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…
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.
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.)
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.
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 usually requires the operating room, but some institutions might also utilize interventional radiology to embolize the bleeding vessel. (Wall 2018)
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
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