Case
A ten year old boy presents with significant bleeding from his mouth and nose. He is learning forward, and although blood is rapidly pouring onto the stretcher, he is able to tell you his name. Two very anxious appearing parents are at the bedside, and are able to tell you that he had a routine tonsillectomy performed 5 days ago…
My approach
Call for help
Significant bleeding may require the operating room. Alert the otolaryngologist and anesthesiologist as soon as possible, assuming you have such services.
Position the patient
Most patients will be alert, with intact airway reflexes. Most blood will be swallowed. Position the patient so that they are comfortable and able to manage the blood by spitting or swallowing. The ideal position, and potentially the only tolerable position, is sitting up. (Wall 2018)
Assess the airway
Gather all your difficult airway equipment to the bedside. In most cases, immediate intubation is not required. Significant bleeding will make this a difficult intubation, preoxygenation will be tricky, and hemodynamic instability puts the patient at high risk. Ideally, I want to keep the patient awake to keep their airway reflexes intact. Intubation may be required to allow for direct pressure, but my preference is to attempt to control the bleeding first.
Vascular access and volume resuscitation
Good vascular access is essential, both for potential transfusion and in case intubation is required. Two quick attempts at an IV should be rapidly followed by intraosseous access if unsuccessful.
Call for blood and start volume resuscitation as needed.
Reverse any known coagulopathies. It may be reasonable to use IV tranexamic acid (but the real solution, like with any accessible bleeding, is direct pressure). (Ker 2012) Empiric administration of DDAVP has also been suggested, as undiagnosed von Willebrand’s disease is relatively common.
Tranexamic acid: 15 mg/kg in children or 1 gram in adults, given intravenously over 10 minutes
DDAVP: 0.3 mcg/kg IV
Once IV access has been obtained, I would also be liberal with my use of antiemetics. The patient has probably swallowed a lot of blood, and vomiting will make both airway management and local hemostasis much more difficult.
Apply direct pressure
Start by removing as much blood and clot from the oropharynx as possible. Good suction and good lighting are essential. A headlamp is ideal, as you are going to need both of your hands free.
Soak gauze in lidocaine, epinephrine, and tranexamic acid. (If the medications are not immediately available, I will start pressure with plain gauze). Use the gauze to apply direct pressure to the bleeding site. This can be done with a finger, but for better control of the foreign body you are introducing into the airway, I would use an instrument such as McGill forceps. (Wall 2018) Direct the pressure laterally. That being said, I would anticipate that very few patients will tolerate direct pressure, especially scared children, so be prepared to rapidly move on to the next step.
If direct pressure is not possible, ipsilateral compression of the carotid artery is an option. (Dalesio 2015) Much like direct pressure, this is unlikely to be tolerated until the patient is sedated or intubated.
Consider sedation
If the patient is unable to tolerate the instrumentation of their oropharynx, I would use ketamine as a sedative. Sedation has to be approached carefully, as sedative agents could result in hemodynamic collapse or airway compromise. I would start with very low doses, and titrate up to effect. If sedation is used, you have to be prepared for immediate intubation. Because all cases of significant post-tonsillectomy hemorrhage will be anticipated difficult airways, any patient requiring sedation should be transferred to the operating room as soon as possible.
(Expert note: Dr. Lewis would skip sedation and go straight to intubation. I think that decision depends on your local set up and how sick your patient looks. If you can go directly to the operating room and intubate in a controlled setting with expert backup, immediate intubation makes sense. If you are working as a solo physician in the emergency department, I think a trial of sedation make sense while you resuscitate the child and gather equipment and personnel, as long as you are ready to immediately proceed to airway management if necessary.)
Airway plan
Aim for the best possible pre-oxygenation, using flush rate oxygen. Ensure multiple large bore suctions are available. Ensure all difficult airway equipment is out and ready.
State to the room that this is an anticipated difficult airway. Clearly state the plan, including the potential for surgical front of neck access.
Optional step: consider placing a nasogastric tube prior to intubating, as the stomach will be full of swallowed blood. (I anticipate that this won’t be possible for most actively bleeding patients who need emergent airway management.)
There are a number of options for induction, but a classic rapid sequence intubation will probably be the choice for most emergency providers (with dose adjustment for hemodynamic instability, if necessary).
An LMA is an appropriate backup plan. (Wall 2018; Dalesio 2015) Tonsillectomies are frequently performed using an LMA, and the LMA will still allow access to apply pressure to the bleeding site. Once stable, an intubating fiberoptic scope can be used to intubate through the LMA if necessary.
Definitive management
Definitive management usually requires the operating room, but some institutions might also utilize interventional radiology to embolize the bleeding vessel. (Wall 2018)
Notes
Huge thanks to Dr. Casey Parker (GP/Emergency medicine/ Anesthesia) and Dr. Richard Lewis (ENT) for providing peer review on this post.
