CASE REPORT tPA, lingual hemorrhage

Tissue Plasminogen Activator.Associated Lingual Artery Hemorrhage

Reported is the case of a patient with vertebrobasilar artery ischemia who received tissue plasminogen activator with resulting hemorrhage into the tongue and nearly exsanguinating hemorrhage from a branch of the lin- gual artery. Suggestions for immediate management of the hemorrhage as well as prevention are presented. As the use of thrombolytic agents in- creases and the list of their indications expands, unusual life-threatening hemorrhagic problems other than gastrointestinal or intracranial bleeding will be seen, and management decisions may be life saving. [Wrenn K: Tissue plasminogen activator-associated lingual artery hemorrhage. Ann Emerg Med October 1990;19:1184-1186.]

INTRODUCTION Tissue plasminogen activator (tPA) and other thrombolytic agents such

as streptokinase are commonly used in the setting of acute myocardial infarction. 1 Other uses include massive pulmonary embolism,2 deep venous thrombosis, 3 and ischemic cerebrovascular insults. 4 As these agents are used more often and as invasive procedures are applied in the critical care setting, hemorrhagic complications will occur. The most com- mon serious complications of use of tPA involve intracranial or gastroin- testinal bleeding or hemorrhage into a noncompressible site such as that of prior surgery, trauma, or placement of a central venous access line. s

CASE REPORT A 55-year-old man presented to the ED after several hours of vertiginous

dizziness and right hemiparesis associated with bilateral facial weakness, difficulty in swallowing, absent gag reflex, left lateral nystagmus, and dys- arthric speech. Computed tomography brain scan revealed no abnormality other than calcification of the circle of Willis. Medical history included a three-vessel coronary artery bypass grafting procedure four years earlier, chronic obstructive pulmonary disease, essential hypertension, and peptic ulcer disease that had been quiescent for 18 years. Medications included nifedipine and a thiazide diuretic.

During the next several hours, the patient experienced alternating right and left hemiparesis and was unable to handle his secretions. Because of an admission hemoglobin of 17.1 g/dL, he was phlebotomized of one unit of blood and given hetastarch volume expansion. In addition, an oral endo- tracheal intubation was performed with minimal difficulty to protect his airway.

Because of continued evidence of active brainstem ischemia, the deci- sion was made to administer 100 mg tPA over three hours followed by heparinization. A lyric state was documented by both an elevated pro- thrombin time (24 seconds) and partial thromboplastin time (62 seconds) after tPA administration. There was significant resolution of weakness on both sides as well as improvement in the vertigo and nystagmus, but dur- ing the next 36 hours he showed progressive enlargement of his tongue.

On the sixth hospital day, the patient was doing well when sudden mas- sive hemorrhage from his mouth was noted by nursing personnel. His par- tial thromboplastin time was 61.6 seconds. Despite suctioning, a bleeding site was not readily visible. Heparin was discontinued, and normal saline infused rapidly. The patient's systolic blood pressure was never less than

Keith Wrenn, MD Rochester, New York

From the Emergency Medicine Residency Program, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia.

Received for publication February 9, 1990. Accepted for publication February 21, 1990.

Address for reprints: Keith Wrenn, MD, Emergency Department, Strong Memorial Hospital, 601 EImwood Avenue, Rochester, New York 14642.

19:10 October 1990 Annals of Emergency Medicine 1184/167

LINGUAL ARTERY HEMORRHAGE Wrenn

100 m m Hg. The only maneuver that ame l io ra t ed the b leeding was pres- sure wi th a tongue blade wrapped in gauze to the left side of the base of the tongue.

Eventually, an otolaryngologic con- sul tant arr ived and was able to visu- alize the specific bleeding site. Bleed- ing resolved wi th sutur ing of a lacer- ated branch of the left l ingual artery and t h r o m b i n pack ing of the si te . During the acute episode, more than 1,000 mL of b lood was suc t ioned ; dur ing the nex t 24 hours , the pa- t i en t ' s h e m o g l o b i n dec reased f rom 11.1 to 7.1 g /dL despi te the adminis- t ra t ion of 2 uni t s of packed RBCs. Wi th in hours, he had return of signs of b r a i n s t e m ischemia , and hepar in was res tar ted wi thou t a bolus.

Subsequently, the pa t ien t did well wi th the only other compl ica t ion be- ing an asp i ra t ion p n e u m o n i a in the left lower lobe. One further episode of oozing from his tongue occurred; the pa t ien t responded to local cauter- iza t ion w i t h s i lver n i t ra te . He was able to be extubated on the l l t h hos- pi ta l day and was subsequent ly dis- charged to a rehabi l i t a t ion center on 5 mg warfarin daily.

