Catastrophic bleeding (haemoptysis, haematemesis, carotid artery erosion)

Patients may have been identified as being at risk of haemorrhage. Risks include:

• previous small bleeds
• imaging showing necrotic tumour near major blood vessels
• coagulopathy.

Just prior to a major haemorrhage patients often report feeling very unwell with a sense of “impending doom”.

• If a catastrophic bleed is anticipated, prepare the patient and family and ascertain wishes where possible
• Position the patient comfortably (often best sitting forward and well supported)
• Use dark towels to absorb as much of the blood as possible
• If the patient is distressed, a rapidly acting benzodiazepine is indicated.
• The route of administration guides the choice of drug:
• intravenous (IV) access available: †midazolam 10mg IV or †diazepam (emulsion for IV injection) 10mg IV.
• intramuscular (IM) injection: †midazolam 10mg can be given into a large muscle such as deltoid, gluteal.
• rectal route or via a stoma: †diazepam rectal solution 10mg.
• sublingual: †midazolam 10mg can be given using a parenteral preparation
• buccal: †midazolam 10mg  (Buccolam® or Epistatus®)
• If a patient begins to haemorrhage death often occurs rapidly so it is more important to have someone at the bedside providing support than leaving to get medication
• Family often need some support in bereavement, especially if a haemorrhage has occurred at home.