Ear, Nose & Throat
A 15 year old is brought to the Emergency Department by her mother. She had a tonsillectomy 7 days ago and was recovering well until today. She started coughing up blood and the bleeding continued for around 1 hour. On examination you note the bleeding has now stopped. The patient is haemodynamically stable. How should this patient be managed?
Answer:
Post-tonsillectomy bleeding is an uncommon, but potentially life threatening event. While the majority of post-tonsillectomy bleeds are self-limiting, a significant minority need to return to theatre urgently for control of the haemorrhage. ENT should be notified about ALL patients admitted with post-tonsillectomy bleeding. A small, self-limiting bleed may often be a prelude to a larger bleed (a 'heralding bleed') within the next 24 hours and thus all patients must be admitted for observation for 12 - 24 hours. The main difficulties arise from airway obstruction and hypovolaemic shock.Post-Tonsillectomy Haemorrhage
Ear, Nose & Throat
Last Updated: 12th February 2021
Post-tonsillectomy bleeding is an uncommon, but potentially life threatening event. While the majority of post-tonsillectomy bleeds are self-limiting, a significant minority need to return to theatre urgently for control of the haemorrhage. ENT should be notified about ALL patients admitted with post-tonsillectomy bleeding. A small, self-limiting bleed may often be a prelude to a larger bleed (a 'heralding bleed') within the next 24 hours and thus all patients must be admitted for observation for 12 - 24 hours. The main difficulties arise from airway obstruction and hypovolaemic shock.
Types
- Primary haemorrhage - occurs within the first 24 hours of procedure
- Secondary haemorrhage - occurs after more than 24 hours from procedure (most commonly seen between days 5 and 10 post-op when the fibrin clot sloughs off, may be associated with infection)
Clinical features
- Symptoms
- 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 haematemesis.
- Excessive swallowing may also be an indicator of ongoing bleeding in young children. Have a high index of suspicion - the amount of bleeding is frequently underestimated in young children.
- Signs
- 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.
Management
- 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/anaesthetist as required
- 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
- Group and Save/Cross match
- Venous Blood Gas
- IV fluid resuscitation
- IV analgesia
- Consider IV antibiotics (e.g. benzylpenicillin and metronidazole)
- Consider IV tranexamic acid
- Consider blood transfusion
- If not heavily bleeding, hydrogen peroxide gargles
- If severe bleeding and awaiting review/transfer, adrenaline soaked gauze pressed and held in the tonsillar fossa for as long as possible
- Admit under ENT
Report A Problem
Is there something wrong with this question? Let us know and we’ll fix it as soon as possible.
Loading Form...
- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
