What is the management for a patient with thrombocytopenia (low platelet count) presenting with a hematoma over the buccal mucosa?

Management of Haematoma over Buccal Mucosa due to Thrombocytopenia

For a patient with thrombocytopenia presenting with a hematoma over the buccal mucosa, immediate platelet transfusion should be considered if the platelet count is below 20×10⁹/L, along with local hemostatic measures and treatment of the underlying cause of thrombocytopenia. 1

Assessment and Initial Management

1. Determine severity of thrombocytopenia:

   • Check platelet count immediately
   • Classify severity:
     • Mild: 50-150×10⁹/L
     • Moderate: 20-50×10⁹/L
     • Severe: <20×10⁹/L
     • Very severe: <10×10⁹/L 1

2. Local management of buccal hematoma:

   • Apply gentle pressure with gauze soaked in tranexamic acid if available
   • Cold compresses to reduce bleeding and swelling
   • Avoid trauma to the area and irritating foods/drinks
   • Consider topical hemostatic agents

3. Systemic management based on platelet count:

   Platelet Count	Management Approach
   <10×10⁹/L	Immediate platelet transfusion regardless of symptoms 1, 2
   10-20×10⁹/L	Platelet transfusion if active bleeding or additional risk factors 1
   20-50×10⁹/L	Consider platelet transfusion if persistent bleeding; initiate specific treatment for underlying cause 1
   >50×10⁹/L	Usually no platelet transfusion needed; treat underlying cause 1

Treatment Based on Underlying Cause

For Immune Thrombocytopenia (ITP)

1. First-line therapy:

   • Corticosteroids: Prednisone 0.5-2 mg/kg/day until platelet count increases to 30-50×10⁹/L 1
   • Consider IVIG for severe bleeding or very low platelet counts requiring rapid increase

2. Second-line therapy (for insufficient response):

   • Thrombopoietic agents:
     • Romiplostim (Nplate): Initial dose 1 mcg/kg subcutaneously weekly, adjust by 1 mcg/kg increments to maintain platelet count ≥50×10⁹/L; maximum 10 mcg/kg 3
     • Eltrombopag (ALVAIZ): Initial dose 36 mg orally once daily (18 mg for East-/Southeast-Asian patients or those with hepatic impairment) 4

3. Monitoring:

   • Weekly platelet counts during dose adjustment phase
   • Monthly counts after establishing stable dose
   • Weekly counts for at least 2 weeks after discontinuing treatment 3

For Drug-Induced Thrombocytopenia

1. Immediate discontinuation of suspected causative medication 5, 6
2. Platelet recovery typically occurs within days to weeks after drug cessation
3. Document the suspected drug reaction to prevent re-exposure

For Heparin-Induced Thrombocytopenia (HIT)

1. Immediately discontinue all heparin products 1, 5
2. Initiate non-heparin anticoagulant (argatroban, bivalirudin, fondaparinux, or DOAC) 1
3. Avoid platelet transfusions unless life-threatening bleeding 5

Special Considerations for Oral Hematomas

1. Oral care recommendations:

   • Soft toothbrush or foam swabs for oral hygiene
   • Avoid alcohol-containing mouthwashes
   • Maintain good oral hygiene to prevent infection
   • Soft diet to avoid trauma to the hematoma

2. When to consult specialists:

   • Hematology consultation for persistent thrombocytopenia
   • Dental/oral surgery consultation if hematoma is large, causing airway concerns, or not resolving

3. Activity restrictions:

   • Patients with platelet counts <50×10⁹/L should avoid activities with high risk of trauma 1, 2
   • Avoid alcohol (≤1 drink/week) and binge drinking completely 1
   • Avoid medications that affect platelet function (aspirin, NSAIDs) 1

Monitoring and Follow-up

1. Platelet count monitoring:

   • Daily if <10×10⁹/L with active bleeding
   • Every 2-3 days if 10-20×10⁹/L
   • Weekly during treatment adjustment
   • Monthly after stabilization 1

2. Warning signs requiring immediate attention:

   • New or worsening oral bleeding
   • Difficulty swallowing or breathing
   • Expanding hematoma size
   • Development of additional bleeding sites

Buccal mucosal hematomas can be an early sign of significant thrombocytopenia and should not be ignored, as they may precede more serious bleeding complications 6, 7. The oral cavity is a frequent site of hemorrhage in thrombocytopenia and may sometimes be the only manifestation of the disease 6.