Mucous Membrane Bleeding
Giving factor
Mucous membrane bleeding may require medical care in the emergency department. Patients should receive factor who:
- are experiencing profuse and/or prolonged bleeding
- have sustained a known injury to the mouth, tongue, or nose
- have severe swelling in the mouth or throat area
- are experiencing respiratory distress
- have difficulty swallowing
The patient may not know the reason for the symptom or bleeding. It may have been caused by trauma, infection, or the bleed may be spontaneous. If airway blockage is suspected, the patient should immediately receive a major dose of factor. After the factor level has been raised, further interventions including invasive procedures may be done.
Do not make a person with hemophilia wait for factor replacement. The longer he waits, the more bleeding takes place. If the bleed is in a closed space, the accumulation of blood will cause surrounding tissue damage, airway obstruction, and enhance pain.
Epistaxis
A person with epistaxis who is unable to control the bleed himself may need a routine dose of factor and anti-fibrinolytic treatment (Amicar). Be sure the person knows how to control and stop the bleeding.
Oral Cavity
Bleeding in the mouth can be hard to control. The patient will probably need factor. A single infusion of a routine dose of factor may temporarily stop the bleeding, but clots break down normally on days 3-5 and bleeding may start again at that time. An anti-fibrinolytic may be indicated to maintain hemostasis. Anti-fibrinolytics may be available through the patient's home health company for next day delivery. A modified diet should be started at the same time as factor therapy.
Bleeding may occur with erupting or exfoliating teeth. It is more common with exfoliating teeth, especially a tooth that is very loose. A dental consult may be needed to extract the tooth since it will continue to lacerate the tooth socket as long as it is in place. A routine dose of factor should be given prior to extraction. A frenulum or tongue laceration will require a routine dose of factor.
Retropharyngeal
After the major dose of factor is given, further observation, x-rays and admission may be required.
Discharge Instructions
Patients should follow-up with their treatment center or hematologist the next day. Instruct the patient on the following as needed.
- Controlling epistaxis
- Anti-fibrinolytics
- Diet modifications
Refer to the following for additional information.
Controlling Epistaxis
Instruct the patient:
1. To gently blow his nose to remove mucous and unstable clots which will interfere with hemostasis.
2. Tilt his head forward so any blood will come out the nares and not down the back of the throat.
3. Apply firm pressure to the entire side of the nose that is bleeding for 15 minutes.
4. Release the pressure to see if bleeding has stopped, blow out any soft clots.
5. If the bleeding continues, reapply pressure for another five minutes.
6. Factor replacement at a routine dose and/or anti-fibrinolytic agents (see next page) may be needed.
7. During active bleeding, or when the bleeding has stopped, spray or apply two drops of oxymetazoline (ex. NeoSynephrine, Dristan, or Afrin) nasal spray/drops to the side that was bleeding. These can be used at home PRN for epistaxis.
8. Instruct the patient to use Vaseline in the nares to keep the membranes soft and moist, and prevent the formation of hard crusts which might crack and restart bleeding.
9. An ENT consult may be required for possible cauterization of a vessel.
Anti-Fibrinolytics
Anti-fibrinolytics may also be indicated in nasal or oral bleeding. Amicar and Cyklokapron are both anti-fibrinolytic agents. Either may be prescribed for mucous membrane bleeding to promote clot adhesion in conjunction with factor replacement at a routine dose. In some cases they may be prescribed without factor replacement.
Amicar - aminocaproic acid - Recommended dosage:
child: oral dose 50-100 mg/kg (not to exceed 4 Gms) every 6 hours for 3 - 10 days
adult: oral dose 3-4 Gms every 6 hours for 3 -10 days
Cyklokapron - tranexamic acid (may not be available in the USA)
- Recommended dosage:
child and adult: oral dose 25 mg/kg every 8 hours for 3 - 8 days
These medications must be given around the clock to keep blood levels constant.
These medications may be available through the family's home health company, the hemophilia treatment center, or the family may have a supply at home. They are difficult to obtain from most pharmacies.
Follow-up through the hemophilia treatment center or patient's hematologist.
Topical agents such as Topical Thrombin and Gelfoam may also be used to help control mucous membrane bleeding.
Antibiotics and pain medications may also be indicated.
Diet Modifications
Instruct the patient:
1. Diet should be restricted to soft, cool, or lukewarm foods until the area is fully healed. Suggested foods: Jello, noncarbonated drinks, sherbert, lukewarm soups (not cream soups), baby foods, blenderized or pureed foods, spaghetti.
2. Avoid milk products and foods made with milk. Milk products may contribute to clot breakdown and may also cause nausea and vomiting if the patient has swallowed blood.
3. Avoid using a straw. Negative pressure from the sucking action can dislodge the clot and aggravate the bleeding site.
4. Avoid hard foods like chips, popcorn, tacos, etc.