Post Tonsillectomy Bleed
Post-surgical bleeding following a tonsillectomy and adenoidectomy (T&A) has given me several memorable patient care experiences over the years. Honestly, the word "memorable" is actually a euphemism for terrifying - Larry Mellick MD
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Post-Tonsillectomy Hemorrhage Management
Major Bleeding Management
- Mobilize the troops up in the OR.
- Have child lean forward (to help keep blood out of airway).
- Shed lots of light on the subject (headlamp will be vital for you).
- Grab your Magill Forceps and a ton of gauze and suction.
- Try to evacuate as much of the clotted blood as possible so you can get to the tonsillar fossae.
- Now apply direct pressure on the tonsillar fossae with the gauze wrapped around the end of the Magill’s.
- Adding some epinephrine (1:10,000) to the gauze has been shown to help (but I wouldn’t wait around … start with direct pressure).
- Remember…
Resources
Massive Hemorrhage Post-Tonsillectomy
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.
A Case Report of Nebulized Tranexamic Acid for Post-tonsillectomy Hemorrhage in an Adult
In the pediatric population both inhaled epinephrine and inhaled TXA have proven efficacious and safe. A well-documented risk factor for post-tonsillectomy bleeding is increased age, putting adults at potentially higher risk.
Post-Tonsillectomy and Adenoidectomy Bleeding Emergencies
Part of the problem with post-T&A bleeding is the patient. Typically, it's a pediatric patient who for hours has been quietly bleeding into the posterior pharynx while quietly swallowing the evidence (e.g., blood).
Post-Tonsillectomy Hemorrhage Management
We know that all bleeding eventually stops: ideally, by means that we have imposed rather than by exhaustion of the patient’s RBC resources. We also know that the easiest, and often most efficacious, way to halt bleeding is to put some manual pressure on the source of bleeding. Well, that isn’t always so easy to accomplish. How do you put your finger on a bleeding tonsil?
WikEM
No guidelines provide a stepwise approach so all of these therapies can be attempted in addition to emergent ENT consult aggressive suction, and direct pressure if possible. Nebulized Tranexamic acid - 250 mg for patients < 25kg and 500mg if > 25kg[4] Nebulized racemic epinephrine - 0.5 mL of 2.25% solution in 3 mL Lidocaine with epinephrine soaked pledgets Thrombin powder
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