Tonsillectomy - management of post-tonsillectomy bleed in CED
Post tonsillectomy bleeding is an uncommon, but potentially life threatening event. The main difficulties arise from airway obstruction and hypovolemic shock.
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.
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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