scan does not erase a credible intermittent sentinel bleed.
06
Structured preparedness review
Why
Confirm goals, emergency numbers, kit, medicine, route, expiry, competency, family understanding and post-event support.
Interpretation and limitations
Operational readiness is the gold standard for crisis planning; a narrative note hidden in the record is insufficient.

04Treatment approachPreparation, options, escalation and aftercare.

01Risk reductionTreat the source before catastropheFirst stepSentinel bleeding or anatomy indicates a credible major-haemorrhage risk and intervention may provide worthwhile benefit.

1EscalationEscalate to the relevant oncology, surgery, endoscopy or interventional team and define source, vessel involvement, haemostatic defects and current antithrombotics.
2Choose local care, radiotherapy, embolisation, covered stent, endoscopic therapy, surgery, reversal or component support according to mechanism and goal.
3Document treatment response and residual risk, then build a crisis plan even when preventive treatment appears successful.

02Advance preparationCreate a calm operational home or ward planResidual catastrophic risk is significant and the person wants preparation for a possible terminal event.

1Ask information preferences and discuss uncertainty, likely experience, desired emergency response and who should be present or contacted.
2Place dark towels, protective equipment, telephone details and route-specific prescribed medicine accessibly and train willing staff or carers in their limited role.
3Write a one-page plan covering presence, pressure, positioning, emergency call, medicine, tasks to avoid and debrief, and share it across relevant services.

03Active rescueActivate major-haemorrhage care and source controlA major bleed occurs and the agreed plan includes resuscitation, transfusion or procedural haemostasis.

1Call the emergency or major-haemorrhage team, use ABCDE care, apply direct pressure or an appropriate tourniquet and protect the airway from blood.
2Obtain suitable access, send urgent samples, activate blood components and use reversal or tranexamic treatment only according to source-specific protocol.
3Move rapidly to endoscopy, embolisation, bronchoscopy or surgery while communicating prognosis and revisiting ceilings if haemostasis is not achievable.

04Terminal bleedStay, reassure and relieve panicCatastrophic bleeding occurs under an agreed comfort-only plan or death is imminent despite attempted control.

1Call nearby support but do not abandon the person; use calm words and touch, safe side positioning or pressure and dark absorbent towels.
2Give the pre-prescribed rapid midazolam by the fastest authorised route if the person remains distressed long enough, without delaying human presence.
3Afterwards support family and staff, arrange respectful cleaning and verification, explain the event and offer bereavement and clinical debrief follow-up.

05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.

Provides rapid anxiolysis and sedation when a conscious person remains terrified during an otherwise uncontrollable terminal haemorrhage.

Pre-authorised midazolam for terminal bleeding panic

A common specialist crisis prescription is midazolam 10 mg by intravenous, intramuscular or buccal route according to existing access and local palliative protocol, repeated only under the documented response plan.

The event may be faster than drug effect, so never delay presence; route and administrator must be lawful and feasible and frailty, prior benzodiazepine exposure and respiratory state require the prewritten plan.

Inhibits fibrinolysis and can reduce selected mucosal, wound or active major bleeding while definitive source control is arranged.

Tranexamic acid for selected non-terminal bleeding

Use a site-specific oral, topical or intravenous regimen only after thrombosis, renal function, haematuria and the intended haemostatic procedure have been reviewed under the local bleeding pathway.

It is not universal treatment for every tumour bleed; adjust in renal impairment and avoid uncritical use with upper urinary-tract bleeding or major thrombotic risk.

Restores haemostatic function when antithrombotic exposure materially contributes to a life-threatening bleed and active rescue is intended.

Anticoagulant reversal under emergency protocol

Use the agent-specific reversal pathway based on anticoagulant, last dose, renal function, measured effect where available, bleed site and urgency; involve haematology and transfusion early.

Reversal can cause thrombosis and should accompany, not replace, source control; do not infer treatment wishes from DNACPR status alone.

06Complications, monitoring and follow-upAdverse effects, response and longer-term review.

After a sentinel bleed track site, frequency, estimated volume, precipitant, haemoglobin and haemostatic results only when they can change prevention.
Review anticoagulant, antiplatelet and interacting medicines after every bleed and document the risk-benefit decision rather than silently stopping treatment.
After radiotherapy, endoscopy or embolisation record whether bleeding ceased and whether residual catastrophic anatomy remains.
Check the crisis kit, medicine route, expiry, administration authority and contact details at each change of setting.
Confirm family understanding without repeated graphic discussion and offer them permission not to administer medicine or manage blood.
During an active rescue follow haemodynamics, airway, coagulation and source response under the major-haemorrhage protocol.
After any event provide psychological follow-up and review whether the plan, communication and equipment need to change.

07Special situationsVariants, exceptions and circumstances that change the usual approach.

Planning is not prediction

Explaining that a bleed may never occur allows preparation without presenting catastrophe as inevitable.

A small bleed may be large information

A self-limiting sentinel episode can be the only warning before arterial erosion and deserves urgent anatomical review.

Presence outruns pharmacology

During a bleed measured in minutes, a familiar voice and touch often reach the patient before any prescribed sedative.

Dark towels are psychological care

They do not achieve haemostasis but reduce the visual impact for the patient, relatives and staff.

DNACPR answers one question

It addresses cardiopulmonary resuscitation after arrest, not transfusion, embolisation, transfer or treatment of a reversible bleed.

Witnesses need aftercare

A technically well-managed event can still cause intrusive memories, guilt and distress that merit proactive debrief and bereavement support.

08Common pitfallsFrequent interpretation and management errors.

01
Assuming a catastrophic bleed is inevitable from tumour site and frightening the patient unnecessarily.
02
Dismissing a sentinel bleed because it stopped without treatment.
03
Creating a comfort plan before reviewing a preventable arterial, endoscopic or radiotherapy option.
04
Treating DNACPR as a decision against all haemorrhage treatment.
05
Hiding the plan in lengthy notes that community or night staff cannot find.
06
Leaving the patient alone while searching for midazolam during a rapidly fatal event.
07
Expecting untrained relatives to give an injection or manage massive blood loss.
08
Using bright towels when dark absorbent material is available and acceptable.
09
Prescribing tranexamic acid without checking site-specific harm, renal function and thrombosis.
10
Failing to debrief relatives and staff after a distressing bleed.