Post-tonsillectomy bleed

EC10 ENT MRCEM syllabus

	Most bleeds are self-limiting
Etiology	Reactive bleed: 1st 24h; secondary bleed = day 4-9 Most bleeds occur day 10 post-op. Smaller herald bleeds can preclude a larger bleed.
Epidemiology	Risk factors: - surgery done for recurrent tonsillitis - ↑ age - post-op infection
Clinical presentation	haematemesis, haemoptysis, nosebleed children tend to swallow blood rather than spit it out. O/E: sloughy = normal. - Active bleeding: isolate bleeding point (L/R, sup/inf pole) - No active bleeding: old clot, clot on tonsillar fossae
Pathogenesis	Secondary bleeds - usually due to infection
Diagnostic investigations	Bloods as per a bleeding patient (FBC, clotting, VBG, G+S)
Management	`airway doom from blood, foreign body...` see Impending bleeding doom \| Airway assessment #airway #emergencies Impending bleeding doom Escalate early (to whichever specialty should be stopping the bleed) Right place - resus, and on to theatre? IR? Vasc access and bloods: 2x large bore cannula Crossmatch, FBC, coag screen, VBG, LFT Haemostatic rescuscitation: TXA (not for UGIB/peptic ulcer disease) Correct coagulopathy Anticoagulant reversal Optimise clotting: keep warm, aim iCa >1.1 (10ml 10% Ca gluconate PRN) See Massive haemorrhage Other temporising measures: - NBM - Analgesia (post-tonsillectomy pain peaks day 5) - Topical co-phenylcaine?? Adrenaline-soaked gauze with a tail outside mouth held with magills??

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