Major haemorrhage

Massive bleeding either at the site of malignant disease or as a consequence of systemic effects on coagulation pathways. When sites of bleeding are supplied by major vessels the volume of blood loss can be vast, rapid, and terrifying.

Those at risk

• Tumours of the head and neck eroding through an artery
• Large lung tumours
• Gastrointestinal and pelvic tumours
• Those in whom bleeding has been a feature early in their disease process
• Coexisting disease related to bleeding e.g. liver failure, thrombocytopenia, gastrointestinal bleeding
• Patients taking medications that prolong bleeding times

Non-drug treatment

• Stop medications which may worsen bleeding e.g. anticoagulants, antiplatelets in advance, when risk of massive haemorrhage identified
• Discussion with patient and those caring for them about what to expect and suggest nursing with dark coloured materials which will make large volumes of blood less alarming
• Discuss and formalise an advance care plan, particularly including actions in case of massive haemorrhage

Drug treatments

• Tranexamic acid may be beneficial in slower bleeding
• Supply carers with buccal midazolam 10mg or rectal diazepam 10mg as part of an advance care plan to use (if possible) in the event of a massive haemorrhage
• Anticipatory medications for use subcutaneously should also be available