Some of our patients are total daredevils. This unique population keeps us on our toes. Our weird and wild series recently discussed laceration repair involving tattoos, but problematic piercings also present to the ED.
Traditional through-and-through piercing of the tongue body without complication. Photo: Creative Commons.
An 18-year-old otherwise healthy woman presented to the emergency department with tongue swelling and mouth pain. Your first thought may be that this is an allergic reaction, but you quickly realize this is not the patient you expected. This patient just had her tongue pierced, and something has gone wrong.
Traditional tongue piercing involving the body of the tongue and accidental piercing of the frenulum linguae (left). Ventral tongue anatomy, right. Piercing involving the frenulum or areas of the ventral tongue surface and tongue floor can be complicated and dangerous. Photos: Creative Commons.
The patient was tripoding on the stretcher, while her friend soothingly patted her back. The patient's vitals were blood pressure of 140/90 mm Hg, heart rate of 120 bpm, respiratory rate of 30 bpm, temperature of 99.2°F, and oxygen saturation of 98% on room air. She was drooling, and there was scant blood in her sputum. She appeared anxious and teary, and could barely speak.
Her physical exam revealed an enlarged tongue with moderate bleeding around the piercing, some bruising to the site, a poorly visualized posterior pharynx, rhinorrhea, and tearing. The piercing had also gone through the frenulum on the ventral surface, which was causing her significant pain and limited range of motion of the tongue. The lips and buccal area were unaffected, and the rest of the ENT exam was otherwise normal. Her lungs were clear, and her heart rate was regular but tachycardic at 120 bpm. Her skin was warm and dry without any rashes, and the rest of her exam was otherwise unremarkable.
The patient mumbled her story as best as she can, revealing she had had her tongue pierced at a local shop the night before and went to bed feeling fine. Her friend said she woke up this morning with severe tongue swelling, difficulty breathing, and pain, so they came right to the emergency department. The patient had no known drug allergies or medical issues, did not take any medications, and this was her first piercing.
She stated that she had just started college in the area, and the place she went to was well-known. Her tongue was so swollen that you couldn't get a good look at the area where the small ball connects to the bar that keeps it stable.
-Tongue piercing removal
-Bleeding control with potential use of TXA
-Monitoring and protection of airway
Consider immediate intubation if the patient shows signs of respiratory depression, altered level of consciousness, oxygen saturation of <92%, or vomiting or bleeding to the point of choking. The best approach would be to use fiberoptic nasal intubation.
This patient is a subject of blind nasal tracheal intubation because of the difficulty with obtaining an oral intubation. This technique is often used in patients with swelling of the upper airway to bypass the tongue and lips. Photo: James R. Roberts, MD.
-Have the patient sit comfortably. Apply nasal cannula to encourage her to breathe through her nose. It will also assist with comfort.
-Use suction to relieve drooling. Allow the patient to hold the suction wand; this will also assist with comfort and effectiveness.
-Have the patient open her mouth as wide as possible, and inject 1-2 mL of 1% lidocaine with epinephrine into the tongue directly around the site of the piercing. Do this on the ventral surface of the tongue so the swelling remains closer to the floor of the mouth.
-Hold pressure on the tongue for two to four minutes. This may help stop the bleeding.
-If the bleeding stops enough for good visualization of the ball attached to the bar of the tongue ring, grab it with small ring forceps.
-Once you have stabilized the ball portion, you can push the tongue down and hold the visible portion of the bar with needle nose forceps. Call your OR if you do not have this equipment readily available in your department. Also, consider your ENT, dental box (or build your own), or a laceration repair kit if in a hurry.
-Have an assistant hold suction to decrease secretion while you twist off the ball from the bar of the tongue ring. If it gets stuck, dry it off with gauze. You can also use the gauze to assist with traction holding the ball during removal.
-Hold pressure on the tongue for five minutes after removing the ball and bar. The patient may also assist with this pressure.
-If bleeding does not improve or you have difficulty removing or visualizing the ball on the tongue, consider applying a tranexamic acid (TXA) paste to the area to assist with oral bleeding control. (Ann Pharmacother 2006;40:2205.)
-Make a paste or solution by combining two to three 650 mg tablets of TXA and 2-3 mLs of sterile water and apply directly on the site. You can also coat gauze with the paste and hold it on the tongue. Note: You are aiming for a paste or mixture that has 1,000-2,000 mg of the medication per dose to the oral area. Usually available options include 650 mg or 500 mg tablets or IV solution of 100 mg/mL of TXA.
-Give one IM dose of Decadron 10 mg to assist with the swelling to patients who weigh more than 50 kg. You may also consider IV steroids if the patient already has IV access or will be admitted. Note: Little evidence has been documented that IM Decadron has benefit in tongue swelling cases related to piercings, but we still feel this clinical decision based on our experience and follow-up is reasonable.
-IV antibiotics have not been shown to help in these immediate cases, but may be required if the tongue laceration does not improve within 24-48 hours.
-Cold, iced liquids advancing to purees for the next two days should be encouraged.
-Tetanus should be updated.
-Consider NS IV hydration 500-1,000 mL (depending on body weight) prior to discharge in anticipation of decreased oral intake.
-Know your equipment and have it easily accessible.
-Consult ENT if the bleeding continues, and consider ordering a coagulation panel to reveal underlying clotting disorder.
-Admit patients who need to be observed without hesitation.
-Nasally intubate patients who cannot maintain their airway.
-Do not let a patient be discharged if she cannot swallow liquids!
-Consider observation in the ED post-Decadron administration.
-The TXA paste may be made by the pharmacist or by you in the ED. Note: The paste made from crushed pills is much less expensive than the IV form of the drug.
Evidence-based Practice Pearl: Topical TXA
What is TXA? Tranexamic acid is a "clot promoter" that can help prevent excessive blood loss. It can be used orally (650 mg tablet), IV (100 mg/mL), or in a topical paste solution. This medication has been making more of an appearance lately in cases related to trauma, vaginal bleeding, and epistaxis.
TXA minimizes blood loss by "inhibiting lysine-binding sites on plasminogen, preventing its binding to lysine residues on fibrin." (J Trauma 2011;71[1 Suppl]:S9.) This "inhibits both plasminogen activity and plasmin activity, thus preventing clot break-down rather than promoting new clot formation." TXA also was shown to reduce bleeding and the need for blood transfusions in surgical patients. (Cochrane Database Syst Rev 2013;:CD010562.) It was noted that the "risk of thromboembolic events was less certain."
Photo: Creative Commons.
Dentists may use a 5% mouth rinse of TXA after tooth extractions or oral surgery to assist with bleeding complications. The pills can be crushed and applied topically or used in a rinse. (Ann Pharmacother 2006;40:2205.) It can also be placed on gauze and applied directly on the area of bleeding. Topical treatment with oral or other solutions of TXA in nosebleeds also yields good results. (Am J Emerg Med 2013;31:1389.) The medication is relatively safe with few complications and rare side effects.
TXA also has been shown to have good results when used in elective procedures such as rhinoplasty. A Journal of Craniofacial Surgery study that looked at using TXA before and during rhinoplasty concluded that the preoperative administration of 1g oral TXA significantly decreased the blood loss in patients undergoing rhinoplastic surgery without any significant adverse effects. (2016;27:97.) Overall, TXA may be a useful adjunct for patients suffering from tongue bleeding or other ENT bleeding complications.