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🩸 Bleeding
Two questions before the site: how much, and what is stopping it clotting? Then find the source. A normal blood pressure in a young person is a compensating patient, not a stable one.
| Major haemorrhage on anticoagulation Must exclude | Any significant bleed on warfarin, a DOAC, heparin or dual antiplatelets. A normal INR does NOT exclude a DOAC effect.Activate the major haemorrhage protocol and reverse by agent — PCC and vitamin K for warfarin, andexanet or idarucizumab where available. Ring haematology. |
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| GI bleed Must exclude | Haematemesis, coffee grounds or melaena. A raised urea with a normal creatinine is a digested protein load, and points upper.Two large cannulae, group and save, Blatchford. Endoscopy within 24 hours, or immediately if unstable. |
| Variceal bleed Must exclude | Large-volume haematemesis in known or suspected cirrhosis, with stigmata of chronic liver disease. Mortality is far higher than non-variceal bleeding.Terlipressin and prophylactic antibiotics BEFORE endoscopy, alongside resuscitation. Sengstaken tube if exsanguinating. |
| Post-operative or occult haemorrhage Must exclude | Tachycardia and a falling pressure after surgery with no visible blood. Retroperitoneal, intra-abdominal and thigh bleeds hide litres.Call the operating team. The observations are the test — serial haemoglobins lag behind the patient. |
| Postpartum haemorrhage Must exclude | Bleeding after birth. The four Ts — tone, trauma, tissue, thrombin — and tone is most of it. Blood loss is routinely underestimated by eye.Rub up the fundus, uterotonics, catheterise, and call obstetrics and anaesthetics. Tranexamic acid early. |
| DIC Must exclude | Bleeding from every puncture site and line at once, in a patient who is septic, obstetric, post-trauma or malignant. Falling platelets and fibrinogen with rising D-dimer.Treat the cause — DIC is never the primary problem. Blood products guided by haematology, not by a protocol alone. |
| Ruptured AAA Must exclude | Back or abdominal pain with collapse in an older patient. The bleeding is internal and there is nothing to see.Vascular surgery immediately. Permissive hypotension — do not over-resuscitate. |
| Epistaxis Time-sensitive | Anterior bleeds are visible and compressible; posterior bleeds run down the throat, are heavier, and are commoner in the elderly and the anticoagulated.Correct first aid for 10–15 minutes by the clock — pinch the soft part, lean forward. Then cautery or packing, and ENT for posterior bleeds. |
| Haemoptysis Time-sensitive | Coughed, frothy and bright red rather than vomited. Infection, PE, malignancy, bronchiectasis, or anticoagulation. Massive haemoptysis kills by drowning, not by exsanguination.CXR and clotting. In massive haemoptysis, lie them BLEEDING SIDE DOWN to protect the good lung, and call for help. |
| Visible haematuria Time-sensitive | Frank blood or clots in the urine, with or without retention from clot. Painless visible haematuria is a cancer until proven otherwise.Three-way catheter and irrigation if clot retention. Urology referral regardless of whether it settles. |
| Lower GI bleed Time-sensitive | Fresh red blood per rectum. Diverticular disease and angiodysplasia in the older patient; haemorrhoids and fissure in the younger, but do not assume.Most settle. Resuscitate, and remember a brisk upper bleed can present this way. |
| Thrombocytopenia Time-sensitive | Petechiae, purpura, mucosal or gum bleeding. Drugs, sepsis, marrow failure, liver disease, hypersplenism — and heparin.FBC with a film. Consider HIT if the platelets fall on heparin, because the answer there is to STOP heparin, not to transfuse platelets. |
| TTP Must exclude | Thrombocytopenia with microangiopathic haemolysis, fever, renal impairment and neurology. Fragments on the film.Haematology emergency — urgent plasma exchange. Platelet transfusion is contraindicated unless there is life-threatening haemorrhage — outside that exception it fuels the microthrombi. |
| Line or catheter site bleeding Common | Oozing from a cannula, central line, drain or arterial puncture. Usually mechanical, but persistent oozing from every site at once is DIC until disproved.Pressure and a review of the anticoagulation. One site is local; several sites at once is systemic. |
| Haemorrhoids / anal fissure Common | Bright red blood on the paper or dripping after defaecation, with pain in fissure and usually none in haemorrhoids.A reasonable explanation in a young patient with a convincing history — and not a sufficient one in an older one without examination. |
15 differentials · 13 open a full pathway in the app.