Post tonsillectomy haemorrhage

Aim 

To guide Emergency Department (ED) 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
  • Morbidity arises from airway obstruction and hypovolaemic shock
• The risk is reduced if the airway is cleared and maintained and the child has adequate fluid resuscitation.
• Haemorrhages can occur in 1 to 5% 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 13% 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 theatre⁴

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)
• Current medication, including antibiotics
• Past history, especially of personal or family history of bleeding disorders, increasing pain, fever, bad breath
• Inter-current illnesses, especially upper respiratory tract infections (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 blood pressure, then major blood loss has already occurred
  • Monitor 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^2,3

• Post tonsillectomy haemorrhage is a potentially life threatening event
• Contact the ENT registrar +/- anaesthetics as soon as condition is recognised
• For patients being transferred, estimated time of arrival 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
• Allow to sit upright, leaning forward if necessary (to help keep blood out of airway)
• Clear airway – use suction if required. Sit upright – spit out blood
• Early IV access
  • Aim to insert a large cannula if possible but any access is better than none
• Consider Intraosseous access if no IV access can be obtained. Refer to Intraosseous Access – ED Guidelines
• Make preparations for a second IV line to be inserted (waiting for topical local anaesthetic e.g. lidocaine (lignocaine) 2.5% with prilocaine 2.5% cream (EMLA^®) is acceptable if stable).
• Obtain full blood count (FBC)
  • To obtain a baseline for haemoglobin (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 AFTER fluid resuscitation or massive blood loss
• Administer lidocaine 5% with phenylephrine 0.5% spray (Co-phenylcaine Forte^®) ⁵ to the oropharynx
  • If tolerated apply an adrenaline (epinephrine) 1:10,000 (1 mg/10 mL) soaked 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 IV tranexamic acid 15 mg/kg (maximum 1000 mg)^6,7
  • Desmopressin (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)
• Consider antibiotics
• Intubation in an emergency is extremely difficult and should be done by the most experienced airway doctor available in the hospital
• Keep nil by mouth

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 cannulas
• Prepare sodium chloride 0.9% IV infusion
• Ensure rapid infusers are on hand
• If initially well, apply topical local anaesthetic e.g. lidocaine (lignocaine) 2.5% with prilocaine 2.5% cream (EMLA^®)

Observations

• Complete and record a full set of observations on the Observation and Response Tool and record additional information on the Clinical Comments chart
• Complete a full set of neurological observations if clinically indicated
• Continuous monitoring while in ED
• Minimum hourly full set of observations

References

1. Pediatric Otolaryngology for the Clinician By: Ron B. Mitchell (Editor), Kevin D. Pereira (Editor) 2010
2. Fleisher and Ludwig's Textbook of Pediatric Emergency Medicine Eighth Edition. Journal of Pediatric Critical Care 8.2 (2021): 116. Web. Kundan Mittal. 
3. 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
4. Smith AL, Cornwall HL, Zhen E, Hinton-Bayre A, Herbert H, Vijayasekaran S. The therapeutic use of tranexamic acid reduces reintervention in paediatric secondary post-tonsillectomy bleeding. Aust J Otolaryngol 2020;3:10.
5. Co-Phenylcaine Forte. MIMs Online Last updated: 1 October 2018. Cited 12 April 2022. Available from: MIMS | MIMS | Full Product Information (health.wa.gov.au)
6. Australian Paediatric Life Support (APLS) Blood and Fluid Therapy Algorithm [Internet]. Melbourne, Australia 2020. Cited 24 February 2023.  Available from: Algorithms | Blood and fluids in trauma (apls.org.au)
7. Tranexamic acid. In: UpToDate [Internet]. Waltham (MA): UpToDate Inc; 2023 [cited 2023 Feb 24].  Available from: Tranexamic acid: Pediatric drug information - UpToDate (health.wa.gov.au)

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