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Tonsillectomy - management of post-tonsillectomy bleed in CED

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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

Post tonsillectomy bleed

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

References

  1. Post-tonsillectomy management: A Framework. (2016) The Royal Australian College of General Practitioners. 45 (5). 289 - 291.
  2. Post tonsillectomy Haemorrhage. Clinical Guideline. Princess Margaret Hospital for Children.
  3. Date First Issued: 25/11/2016. Last reviewed 25/11/2016.
  4. Royal College of Paediatrics and Child Health. Evidence Statement: Major Trauma and the use of tranexamic acid in children. November 2012
  5. Napolitano et al. Tranexamic Acid in Trauma: How should we use it? (2013) Journal of Trauma and Acute Care Surgery. Vol 74 (6). 1575-1586

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Document Control

  • Date last published: 17 September 2018
  • Document type: Clinical Guideline
  • Services responsible: Children’s Emergency Department
  • Owner: K Johnson
  • Editor: Greg Williams
  • Review frequency: 2 years

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