Management

• If significant bleeding can be anticipated, it is usually best to discuss the possibility with the patient and their family.
• Ensure carers at home have an emergency contact number.
• An anticipatory care plan is helpful. This includes having sedative medication prescribed for use if needed.
• If the patient is at home, discuss options for sedation. This may include careful assessment of whether carers are able to administer this medication.
• Discuss resuscitation; document and communicate resuscitation status.
• Ensure a supply of dark sheets or towels along with other equipment: gloves, aprons, plastic sheet, and clinical waste bags.
• Plan for who will clean up after an event and how to contact them.
• Make sure all professionals and services involved are aware of the care plan, including out-of-hours services (refer to Out of hours handover guideline).

Non-pharmacological management

• Try to remain calm. Call for help. Talk to the patient and comfort them.
• Put the patient in the recovery position, if appropriate.
• If able, apply direct pressure to bleeding area; dark coloured towels are best.
• If resuscitation is appropriate, admit to hospital and manage according to local protocols for haemorrhage.
• If the patient has a massive haemorrhage and is clearly dying, support and non‑pharmacological interventions are more important until help arrives than trying to give sedative medication; the patient will usually lose consciousness rapidly and may be frightened especially if left alone.

Sedative medication for use in massive terminal haemorrhage

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 or the buccal liquid (Buccolam or Epistatus) (refer to Practice points section of this guideline).

Note: if the patient is already on large background doses of benzodiazepines, a larger dose may be needed. If they are frail, a smaller dose may be sufficient.

After the event

• Offer debriefing to team and family.
• Ongoing support as necessary for relatives and staff members.
• Disposal of clinical waste appropriately.

Minor bleeding may herald a fatal bleed. Although minor, these bleeds may still be distressing to the patient and family. There are some specific measures (described below) which can be taken to try to control these. It is reasonable to review need for aspirin and any other drugs with antiplatelet effects such as many NSAIDs. Consider also if interventions, including diathermy, laser, embolisation, radiotherapy, surgery (including endoscopy, bronchoscopy, cystoscopy), are relevant.

Assess for appropriateness and need for transfusion or other blood products.