Medication

• Apply direct pressure if possible. This can be with gauze soaked in †tranexamic acid (500mg in 5ml) or †adrenaline (epinephrine) 1 in 1000.
• The tranexamic acid soaks can be left in situ with a dressing on top. Alternatively, a †tranexamic acid paste (4 x 500mg tablets crushed in 60g base such as hydrophilic soft paraffin) can be applied twice daily under dressings or, in the case of oral cavity bleeding, 10ml four times daily of a 4 to 5% aqueous solution of †tranexamic acid may be used as a mouth wash.
• A 5% solution can be made by crushing and dispersing a 500mg tablet in 10ml water or diluting the contents of one 500mg/5ml ampoule to a final volume of 10ml. (If using the ampoules, the ampoule contents must be filtered before use to minimise risk of glass particles.)
• Silver nitrate sticks can be used to cauterise bleeding points.
• Surgical haemostatic sponges can be used at home by patients or families to control fast capillary bleeding.
• Haemostatic alginate dressings such as Kaltostat® can be helpful.
• Nasal tampons or Rapid Rhino® nasal packs can be used for epistaxis as available locally. Local A&E or ENT department may be able to advise on what is available locally and how to obtain.
• If bleeding not thought due to DIC, consider systemic antifibrinolytics such as †tranexamic acid:
• initial dose of 1.5g orally followed thereafter by 1g three times daily
• if not settling after 3 days, increase to 1.5g three times daily
• reduce or discontinue 1 week after bleeding stops; restart if recurs.
• †Sucralfate suspension 2g in 10ml twice daily as mouth wash, or orally for oesophageal lesions or rectally for rectal lesions. A paste made of 2g (2x1g tablets crushed in 5ml aqueous jelly) can be used topically for other lesions.

Additional measures below may be recommended by specialists.

• If severe surface bleeding and above measures fail to control, consider use of †desmopressin with close monitoring.
• If acute rectal mucosal damage following radiotherapy try †Predsol retention enema twice daily. (In chronic ischaemic radiation proctocolitis, use oral or rectal †tranexamic acid).

Where oral route is not appropriate, oral solution can often be given rectally. Please contact the specialist palliative care team or palliative care pharmacist for further advice if required.

• Mortality from haemoptysis is high. Risk of asphyxiation is greater than the risk of exsanguination. Rate of bleeding affects outcome.
• Maintain the airway.
• If the bleeding site is known, lay the patient on the bleeding side to reduce effect on the other lung. Alternatively use a head down position if possible to aid drainage of blood.
• Use oxygen and suction as required.
• Exclude or treat infection or pulmonary thromboembolism (PTE) if appropriate.
• Cough suppressant may be helpful. See Cough guideline.
• †Tranexamic acid (as in section on 'Bleeding from skin and mucous membranes').
• Radiotherapy can give full control of bleeding in 85% of patients with lung bleeding.

• Exclude or treat infection.

Additional measures below may be recommended by specialists.

• Consider †tranexamic acid (as in section on 'Bleeding from skin and mucous membranes') although there is a risk of clot retention until the complete cessation of bleeding.
• Bladder irrigation ± instillations with 0.9% Sodium Chloride or †tranexamic acid (5g in 50ml water) can be tried once or twice daily if oral treatment is unsuccessful.

• H2 antagonist or proton pump inhibitor.
• †Tranexamic acid (as in section on 'Bleeding from skin and mucous membranes').
• †Sucralfate (as in section on 'Bleeding from skin and mucous membranes') for oesophageal bleeding.
• Consider †vitamin K (although paradoxically, hepatic impairment may increase risk of venous thrombosis therefore seek advice).

• Platelet infusion may provide transient benefit in thrombocytopaenia.
• Sensitive discussions will be required regarding the appropriateness of this treatment in marrow failure.