Tonsillectomy - management of post-tonsillectomy bleed in CED

Introduction

• Post tonsillectomy bleeding is an uncommon, but potentially life threatening event.

• The main difficulties arise from airway obstruction and hypovolemic shock.

• Bleeding is often occult in children as they swallow blood rather than spit it out.

Aetiology

Two types of haemorrhages:

Primary haemorrhage

• Occurs within the first 24 hours of the procedure

Secondary haemorrhage

• Occurs after more than 24 hours from the procedure

• Most commonly seen between day 5 & 10 post-op, when the fibrin clot sloughs off

History and Examination

Assessment and recognition

• Patients will present with either a history of bleeding or with active bleeding from the tonsillar fossa(e).

• Parents of younger children may describe finding blood on the child's pillowcase or an episode of haemoptysis or hematemesis.

• Excessive swallowing may also be an indicator of ongoing bleeding in young children.

Examination

• Examine the patient's throat for fresh bleeding. It is normal for the operative site to look yellow-white and sloughy after the operation.

• Try to localise the source - left or right, inferior or superior pole. If the patient is not actively bleeding, look for an old bleeding point or a blood clot in the tonsillar fossae.

• A full set of observations, including a BP should be obtained.

Monday - Friday during daytime hours (0800-1600) via mobile: 021 986 419.
After hours (1600 - 0800)/ weekends via the operator.

Management algorithm

Post Tonsillectomy bleed - active bleed

• Manage patient in Resus

• Sit the patient up and encourage them to spit blood into a bowl.

• Suction should be available if needed.

• The patient should be kept 'Nil by mouth'

• Central monitoring of heart rate, respiratory rate, pulse oximetry & blood pressure

• Notify ENT Registrar

• Early IV access

  • Aim to put in a large cannula if possible but any access is better than none

  • Consider a second IV line. Waiting for Ametop is acceptable if the patient is stable.

• Take bloods

  • FBC

  • Coagulation profile

  • Cross match

  • Venous Blood Gas

• IV Tranexamic Acid - Loading dose 15mg/kg (max 1g). Give over 10 minutes - Dilute to 20 mL of 0.9% NaCl or 5% Glucose

• If ongoing bleeding or haemodynamically unstable - consider giving blood.

• Consider IV analgesia.

• +/- IVABx - discuss with ENT.

• Admit under ENT

• +/- OT

No active bleeding at time of presentation and stable

• Patient should be observed in a high acuity area in CED. Rooms 8-12

• The patient should be kept 'Nil by mouth'

• Hourly observations including heart rate, respiratory rate, pulse oximetry & blood pressure

• Notify ENT Registrar

• IV Access - Ametop can be used and it is acceptable to wait for this if the patient remains haemodynamically stable.

• Take bloods

  • FBC

  • Coagulation profile

  • Group and Hold

• IV Tranexamic Acid - Loading dose 15mg/kg (max 1g)

• Analgesia

• +/- IVABx - discuss with ENT

• Admit under ENT