Post tonsillectomy haemorrhage

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim 

To guide staff with the assessment and management of children who present with post tonsillectomy haemorrhage.

Background

  • Post tonsillectomy bleeding is an uncommon, but potentially devastating event
    • The main difficulties arise from airway obstruction and hypovolaemic shock
  • The risk is reduced if on antibiotics, adequate oral intake and adequate analgesia
  • Haemorrhages can occur in 1 to 2% of operations (less in paediatric than in adult cases)
    • Primary (most common) – within 24 hours and rarely dealt with in ED
    • Secondary – from 24 hours to 14 days post operation, most commonly 6 to 10 days
  • At PCH, approximately 20% of patients will go to the operating theatre from the ED. From those who go to the ward directly from ED approximately 7.5% will have further bleeding requiring theatre.

Assessment

  • Management of bleed occurs concurrently with history and examination
  • Bleeding is often occult in children as they swallow blood rather than spit it out
  • The amount of blood loss is usually more than you estimate
  • Children can tolerate blood loss up to a certain point then will decompensate.

History

  • Timing of operation
  • Analgesia given (especially if ibuprofen or aspirin has been given)
  • Past history, especially of bleeding disorders
  • Inter-current illnesses, especially URTI or other febrile illnesses
  • Estimated amount of blood observed to be lost.

Examination

  • Calm manner and reassuring tone (for parents and child)
  • Heart rate, respiratory rate, blood pressure, capillary refill, pallor, fever
    • If prolonged central capillary refill or low BP, then major blood loss has already occurred
    • Watch pulse changes closely – beware of an increasing tachycardia
  • Look at the back of the throat (within limits of patient cooperation) for signs of active bleeding and/or clot.

Management

  • Potentially life threatening event
  • Contact the ENT registrar +/- anaesthetics as soon as condition is recognised
  • For patients being transferred, ETA should be determined and ENT made aware of time they are needed 
  • Transferred patients may need a medical escort from the transferring hospital.

Initial management

  • Manage patient in resuscitation bay or appropriate high acuity area
  • Early intravenous access
    • Aim to put in a large cannula if possible but any access is better than none
  • Consider Intraosseous access if no IV access can be obtained
  • Make preparations for a second IV line to be inserted (waiting for Emla® is acceptable if stable).
  • Obtain full blood count (FBC)
    • For starting point of Hb and platelets (this may not be representative of blood loss)
  • Coagulation profile +/- von Willebrand’s screen (for unrecognised coagulopathy)
  • Group and Hold +/- crossmatch (depending on severity of symptoms / signs)
    • Inform blood bank if ongoing bleeding or unstable patient
  • IV fluids: 10-20mL/kg boluses of 0.9% saline to correct physiologic parameters
  • Consider giving packed cells (O negative / group specific) if unstable
  • Co-phenylcaine spray to the oropharynx or adrenaline 1:10 000
    • Apply a swab held in artery forceps or similar instrument to an area of bleeding or over the tonsillar beds and push laterally not posteriorly (requires cooperation of patient and skilled operator)
  • Administer intravenous tranexamic acid
    • DDAVP may also be given on advice of ENT or senior ED doctor 
  • Further treatment of bleeding in the pharynx such as removal of clot and cautery (e.g. silver nitrate) needs to be done by a skilled individual (i.e. experienced doctor or ENT registrar / Consultant)
  • Intubation in an emergency is extremely difficult and should be done by the most experienced airway doctor available in the hospita.
  • Keep Nil By Mouth
  • Allow to sit upright, leaning forward if necessary (to help keep blood out of airway).

Admission criteria

  • Assume that all post tonsillectomy bleeding will need admission for observation or operating theatre.

Nursing

  • If airway, breathing or circulation is compromised move the patient to the resuscitation room and activate the resuscitation team
  • Set up for insertion of two IV cannula
  • Prepare 0.9% saline IV infusion
  • Ensure rapid infusers are on hand
  • If initially well, apply Emla® on arrival

Observations

  • Heart rate, respiratory rate and effort, blood pressure, capillary refill, pallor and neurological observations
  • Monitor closely
    • Continuous monitoring while in ED

Bibliography

  1. Pediatric Otolaryngology for the Clinician By: Ron B. Mitchell (Editor), Kevin D. Pereira (Editor) 2010
  2. Cohen, D. and Dor, M. Morbidity and mortality of post-tonsillectomy bleeding: analysis of cases, The Journal of Laryngology and Otology (2008), 122, 88-92
  3. Price R, Donaghy K and King B. Post tonsillectomy haemorrhage: Experience in a Paediatric Emergency Department. Poster presentation – Child and Adolescent Health Research Symposium October 2014, PMH
  4. Textbook of Pediatric Emergency Medicine. 6th ed. Fleisher GR, Ludwig S. Philadelphia: Lippincott Williams & Wilkins, 2010.

Endorsed by:  Emergency Department Guidelines team  Date:  Mar 2018


 Review date:   Mar 2021


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