General Principles:

• Assess vital signs and circulatory status. Initiate intensive care measures if required.
• Send hemogram, PT, APTT, LFT, RFT including electrolytes, HIV, HBsAg, HCV serology and blood for cross matching. 
• Follow "approach to diagnosis of suspected bleeding disorder" to find out hematological causes for bleeding. If found, treat with appropriate blood product/ therapy for the particular disease.
• Use appropriate blood product (platelets/ FFP/ Cryo) including PRBCs till diagnosis is made.
• Use Inj. Tranexamic acid 500-1000mg- TID, except in patient who have hematuria.
• Do appropriate radiological investigation/ scopy to identify the cause of bleeding.
• Get consultation from concerned department, even if cause of bleeding is found to be a hematological disorder.

Bleeding from various sites- Non-hematological causes- Immediate management

Hemoptysis

Non-hematological causes:

• Infections: Pulmonary tuberculosis, pneumonia, lung abscess, bronchitis, bronchiectasis,   aspergillosis
• Malignancies: Carcinoma larynx, bronchogenic carcinoma
• Cardiac: mitral stenosis, LVF, pulmonary embolism, essential hypertension, Eisenmenger syndrome
• Others: Foreign body, pulmonary vasculitis, bronchial AV fistula, idiopathic pulmonary siderosis, Tracheobronchial trauma

Management:

• Place bleeding lung in dependent position
• Diazepam- 5mg- TDS (Allays anxiety and suppresses cough reflex)
• Codeine- 2tsp- TDS
• Consider Angiography-embolization/ surgery

Hematemesis:

Non-hematological causes:

• Swallowed blood, reflux esophagitis, acute gastritis, carcinoma stomach, variceal bleed, Mallory Weiss syndrome, Uremia, Osler Weber Rendou disease, telangiectasis, aortic enteric fistula

Management:

• Inj. Ondansetron- 8mg TID
• Inj. Pantoprazole- 80mg IV stat followed by 8mg/hr- continuous infusion
• Gastric lavage with cold isotonic saline
• Sucralfate 20ml QID
• Diazepam- 10mg- stat
• If variceal bleed is suspected: Inj. Octreotide- 100microgm- IV- Bolus, then 50-100microgm/hr infusion
• Arrange for upper GI endoscopy

Bleeding Gums:

Non-hematological causes:

• Scurvy, injury, dental caries, aphthous ulcer, Vincent angina, pyogenicgranuloma

Management:

• Tranexamic acid mouth wash- TDS

Per Rectal Bleeding (Hematochezia):

Non-hematological causes:

• Hemorrhoids, fissure in ano, colorectal carcinoma, Proctitis, rectal prolapsed, diverticulosis, ischemic colitis, ulcerative colitis, amebic/bacillary dysentery, rectal trauma, vascular ectasia, NSAID induced colitis

Management:

• For fissure- Sitz bath (10min) TID followed by application of Anobliss ointment
• Laxatives if constipated- Cremaffin/Polyethylene glycol
• Colonoscopy if malignancy is suspected

Epitaxis:

Non-hematological causes:

• Systemic hypertension, high grade fever, chronic cough, hemangiomas, trauma, foreign body, nasal tumors, granulomatous disorders

Management:

• Propped up position with leaning forward
• Pinch the nostril for 5 min
• Ice packs
• Botroclot nasal drops/ Xylometazoline nasal drops
• ENT reference for nasal packing

Heavy Menstrual Bleeding (Earlier called menorrhagia):

It is heavy bleeding requiring change of pad more frequently than every 2 hrs or passing of large clots or prolonged bleeding (more than 7 days)

Non-hematological causes:

• Local: Fibroids, adenomyosis, IUCD, chronic tubo-ovarian mass, tubercular endometritis,   retroverted uterus, granulose cell tumor of ovary, endometrial hyperplasia/polyp/malignancy.
• Systemic: CCF, hypertension, hypothyroidism
• Dysfunctional uterine bleeding

Management:

• T. Primolute N- 5mg- 2-2-2 or combined oral contraceptive pills (Increases the level of fibrinogen and factor VII)
• Levonorgestrel intra uterine system/ Mirena

Hematuria:

Non-hematological causes:

• Glomerular: Glomerulonephritis, SLE, renal infarction, HS purpura, benign familial hematuria
• Other kidney disorders: Polycystic kidney disease, renal tumors, renal tuberculosis, vascular abnormalities, hydronephrosis, calculi, Pyelonephritis, papillary necrosis
• Urinary bladder: Cystitis, transitional cell carcinoma, cyclophosphamide induced hemorrhagic cystitis

Other causes of red colored urine:

• Hemoglobinuria (Intravascular hemolysis), Myoglobinuria, porphyrinuria, anthracyclines

Management:

• Refer to “Hemorrhagic cystitis” section of  “Nephro- urological problems of hematological practice” chapter.

Purpura/ Ecchymosis:

Non-hematological causes:

• Disorders of collagenous supporting tissue: Purpura simplex (easy bruising/Devil’s pinches), senile purpura, steroid induced, EhlerDanlos syndrome, Marfan syndrome, Scurvy
• Telangiectasias: Hereditary hemorrhagic telangiectasia (Osler RenduWaber disease), Campbell de Morgan spots, Fabry disease, KasabachMeritt syndrome
• Vasculitis: Necrotizing cutaneous vasculitis, Polyarteritis nodosa, Henoch Schönlein purpura
• Infections: Meningococcemia, severe measles, rickettsial fever
• Drugs (Immune complex deposition)- Arsenic, INH, quinine, sulphonamides
• Other: Fat embolism, dysglobulinemia, cryoglobulinemia, amyloidosis, self abuse/ abuse   by others, itching purpura