Post-Tonsillectomy bleed

Question 1

An 8 year old boy presents to ED with bleeding post-tonsillectomy 8 days go. How would you assess and manage this patient?

Answer 1

Impression
Likely a post-op complication following the patient’s tonsillectomy.

2 main considerations in this setting
- hypovolaemic shock secondary to bleeding
- airway compromise

Consider any underlying bleeding diathesis/disorders which may be contributing.

Goals
- call for senior assistance, start A to E assessment ensure airway is patent and managed appropriately
- consult ENT to determine appropriate definitive management

Question 2

Post-tonsillectomy bleed - Assessment

Answer 2

Assessment
- call for senior assisstance
- Call ENT
- Begin arranging potential emergency theatres

A - patent, maintaining (speaking). bringing up clots?consider CAREFUL need for suction. thorough ENT examination, care to not disrupt any fibrin meshwork clots overlying tonsillectomy.
o position upright and learning forward to ensure blood exits airway rather than goes down if active bleeding
B - RR/SP02. Consider CXR for ?aspiration

C - Assess HD stability: HR/BP/ECG. assess CRT (peripheral and central). IVC access and initial bloods: VBG, FBC, UEC, CRP, G+H, coags.) Bloods resus as required, potentially activate MTP if significant blood loss.
Haemostasis measures;
- apply TXA soaked gauze to sites of bleeding
- medical cautery (silver nitrate)
- cause compression of bleeding area
- don’t disturb any visible clots

DEFG as per normal

Question 3

Post-tonsillectomy bleed - History

Answer 3

History
- re-read op report, post-op management and care
- PC: bleeding: when started, how much (ooze vs lots of volume)
- associated: difficulty swallowing, WOB, SOB, etc
- RISKS: bleeding disorders/coagulopathy, any medications as per these,
- MIST AMPLE and any anaesthetic risks for potential further surgery

• go through consent process with parents for potential further surgery

Question 4

Post-tonsillectomy bleed - Examination + Investigations

Answer 4

Examination
- vital signs
- general inspection
- ENT examination
- Resp exam for ?aspiration (crepitation)

investigations
- as per A to E assessment
- consider further bleeding diathesis work-up

Question 5

Post-tonsillectomy bleed - Management

Answer 5

Management
- early referral to ENT
- hospital admission for monitoring if small bleed in case of ‘herald’ bleed and further large-scale bleeding occurs

Supportive
- analgesia: paracetamol (avoid Reye’s syndrome)
- positioning upright
- parent + patient education

Definitive
- Medical cautery management
- Surgical management
o electrocautery
o suture ligation to stem bleeding
o IR embolisation
- consider further work-up for bleeding diathesis (VWD, haemophilia, etc)