There are a number of different techniques used to remove tonsils, and the highest risk time for bleeding varies somewhat depending on the procedure. In general, a fibrin clot develops within 24 hours of surgery. This clot generally falls off between postoperative day 5 and 7, leaving the vascular bed exposed. This is the time of highest risk for significant hemorrhage. (Wall 2018) I’m not sure it matters clinically, but you will frequently see hemorrhage defined as primary (first 24 hours) or secondary (after 24 hours). (Dalesio 2015; Wall 2018)
Although the focus of First10EM is the critically ill patient, most patients (thankfully) will present with minor bleeding. Any active bleeding, oozing, or clot in the oropharynx generally requires surgical intervention, and a surgeon should be consulted. (Wall 2018) 41% of severe bleeding is preceded by a minor bleeding episode, and 10% of all minor bleeding patients will develop severe bleeding, with up to ½ of patients presenting with minor bleeding requiring surgery. (Sarny 2011; Steketee 1995) For a more in depth discussion of the assessment of the post-tonsillectomy patient, I suggest the Emergency Medicine Clinical of North America article by Dr. Jessica Wall. (Note: The figure that up to half of patients presenting with a minor bleed will require surgery is questioned by our expert otolaryngologist Dr. Lewis. Based on a 3 year audit at his institution, the number was less than 5%. The decision to return to the OR is rather subjective, so a large variance in practice might be expected. Either way, I would involved my local ENT in all clinical decision making.)
In one retrospective study, only 2.7% of intubations done for post-tonsillectomy hemorrhage were deemed to be difficult, but they don’t state how many children had active bleeding. I imagine most of these intubations were for children whose bleeding had already resolved. It is worth noting that none of these 13 difficult intubations were difficult at the time of their initial surgery. (Fields 2010)
Other FOAMed Resources
Pediatric EM Morsels: Post-tonsillectomy hemorrhage
PEMBLOG: Post tonsillectomy hemorrhage
References
Dalesio N. Management of post-tonsillectomy hemorrhage. In: Berkow LC, Sakles JC. Cases in Emergency Airway Management Cambridge. Cambridge University Press; 2015.
Fields RG, Gencorelli FJ, Litman RS. Anesthetic management of the pediatric bleeding tonsil. Paediatric anaesthesia. 2010; 20(11):982-6. PMID: 20964765
Ker K, Edwards P, Perel P, Shakur H, Roberts I. Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. BMJ (Clinical research ed.). 2012; 344:e3054. PMID: 22611164
Sarny S, Ossimitz G, Habermann W, Stammberger H. Hemorrhage following tonsil surgery: A multicenter prospective study The Laryngoscope. 2011; 121(12):2553-2560.
Steketee KG, Reisdorff EJ. Emergency care for posttonsillectomy and postadenoidectomy hemorrhage The American Journal of Emergency Medicine. 1995; 13(5):518-523.
Wall JJ, Tay KY. Postoperative Tonsillectomy Hemorrhage. Emergency medicine clinics of North America. 2018; 36(2):415-426. PMID: 29622331
Morgenstern, J. Massive Hemorrhage Post-Tonsillectomy, First10EM,
August 6, 2018. Available at:
https://doi.org/10.51684/FIRS.6175
7 thoughts on “Massive Hemorrhage Post-Tonsillectomy”
Death from post-tonsillectomy hemmorhage is not from exsanguination. It’s from asphyxiation. Blood clots very well and very fast in a trachea, becoming, as they say in the UK, a ‘coroner’s clot’.
Call anesthesia.
This is not an airway to manage alone.
Pre-induction:
I don’t place an NG, it causes retching, increased venous pressure and may blow any forming clot. I don’t sedate. Full stop- even with the freaking out teenager.
Induction:
2 suctions- as one will clot. Make them DuCanto if you can. One to the L and one to the R of DL (my preference- wide view and no camera to clot off at the tip).
Have water available. (more in a sec)
RSI- stingy on the induction doses. Don’t be greedy with the ETT size. Add post ETI sedation once you know BP post.
Once ETT is in, suction adenoid space (angle suction up into nasopharynx- clot can live there and get sucked into the airway on extubation)
Water down the ETT- it lyses red cells and clot liquifies. Saline not as effective. Suction then look directly with bronch. Water down bronch prn.
OG – big- into the stomach, suction 400cc+ and feel very proud of yourself.
Post ENT exploration:
Suction where adenoids were while patient is deep. Look around w DL/VL. Make sure it’s all good for blood.
Extubation- dexmedetomidine can be helpful for a calm wake up. Don’t be pressed to wake up fast.
Post-extubation: Don’t Dx respiratory distress post extubation as asthma, aspiration, or anything else. Clot formation in the trachea until proven otherwise. May require re-intubation and tracheal clot lysis.
Love the TXA mentioned, DDAVP too
Keep your great post coming Justin Morgenstern!
Laura
Thanks for the valuable comment Laura! Your insight is always greatly appreciated.
Most post tonsillectomy bleeding is secondary and occurs seven to ten days post operatively with the highest risk in patients who have not been drinking adequately and pull the thick escar from the fossa. These are mostly low pressure oozing and form clots in the fossa. Many stop by merely removing the clot and applying silver nitrate.
This article discusses a child who is only five days post operatively with a “massive” bleed in which case this is most likely to be arterial with a “spurter” being the culprit however massive bleeds can originate in larger vessels that may have been damaged by electrocautery or a suture placed too deeply. Monopolar cautery is the most frequent source of damage, bipolar much less so. The lingual, facial and carotid arteries are all at risk for damage.
