Palatal laceration question

[TheTruckGuy]

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I was wondering if I could get some advice from some of y'all. I'm an EM resident, had a patient the other day who had a tiny 1-2mm bleeding lac to his palate. It looked like just barely past the hard palate. He said it was from his dentures popping out while eating and twist or something. He had also taken a lot of aspirin recently for a headache.

The issue was a constant ooze of blood that came out of it. It was definitely venous, no spurting, and it was dark. We tried pressure with some regular gauze, that didn't work. Then we tried quick clot, that didn't work. THen we injected it with lidocaine with epi, and used the quick clot gauze, and that kinda worked. But it went from being constantly oozy, to oozing everytime he said "aaah" or talked. So we told him to just avoid talking for a few hours, lay off the aspirin for a few days.

We thought about throwing in a single suture, but given the location, our limited selection of needle drivers, we thought there'd be a good chance we could just end up causing more localized trauma and make things worse.

tl;dr - for a small, oozy, palatal laceration, what would be the best way to treat?

Thanks

 

[Big Time Hoosier]

These forums aren’t for giving medical advice. That being said, if I personally wore dentures and had a very small laceration on the roof of my mouth that was mildly oozing because of blood thinning medications, I’d just throw my denture right back in since it’d act more or less like a pressure dressing. Again, this is not medical advice. I’m just saying what I would do, and I assume no liability if you copycat me.

***Warning: Many have tried to copycat Big Hoss - they’ve all failed miserably.***

Big Hoss

 

[TheTruckGuy]

Forum description says "For post-graduate dental residents to discuss programs and procedures." So I figured this might be a procedure we could talk about.

It was a lower denture that he said twisted in his mouth and cut his palate.

What about using silver nitrate? We thought about that for a moment, but weren't comfortable sticking it in the soft palate. I did some searching online and it looks like it might have been ok to do. Have any of y'all used silver nitrate to stop bleeding in the mouth?

 

[bigstix808]

Forum description says "For post-graduate dental residents to discuss programs and procedures." So I figured this might be a procedure we could talk about.

It was a lower denture that he said twisted in his mouth and cut his palate.

What about using silver nitrate? We thought about that for a moment, but weren't comfortable sticking it in the soft palate. I did some searching online and it looks like it might have been ok to do. Have any of y'all used silver nitrate to stop bleeding in the mouth?

any pt that "twists" a lower denture to cut the palate is crazy. point blank. good chance they are lying to you on how it happened. but, for arguments sake, yes, silver nitrate could work. a suture could work also. a 4 or 5-0 vicryl to get them out of your room is fine. biggest prob is likely an ill fitting denture that needs to be seen about in a dental clinic. don't worry, the mouth heals pretty quick. hit them with some marcaine with epi in the greater palatine area / block ... and tell em to keep pressure.

 

[Big Time Hoosier]

any pt that "twists" a lower denture to cut the palate is crazy. point blank. good chance they are lying to you on how it happened.

Oh, the things you hear and see in the ER! When I was a volunteer years ago in a small community ER, we had a patient come in that had gotten a light bulb stuck in his rectum. I have absolutely no idea how he got it up there without it breaking. Because my shift ended, I’m not sure how they got it out without breaking and shredding him up. That’s a much harder problem to solve than an oozy palatal laceration.

Big Hoss

 

[TheTruckGuy]

Thanks bigstix. He did also mention something about the use of a dremel to smooth out something on his denture. Maybe that had something to do with it.

QUOTE="Big Time Hoosier, post: 19384592, member: 667854"]Oh, the things you hear and see in the ER! When I was a volunteer years ago in a small community ER, we had a patient come in that had gotten a light bulb stuck in his rectum. I have absolutely no idea how he got it up there without it breaking. Because my shift ended, I’m not sure how they got it out without breaking and shredding him up. That’s a much harder problem to solve than an oozy palatal laceration.

Big Hoss[/QUOTE]
Yeah, rectal foreign bodies are surprisingly common. In the case of rounded stuff like light bulbs, or even other objects that aren't likely to break, they create a suction effect when you try to pull them out, so you have to slip something around and behind them to try and break that seal and allow air flow around. Usually a foley cather works well, because you can also inflate the balloon and use it to provide traction from the far side.

In the case of a light bulb, however, if the ER doc was gutsy and had good tools on hand, he could've sedated the person and used a rectal speculum to go after it. More than likely though, you admit those to surgery because if you lacerate one of the hemorrhoid veins pulling it out, you're going to be stuck attempting a repair under less than ideal conditions while trying to also manage a sedated patient w/ an unsecured airway. Interestingly enough though, there are quite a few documented cases of people eating razor blades that passed through their system without perforating or causing serious damage. Not sure if you really wanted to know all that.

 

[nealofgrafton]

again take this with a grain of salt but when i was a resident and had a patient with a small 'bleeder' on the hard palate it was midnight and i was tired. i may or may not have used a silver nitrate stick on her with the bit of advise "this may tickle a bit". if you aren't comfortable throwing in a suture in there- don't. there is also wound glues you could see if they have, can't remember if they are approved for intra oral use

 

[Big Time Hoosier]

And people tell me I have a gross job working all day in someone’s mouth. It’s better than the other end!

Big Hoss

 

[vellnueve]

A suture won't hurt.
If desperate, our ED has those weak disposable bovies.

 

[FLOSS UR TEETH]

1. Suture with a single 3-0 or 4-0 chromic gut
2. If it was really "1 mm" large then direct pressure for 30s will stop the bleeding or cauterize with a silver nitrate stick

Also check to see if if pt on anticoagulation meds, bleeding disorders etc.

 

[armorshell]

Just make sure to tourniquet the proximal blood supply before attempting the repair. It makes things way easier, and you don't even need any kind of sedation!

 

[TheTruckGuy]

Just make sure to tourniquet the proximal blood supply before attempting the repair. It makes things way easier, and you don't even need any kind of sedation!

Do you prefer using the CAT tourniquet or SOFT-T for this purpose?

 

[armorshell]

Do you prefer using the CAT tourniquet or SOFT-T for this purpose?

I use whatever is handy (usually the patient's gown) with a technique called the RNC. There's a good article on the technique here: The Physiology of a Rear Naked Choke, or: What Happens When You Get Choked Out