D I S C U S S I O N Bleeding f rom the m o u t h is not an

u n c o m m o n even t in h e m o p h i l i a c s , pa t i en t s w i t h yon Wi l l eb rand ' s dis- ease, or pa t ien ts wi th cancer (partic- ular ly leukemia) t reated wi th chemo- the rapy . 6-9 Such b l e e d i n g m a y be spon taneous or occur after t rauma, dental work, or oral surgery. Signifi- c a n t t o n g u e b l e e d i n g in p a t i e n t s wi thou t an under ly ing bleeding dis- order is far less common. Lingual ar- tery hemorrhage is rare and usual ly occurs w i t h t r auma (ei ther sponta- neous or ia t rogenic) or f rom t u m o r invasion, m43 Bleeding from enlarged subl ingual varicose veins at the base of t h e t o n g u e has a l s o b e e n re- por tedJ 4

In this pat ient , t r auma to the left base of the tongue was caused by pressure necros i s f rom the tee th in a p p o s i t i o n to the e x p a n d i n g in t ra - l ingual h e m a t o m a . The presence of an e n d o t r a c h e a l t ube on the r ight side of his m o u t h also contr ibuted to this condit ion. Laryngoscopic t rauma r e s u l t i n g in l i n g u a l b l e e d i n g a lso may have occurred and has been pre- viously descr ibedJ 3

The i n t r a l i n g u a l h e m a t o m a was undoubted ly related to laryngoscopic

t r auma and the use of tPA. Hema- tomas of the tongue causing airway obs t ruc t ion , as in our pa t ien t , have also been reported, inc luding a report of spontaneous hemorrhage into the tongue in a s soc ia t ion wi th warfar in u s e , 15

In our pat ient , the bleeding event was l ife t h r e a t e n ing , no t on ly be- cause of the amoun t of bleeding but because of the threat to cerebral per- fusion. As in all cases of hemorrhage, a t t en t i on to oxygen de l ivery by in- creasing oxygen sa tu ra t ion and he- moglobin and ensuring adequate car- diac ou tpu t is paramount . The other obvious p rob lem wi th mass ive l in- gual ar tery hemorrhage is aspirat ion of blood.

In l ingual ar tery bleeding, several op t ions are ava i lab le . D i s c o n t i n u a - t ion of ant icoagulants is required. If a i r w a y c o m p r o m i s e is i m m i n e n t , early endotracheal in tuba t ion is indi- cated. Bronchoscopical ly guided oro- tracheal in tuba t ion would appear to be the ideal method. In the absence of a coagulopathy, nasotracheal intu- ba t ion migh t be a t t e m p t e d wi th or w i thou t b ronchoscop ic guidance. If bleeding prohibi ts in tubat ion, emer- gency t r acheos tomy or cricothyroid- o t o m y m a y have to be per formed. This procedure would pose problems for the surgeon in the pat ient who is ant icoagulated.

Other opt ions to control the hem- orrhage inc lude direct compress ion , surgical l igat ion of the l ingual or ex- ternal carot id artery, and therapeut ic e m b o l i z a t i o n at angiography.lZ, 16 A c o n s e r v a t i v e a p p r o a c h u s i n g pro- coagulant drugs and a i rway cont ro l may be used wi th expanding hema- tomas, lz but in our pat ient mass ive h e m o r r h a g e n e c e s s i t a t e d p r o m p t cont ro l . In add i t ion , g iven the pa- t i en t ' s u n d e r l y i n g b r a i n s t e m ische- m i a , t h e u s e of s y s t e m i c p r o - coagulants such as p ro tamine sulfate, f resh f rozen p la sma , a m i n o c a p r o i c acid, t ranexamic acid, 6 or cryoprecip- i ta te migh t have worsened his neuro- log ic s t a t u s . Local p r o c o a g u l a n t s , however, m a y be helpful.

When presented wi th a s imilar sit- ua t ion in wh ich a bleeding site can- not be visualized, the best in i t ia l ma- neuver is to put direct pressure wi th a g loved f inger on e i the r the per- ceived area of bleeding or the poste- rior base of the tongue where the lin- gual arteries are in close proximity. The la t ter maneuver was described in

a s soc ia t ion w i th the exc is ion of in- t raoral ma l ignan t t umors to reduce pe r iopera t ive bleeding, t7 It requires e i ther a coopera t ive or an anes the- t ized pat ient . In our pat ient , his large in t ra l ingua l h e m a t o m a made inser- t ion of fingers into the m o u t h impos- sible.

Ano the r poss ib i l i ty is to put pres- sure at the posterola tera l base of the tongue wi th a gauze-wrapped tongue blade because the l ingual arteries and veins course through this area. If the site of bleeding is t ru ly unknown, bi- lateral compress ion of the base of the t o n g u e w i t h t w o g a u z e - w r a p p e d b l a d e s u s i n g a s c i s s o r i n g a c t i o n might be useful ini t ial ly. In our pa- t ient, uni la te ra l compress ion reduced bleeding successfully.

S U M M A R Y The case of a pa t ien t wi th an un-

usual l i f e - th rea ten ing c o m p l i c a t i o n of tPA is p resen ted . As the use of th romboly t i c agents increases, novel bleeding compl ica t ions will be seen, and acu te m a n a g e m e n t op t i o ns to control bleeding may prove life sav- ing. In the case of mass ive l ingual he- m a t o m a or bleeding, a t t en t ion to air- way c o n t r o l and k n o w l e d g e of the a n a t o m y of the v a s c u l a r supp ly of the tongue is crit ical . When intuba- t ion is performed, the impor tance of careful gent le i n t u b a t i o n is obvious w h e n t P A or o t h e r t h r o m b o l y t i c agents have been used or are be ing considered. Nasal in tuba t ion is con- t raindicated, and oral in tuba t ion over a bronchoscope may be the safest and least t r aumat ic me thod to use in this s i tuat ion.

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