ACEP ID:

Pediatric Emergency Medicine

Pearls & Pitfalls- An Adolescent With a Tongue Hematoma

Jennifer McCain, DO, PGY 2
Emergency Medicine Resident
Georgia Regents University
Augusta, Georgia

Larry B. Mellick, MD, FAAP, FACEP
Professor of Emergency Medicine and Pediatrics
Department of Emergency Medicine
Georgia Regents University
Augusta, GA

Pearl: Patients with hemophilia can experience many episodes of oral bleeding over their lifetime. Minor oral bleeds can be managed with local care, while major bleeding requires factor replacement.

Case: A 15-year-old boy with hemophilia A presented to the emergency department with 4 days of pain and bleeding after accidently biting his tongue. The patient had no other complaints, and the past medical history and review of systems were otherwise non-contributory. The physical examination on presentation revealed normal vital signs and a large icicle-shaped hematoma extending from the tongue with minimal ongoing bleeding. 

Discussion: Hemophilia A (factor VIII deficiency) is the second most common coagulation factor deficiency after von Willebrand disease. Hemophilia is an X-linked, recessive condition. The prevalence of hemophilia A in the United States is 20 per 10,000 males.1  

People with hemophilia can experience many episodes of oral bleeding over their lifetime. Oral bleeding is usually the result of trauma, although events can be induced by poor oral hygiene or iatrogenic factors.2 The frequency of oral hemorrhage in different areas of the mouth is as follows: gingiva, 54%; dental pulp, 11%; tongue, 6%; lip, 6%; palate, 1.6%; and buccal mucosa, 1%.3

Minor oral bleeds can be managed by local care, while major bleeding requires factor replacement. Desired FVIII levels in cases of significant oral bleeding range from 5-30%.4 Oral bleeding can be difficult to control secondary to the increased fibrinolytic activity of saliva. Often antifibrinolytics are used in addition to FVIII replacement. The most common antifibrinolytic used for oral mucosal bleeding is epsilon aminocaproic acid (EACA) or Amicar®. Tranexamic acid is another potent antifibrinolytic agent that promotes clot stability with minimal side effects. In mild cases, antifibrinolytics may be used alone. Topical agents, such as fibrin sealant, bovine thrombin, and human recombinant thrombin, can also be used.5

Treatment: This patient received a liter of normal saline and was treated with 3000 U of Kogenate® FS Antihemophilic Factor (recombinant factor VIII). The clot denuded spontaneously on the morning of discharge two days later.

References:  

  1. Franchini M, Mannucci PM. Past, present and future of hemophilia: A narrative review. Orphanet J Rare Dis. 2012;7:24.
  2. Sonis AL, Musselman RJ. Oral bleeding in classic hemophilia. Oral Surg Oral Med Oral Pathol. 1982;53(4):363-366.
  3. Kaneda T, Shikimori M, Watanabe I, et al. The importance of local hemostatic procedures in dental extractions and oral mucosal bleeding of hemophiliac patients. Int J Oral Surg. 1981;10(4):266-271.
  4. Corrigan JJ, Jr. Oral bleeding in hemophilia: Treatment with epsilon aminocaproic acid and replacement therapy. J Pediatr. 1972;80(1):124-128.
  5. Chapman WC, Singla N, Genyk Y, et al. A phase 3, randomized, double-blind comparative study of the efficacy and safety of topical recombinant human thrombin and bovine thrombin in surgical hemostasis. J Am Coll Surg. 2007;205(2):256-265.

Online Resources:  

  1. http://www.hemophilia.org/NHFWeb/MainPgs/MainNHF.aspx?menuid=180&contentid=45
  2. http://www.hemophilia.ca/files/MildHemophilia.pdf
  3. http://emedicine.medscape.com/article/779322-treatment

 

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