What should you do if someone has copious bleeding and tooth involvement following trauma?

From the Guidelines

If someone has copious bleeding and tooth involvement following trauma, immediately apply direct pressure to the bleeding area using clean gauze or cloth and seek urgent dental or emergency care. The management of such cases involves several key steps to ensure the best possible outcome in terms of morbidity, mortality, and quality of life.

• First, control the bleeding by applying direct pressure with gauze or a clean cloth, as recommended by the American Heart Association and American Red Cross guidelines for first aid 1.
• If a tooth has been knocked out (avulsed), handle it by the crown, not the root, to avoid further damage, and attempt to reinsert it into the socket if possible. If reinsertion is not feasible, store the tooth in milk, saline solution, or the patient's saliva to keep it moist until professional dental care can be obtained.
• For severe bleeding that does not stop with pressure, continue applying pressure while heading to the emergency room. It's also crucial to manage pain appropriately; acetaminophen (Tylenol) can be used at standard dosing (500-1000mg every 6 hours, not exceeding 4000mg daily), but aspirin or ibuprofen should be avoided as they may exacerbate bleeding.
• The use of antifibrinolytic agents like tranexamic acid (TXA) has been recommended in the management of major bleeding and coagulopathy following trauma, administered as soon as possible at a loading dose of 1g infused over 10 minutes, followed by an intravenous infusion of 1g over 8 hours 1.
• Quick action is crucial because the success of reimplanting knocked-out teeth decreases significantly after 30 minutes, and controlling bleeding is essential to prevent further complications such as infection or excessive blood loss.
• After the immediate emergency is addressed, follow-up dental care is necessary to assess and manage any damage to teeth, gums, and jaw, ensuring the best possible recovery and minimizing long-term morbidity.

From the FDA Drug Label

Tranexamic acid injection is indicated in patients with hemophilia for short-term use (2 to 8 days) to reduce or prevent hemorrhage and reduce the need for replacement therapy during and following tooth extraction. The answer to the question is not directly supported by the information provided in the drug label, as it specifically mentions patients with hemophilia and tooth extraction, not general trauma cases. Key points:

• The label does not directly address the question of what to do in cases of copious bleeding and tooth involvement following general trauma.
• The indication is specific to patients with hemophilia and tooth extraction. Therefore, The FDA drug label does not answer the question.

From the Research

Immediate Response to Dental Trauma with Copious Bleeding

If someone has copious bleeding and tooth involvement following trauma, the first step is to ensure the patient's airway is secure and they are breathing properly.

• Apply pressure to the wound using gauze or a clean cloth to control bleeding, as seen in studies 2, 3.
• If available, topical tranexamic acid (TXA) can be applied to the gauze to aid in hemostasis, as it has been shown to be effective in stopping mild bleeding events 2, 3.
• The quality of the bleeding should be assessed, as this will influence the choice of hemostatic measure, with sutures and native collagen fleeces being favored for moderate and severe bleeding 2.

Stabilization and Transport

• If the bleeding is severe or cannot be controlled, the patient should be transported to a hospital or a specialized dental trauma facility as soon as possible.
• During transport, continue to apply pressure to the wound and monitor the patient's vital signs.
• The use of tranexamic acid has been shown to lead to clot stabilization and a reduction of fibrinolytic activity, causing a decrease in fibrin degradation products buildup (D-dimer) 4.

Initial Management of Dental Trauma

• Initial management of dental trauma on the day of injury has a determining influence on healing and thus on the prognosis of the affected teeth 5.
• A three-tiered approach can be used to illustrate which initial management measures are absolutely essential (MUSTS), which should ideally be performed (SHOULDS), and which are not top priorities but can be performed (CANS) if the necessary time, training and experience, and equipment and facilities are available 5.

Topical Tranexamic Acid Formulation

• Topical tranexamic acid inhibits fibrinolysis more effectively when formulated with self-propelling particles, which can increase the efficacy of TXA and enable both local and systemic delivery 6.
• This formulation may have several advantages, including supporting local clot stabilization, reducing blood loss from wounds, and providing systemic delivery of TXA, and could improve and simplify prehospital trauma care for penetrating injury 6.