Abstract
Introduction
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Incidence and Etiology
Patients with head and neck cancers have the highest incidence, as carotid rupture can occur in 3% to 4%. Other etiologies are (1) anatomical (e.g., from local tumor erosion); (2) systemic (e.g., due to thrombocytopenia from bone marrow infiltration); or (3) combined. Common presentations are hemoptysis in cancer or cystic fibrosis, gastrointestinal bleeding in liver disease, and vaginal bleeding in cervical or uterine cancer. 2
Risk Factors and Clinical Manifestations
Retrospectively, clinicians may recognize a “sentinel” or “herald” bleed of often trivial amount occurring 24 to 48 hours before a major arterial bleed. Naturally this may lead clinicians to worry they had not done enough to prepare for its dramatic presentation. Prospectively, however, it can be clinically challenging to appropriately address “herald bleeds.” Impending arterial rupture sometimes may be identified by the presence of a ballooning or visible pulsation in arterial vasculature. Yet in most cases, true catastrophic terminal hemorrhage events do not occur even in at-risk patients. Hence when preparing patients and/or families for the possibility of a terminal hemorrhage, it is also important for clinicians to allay anxiety by discussing the rarity of the event.
Management
While there is scant clinical research to guide clinical management of terminal hemorrhage, initial measures include identification of the source of bleed, applying pressure to the source if appropriate, ensuring a care provider presence to offer calm direction, and using dark towels to camouflage bleeding. Pharmacologic management may be useful in slower bleeds, but it should not detract from nonpharmacologic approaches. A semistructured interview of nurses suggested that patients who terminally hemorrhaged often bled out so quickly that pharmacology had no impact on comfort and may have distracted from the reassurance and nursing interventions, which could have been more effective. 3 Regardless, a three-step approach is proposed by many experts4–6 :
• Identify “at-risk” patients: those with a herald bleed, head and neck cancers, hematological cancers, or tumors encasing major vessels. In home hospice settings, consider use of crisis care if terminal hemorrhage is strongly anticipated in one to two days.
• Address modifiable risk factors by ensuring anticoagulants, NSAIDs, and aspirin have been discontinued. Consider use of platelet transfusions, Vitamin K, or Fresh Frozen Plasma (FFP) if such interventions are easily available and clinically warranted immediately after a herald bleed. If consistent with goals and/or medically feasible, consider the use of radiation or interventional therapies such as embolization or coiling to curtail the risk of bleeding.
• Formulate a plan of action that includes what to expect with regards to prognosis and symptoms when hemorrhage occurs, who to contact, and whether life support will be pursued.
• Communicate this plan with the patient, caregivers, and health care providers.
• Prepare a “crisis pack” containing:
○ Sedatives and analgesics: predrawn and at bedside for rapid palliation of dyspnea or pain.
○ Large dark towels, a dark basin, and gloves.
○ Suction device—typically only beneficial when patients are choking or aspirating on blood.
○ Warm blankets—patients are likely to be cold from ensuing hypotension.
○ Face cloth—to clean patient's face and mouth.
○ Yellow bags—for disposal of waste and blood-stained materials
Reassure the patient you will not abandon them and provide a comforting touch when appropriate. Control symptoms when possible using predrawn “crisis” medications. Consider positioning family members and children so that they can be in close physical contact with the patient but not in direct visual view of the catastrophic bleed. If possible, position the patient so that bleeding sites are against gravity and blood pooling in dependent areas is minimized.
Provide bereavement support to all involved, including family members who may be traumatized from witnessing the event and subsequently at risk for complicated grief and posttraumatic stress symptoms (see Fast Fact #254). In the home setting, hospice teams can be of great benefit to the bereaved by properly disposing of clinical waste and using appropriate personal protective equipment.