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Tonsillectomy - management of post-tonsillectomy bleed in CED

Date last published:

Post tonsillectomy bleeding is an uncommon, but potentially life threatening event. The main difficulties arise from airway obstruction and hypovolemic shock.

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Starship clinical guidelines

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.

Refer all children to the on call ENT Registrar

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

Management algorithm

Image: Tonsillectomy - management of post-tonsillectomy bleed in CED - 426

 

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

 

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