Serious Bleeding and DIC During Cancer Care

MedlinePlus draws one clear line for this. Go to the emergency room, or call 911 or your local emergency number, if you have bleeding that does not stop.

That is the trigger. Not the volume, not the site. Whether it stops.

So the practical test is the one in the next section: press, and see.

No clinician has reviewed this page yet. If your team gave you different instructions, use theirs.

There is a myth worth clearing up. You do not need to have been taught a special technique for a specific site before you are allowed to help.

NCI's instruction is ordinary first aid. If you start to bleed, press down firmly on the area with a clean cloth. Keep pressing until the bleeding stops. If you bruise instead, put ice on the area.

Two things people get wrong. They press too gently, and they keep lifting the cloth to look. Firm and continuous is what works.

If it is still bleeding after a few minutes of that, you are now in the situation MedlinePlus described above.

Some things shift that judgement earlier rather than later. Bleeding from the head, the neck, the chest or a wound you cannot see the bottom of. A lot of blood, or blood coming quickly. Any bleeding after a knock to the head. Feeling faint, cold, breathless or grey with it. And if you take a blood thinner, or your platelets are low, treat all of it as more serious sooner. Never stop or change an anticoagulant on your own to slow a bleed; ring the team, or take the written emergency plan you were given with you.

Not everything on this page is an ambulance. NCI puts a specific list at the level of calling your doctor or nurse, and it is worth respecting the difference rather than sending everyone to the emergency department.

NCI says call for more serious problems such as:

• Bleeding that does not stop after a few minutes.
• Bleeding from your mouth or nose, or when you vomit.
• Vaginal bleeding when you are not having a period.
• Urine that is red or pink.
• Stools that are black or bloody.
• A period that is heavier or lasts longer than normal.
• Head or vision changes: bad headaches, changes in how well you see, or feeling confused or very sleepy.

That last line is the one people skim. A bad headache in someone with low platelets is a phone call, made straight away, not something to sleep on.

There is one question NCI itself suggests asking your team, and it is the right one: how long should I wait for the bleeding to stop before I call you or go to the emergency room? Get a number, in minutes, and write it down.

NCI explains the mechanism. Some cancer treatments, including chemotherapy and targeted therapy, lower the number of platelets, the cells that help blood clot and stop bleeding.

When the platelet count is low, you may bruise or bleed a lot or very easily, and get tiny purple or red spots on the skin. NCI calls that condition thrombocytopenia.

This is why a bleed that would be trivial in a well person is treated seriously here. Nothing about the injury has changed. The blood's ability to close it has.

Disseminated intravascular coagulation is a different problem from low platelets, and a stranger one.

MedlinePlus describes it as a serious disorder in which the proteins that control blood clotting become overactive. Two things then happen at once.

Small clots form in the blood vessels. Some block the vessels and cut off the normal blood supply to organs such as the liver, brain or kidneys, which can cause major injury.

And the clotting proteins get used up. Once they are consumed, the risk of serious bleeding is high, even from a minor injury, or with no injury at all.

MedlinePlus lists the symptoms: bleeding from many sites in the body, blood clots, bruising, a drop in blood pressure, shortness of breath, confusion or memory loss or a change in behaviour, and fever.

Its risk factors include cancer, especially certain types of leukemia, and infection in the blood, particularly by bacteria or fungus. Recent surgery or anesthesia, severe tissue injury, liver disease and blood transfusion reactions are also on the list.

MedlinePlus says DIC can be life threatening, and names stroke among its possible complications.

DIC is not diagnosed by how something looks. MedlinePlus lists five blood tests:

• Complete blood count with a blood smear exam.
• Partial thromboplastin time (PTT).
• Prothrombin time (PT).
• Fibrinogen.
• D-dimer.

That is why this diagnosis usually gets made in a hospital, on a lab result, rather than at a kitchen table. If someone mentions DIC to you, asking to see those numbers and what they are doing over time is a reasonable request.

Treatment follows the same logic. MedlinePlus says there is no specific treatment for DIC and the goal is to find and treat the underlying cause. Supportive treatment may include transfusions to replace what is being used up, and in some situations a blood thinner where clotting is the dominant problem. Those are decisions made hour by hour in hospital, on the basis of blood tests, and they are here only to explain why the same illness can be treated in what look like opposite directions.

The instructions below are the ones MedlinePlus gives for warfarin specifically. Other blood thinners have their own rules, so ask which apply to yours.

Do not change the dose on your own. MedlinePlus says to take warfarin exactly as you have been told, take only the dose your provider prescribed, and contact your provider for advice if a dose is missed.

It also adds a red flag that is easy to miss: contact your provider after a serious fall, or if you hit your head. On an anticoagulant, a bump that looks like nothing can matter.

MedlinePlus says to ask your provider about wearing a medical alert bracelet or necklace saying you take warfarin, so that anyone treating you in an emergency knows.

NCI's prevention advice is unglamorous and effective:

• Brush your teeth gently, with a very soft toothbrush.
• Wear shoes, even indoors.
• Use an electric shaver rather than a razor.
• Take extra care with sharp objects.
• Use lotion and lip balm to prevent dry, chapped skin and lips.
• Tell your doctor or nurse about constipation or bleeding from the rectum.

On medicines, NCI notes that many over-the-counter products contain aspirin or ibuprofen, which raise the risk of bleeding, so check the label when in doubt. Ask your health care team for a written list of medicines and products to stay away from. NCI also says people may be advised to limit alcohol when the platelet count is low.

Creating a Cancer Symptom and Call Plan, What to Have Ready for an Urgent Oncology Call, and Preparing for an Emergency Department Visit With Cancer.

• National Cancer Institute — Bleeding and Bruising (Thrombocytopenia) and Cancer Treatment
• MedlinePlus — Disseminated intravascular coagulation (DIC)
• MedlinePlus — Taking warfarin