In cases such as this it is most important to control the hemorrhage.immediately for a 20 Kg child can bleed out rapidly. Here are the steps to be take, some delineated within the article:
– Position the child in the upright position with an assistant, Nurse or Aid behind to hold the head
-Load a guaze 2×2 or 3×3 on a hemostat or ring forceps. If available soak it with Neosynephrine or Epinephrine and 4% Lidocaine
. -With headlight illumination and tongue depressors, open the mouth and suction the oropharynx identifying which fossa is bleeding.
-Push the sponge on the hemostat into the fossa, pressing it against fingers in the exterior neck. This can be held with one hand and the airway suctioned again and oxygen administered. Surprisingly, the child will normally calm down as they rest again your arm.
-Venous access is then obtained as additional help arrives.and fluids are administered. The child is transferred to the OR for controlled management of anesthesia and the hemorrhage.
In the OR once available with appropriate personnel, a rapid sequence induction is carried out with atropine and lidocaine (2 mg/kg) given up front. The mouth is suctioned one final time then propofol and succinyl choline are given as cricoid pressure applied the child laid back to forty-five degrees, a Mac Blade introduced, the patient suctioned again and intubated with a cuffed tube. It is important to use an open blade like the Mac as it is often not possible to suction and/or intubate through the narrow Miller blade around a clot.
Smaller arteries will often retract and go into spasm and the active bleeding stop. Beware of these as they are liable to open up again as soon as the succinyl choline is given. In cases such as this it is important to move quickly before the field is obscured with new bleeding.
Fortunately massive bleeding such as these are rare and have become rarer as bipolar cautery limits the depth of burn and sutures seldom used. In the past 52 years I have had to do this no more than half a dozen times, in each case on an inherited child, the last being 20 years ago when I held pressure after the patient was intubated while a vascular surgeon colleague tied the vessels of the external carotid one by one until tying the facial solved the problem. Naturally this was the child of a lawyer.
As a fellow in Pittsburgh in 1977 I co-authored a chapter on Post Tonsillectomy Hemorrhage with Sylvan Stool for Prof John Connolly’s book on the Complications of Head and Neck Surgery. All of the principles we described then are unchanged although we have had great improvement in Anesthesia, drugs and monitoring. Successful outcome depends upon a willingness to intervene aggressively and the availability of a few simple instruments, adequate light.and suction. If bleeding can be controlled until the OR situation above can be reached that successful outcome should be attained.
I agree with Doctor Donaldson’s comment and approach. The approach to massive post tonsillectomy bleeding described in this review seems protracted and time-consuming with all the preparations. My experience is similar to dr. Donaldson. After a minute or so with pressure held in the tonsil fossa with a folded 2 x 2 or 4 x 4 gauze on a hemostat, the patient’s sensitivities diminish and patient objection and resistance diminishes as well. Most bleeding will stop by clotting or vasospasm allowing intubation in a dry air way. If not, pressure can be held until intubation is all prepared and can be done quickly. I never have needed to use external neck counter pressure and feel that this may occlude the carotid or perhaps produce vasovagal effects unnecessarily. In my experience, extreme pressure is not needed, just enough to control the bleeding. I would apply external counter pressure only if oropharyngeal pressure was inadequate to control bleeding. Although I have never encountered the large vessel bleeding described by dr. Donaldson, I am aware that it can occur and one needs to be prepared for management.
I question the merits of an LMA for intubation in active bleeding due to concern of pushing a clot that tends to form in the oropharynx and hypopharynx into the tracheal airway with the larger dimension of the LMA. I think that suctioning and tube intubation in the OR, hopefully with controlled bleeding by pressure in the offending tonsil fossa, is the best approach.
in 29 years of general otolaryngology I have encountered several post tonsillectomy hemorrhages in my own patients and even more in patients of other otolaryngologists. All have been managed successfully in the above manner.
Thank you for your comment,
I wonder if you could clarify for me what parts of the original approach you would change.
The approach described is: call for help –> position the patient –> prepare airway equipment/ assess need for immediate airway intervention (generally done by a team member)–> obtain vascular access and resuscitate if needed (again performed in parallel by nursing team members)–> apply direct pressure (this is done at the same time as vascular access, by different team members) –> use sedation as necessary –> control the airway.
Although direct pressure is clearly the definitive intervention, I don’t think you can get there without first positioning the patient and examining them. You also need to make a rapid assessment of whether the airway needs immediate intervention or can wait. And I think it would be a mistake to fail to call for help. These are all mental steps that will only take seconds to perform, but I think are important to discuss in the plan and mental rehearse before seeing this kind of patient.
In terms of the LMA – it is suggested as a backup plan. Bloody airways can be incredibly challenging. Surely, we should have a backup plan in place. This is widely suggested throughout the literature. If you wouldn’t use the LMA as a backup, what would your plan be after a failed intubation attempt with low oxygen saturations?
I note you say that sux can sometimes start the bleeding again. Would it be better to use a non-depolarising agent like Roc instead?