Massive bleeding status post routine dental extraction

[migm]

Anyone ever seen this before? DAPT lady who came in with a BP of 50, looking like a vampire who bit into the jugular of an elephant, covered in blood. Took a few moments to realize this was not a upper GI bleed but coming from an extracted molar socket. Dropped her hgb almost 5 points from prior. I had never seen or heard of this before but definitely quickened the heart rate. Considered an AVM but per consultant this was just bleeding from a nutrient vessel that was quite impressive and exacerbated by the thinners.

TIL. Thought you all might want to hear about it.

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[mauricekenter]

Seen it once in a 20ish year old after molar extraction. Also hypotensive needing blood. I just stuck my finger on the vessel and held pressure for 10 mins and called OMFS. It was pretty impressive how much he bled.

 

[BoardingDoc]

Gauze soaked in TXA with constant direct pressure.

 

[gutonc]

Gauze soaked in TXA with constant direct pressure.

This is what we (heme) recommend for all profound dental bleeders on anticoag or for hemophiliacs.

 

[WilcoWorld]

Gauze soaked in TXA with constant direct pressure.

And NO PEEKING!

 

[GonnaBeADoc2222]

I love TXA so ***damn much. Another cool application is nebulizing it for post-tonsillectomy bleeds.

 

[migm]

Txa gauze and pressure were my go to moves. The clumsy consultant wanted surgicel

 

[tkim]

was 1/2 using TXA. One pt had 22 teeth removed in one go, TXA-soaked gauze and swish-n-spit worked for him. The other pt did same thing for wisdom teeth removal, but never stopped bleeding, had to xfer to OMFS 2.5 hours away.

 

[Rendar5]

Lido with Epi injection and pack the socket with chopped up surgicel has worked for me with direct pressure on the packing for a couple minutes has worked when a teabag has failed. Don’t have to txa gauze afaik at my shop.

 

[BoardingDoc]

Don’t have to txa gauze afaik at my shop.

Do you not have TXA at all (or aminocaproic acid)? And gauze?

 

[Rendar5]

Do you not have TXA at all (or aminocaproic acid)? And gauze?

Have both. Never learned how to impregnate gauze with a pill. I’m sure you can educate but doesn’t seem intuitive.

 

[southerndoc]

Have both. Never learned how to impregnate gauze with a pill. I’m sure you can educate but doesn’t seem intuitive.

You use the IV formulation.

 

[Angry Birds]

Can you use TXA impregnated gauze for any site of bleeding or just mucosal?

I need to read up on TXA more.

 

[southerndoc]

Can you use TXA impregnated gauze for any site of bleeding or just mucosal?

I need to read up on TXA more.

It's cheaper to use something like QuikClot on non-mucosal surfaces.

 

[Psai]

Have both. Never learned how to impregnate gauze with a pill. I’m sure you can educate but doesn’t seem intuitive.

Cut the pill open, put the powder in some water. Or crush it with mortar and pestle

 

[BoardingDoc]

It's cheaper to use something like QuikClot on non-mucosal surfaces.

I don't use TXA on non-mucosal surfaces, but are you sure it's cheaper to use quickclot? IDK how much quickclot costs, but I know that TXA is dirt freaking cheap.

 

[southerndoc]

I don't use TXA on non-mucosal surfaces, but are you sure it's cheaper to use quickclot? IDK how much quickclot costs, but I know that TXA is dirt freaking cheap.

I think TXA is around $50/vial whereas QuickClot is around $15 (this is what my EMS agencies pay at least).

Besides, kaolin works better than TXA.

 

[BoardingDoc]

I think TXA is around $50/vial whereas QuickClot is around $15 (this is what my EMS agencies pay at least).

Besides, kaolin works better than TXA.

Interesting. I think my hospital pays something like 10-20/vial. Whatever, they're both cheap and I agree, I don't use TXA on non-mucosal surfaces anyway because there are better options.

 

[Janders]

Have both. Never learned how to impregnate gauze with a pill. I’m sure you can educate but doesn’t seem intuitive.

Try this Trick of the Trade: Topical Tranexamic Acid Paste for Hemostasis

Also, I strongly suspect your hospital has the IV formulation somewhere-- gets used in the OR by ortho all-the-time. Thats how I finally got it in the ED when our hospital didn't have it... teamed up with the joint-replacement ortho people who were screaming to get it on formulary and between their cash-cows and my cool CRASH-2 trial, boom we got TXA. And now we use it for everything. And some of the local EMS rigs use it too!

http://www.jems.com/articles/print/...rug-that-s-too-cheap-to-bother-using.html?c=1

Anyway I think every ED (and hell, every EMS service) should have IV TXA available for the walk-in massive traumas to get, even if your plan is immediate transfer to higher level of care. And once you have IV TXA lying around, you can use it for all sorts of things. The WOMAN trial also makes it basically 100% necessary for maternal hemorrhage post-delivery. Its on the WHO list of mandatory drugs for all hospitals.

So if you DON'T have IV TXA, it should be a very easy sell to your P&T committee and pharmacy and admin. CRASH-2, WOMAN, WHO recommendations, ACS trauma recommendations, ACOG recommendations. Done.

 

[medic25]

I think TXA is around $50/vial whereas QuickClot is around $15 (this is what my EMS agencies pay at least).

Besides, kaolin works better than TXA.

Used QuikClot for a big dental bleed once and it worked beautifully. Poor guy had a couple of wisdom teeth extracted, then later in the day had an ischemic stroke. OSH gave him tPA and flew him to us; he was oozing continuously through the packing they'd placed. Swapped it out for some QuikClot and was able to get things under control.