Post-Tonsillectomy Bleeding

Incidence and Timing

• Incidence: Occurs in approximately 5% of cases.
• Primary Bleed: Within the first 24 hours.
• Secondary Bleed: After 24 hours, most frequently on days 5-9, up to 28 days.

Red Flags

• Heavy Bleeding: Continuous or significant blood loss.
• Hemodynamic Instability: Hypotension, tachycardia, pallor, dizziness, or syncope.
• Difficulty Breathing: Signs of airway obstruction or respiratory distress.
• Frequent Swallowing: Indicates blood ingestion, especially in children.
• Vomiting Blood: Presence of fresh or clotted blood in vomit.
• Excessive Pain: Severe, out-of-proportion pain.

Assessment

1. History
   • Hematemesis/hemoptysis.
   • Bleeding from the nose.
   • Tasting blood/metallic taste.
   • Excessive swallowing in young children.
   • Blood on pillowcase.
   • Estimated blood loss.
   • Time of operation.
   • Post-operative analgesia (ibuprofen or aspirin).
   • Medical history (bleeding disorders).
   • Inter-current illnesses (e.g., URTI).
2. Physical Examination
3. • General Appearance: Assess for signs of distress or shock.
   • Vital Signs: Blood pressure, heart rate, respiratory rate, and oxygen saturation.
   • Oral Examination:
     • Use a headlamp or ensure good lighting.
     • Look for active bleeding, clots, or scabs.
     • Do not disturb formed clots.
       • Healing Signs: Scab formation typically visible 7-10 days post-surgery, appears yellow-white.
       • Infection Indicators: Redness, swelling, purulent discharge.
     • Assess for signs of infection (redness, swelling, discharge).

Laboratory Tests (if indicated)

• Complete blood count (CBC).
• Coagulation profile.

ABCDE Assessment

• Airway: Check for compromise.
• Breathing: Evaluate respiratory status.
• Circulation: Assess hemodynamic stability.
• Disability: Monitor neurological status.
• Exposure: Examine for additional signs of bleeding.

Management of Active Bleeding

1. Call for Help
   • transfer to ED
   • Notify seniors in ED, ENT, and anesthetics.
2. Patient Positioning
   • Sit the patient up.
   • Maintain a calm and reassuring manner.
3. Volume Resuscitation
   • Insert two large-bore cannulae.
   • Consider resuscitation with packed cells.
   • Administer tranexamic acid:
     • 15 mg/kg in children.
     • 1 gram in adults, intravenously over 10 minutes.
   • Correct coagulopathy (consult haematology if needed).
4. Stem the Bleeding
   • Suction blood from the mouth under direct vision.
   • Apply co-phenylcaine (lidocaine with phenylephrine) spray or topical adrenaline:
     • Soak gauze with 1:10,000 adrenaline.
     • Apply to the bleeding point using Magill’s forceps, directing pressure laterally.
5. Additional Measures
   • Ensure the patient is nil by mouth.
   • Administer intravenous analgesia if required.
   • Consider intravenous antibiotics if indicated.
   • Consider sedation for airway control if needed.
   • Consider early intubation if haemostasis is not achieved.

Learning bites

• It is easy to underestimate blood loss, especially in children who are unable to give a full history and can compensate well haemodynamically.
• Small bleeds may be a prelude to a larger bleed.

Post-Tonsillectomy Home Care Advice

Eating and Drinking

• Diet: Encourage a normal soft diet.
  • Examples: Puddings, mashed potatoes, pasta, scrambled eggs, yogurt, jelly, ice cream.
  • Avoid: Hard, crunchy, spicy, or acidic foods that can irritate the throat.
• Hydration: Maintain adequate fluid intake.
  • Encourage: Water, cordial, fruit juice.
  • Avoid: Citrus juices and carbonated drinks that may cause discomfort.

Pain Management

• Regular Pain Relief:
  • Paracetamol: Administer regularly according to the prescribed dose, even during the night for the first few days.
  • Ibuprofen: Alternate with paracetamol every three hours, as per the hospital’s dosing instructions (higher than standard box doses).
  • Eating: Offer something to eat about 20 minutes after giving pain relief to minimize discomfort.
• Ear Pain: Common due to referred pain from the throat. Reassure that this is normal.
• Structured Regimen: Maintain a strict schedule for pain medications to manage discomfort effectively.

Bleeding Risks

• Monitor for Bleeding: Watch for signs of bleeding, such as:
  • Fresh blood in the mouth or vomit.
  • Excessive swallowing, indicating blood ingestion.
  • Blood on pillowcases or in saliva.
• Immediate Action: Contact medical services immediately if there is any significant bleeding.

Other Risks and Management

• Risk of Infection:
  • Look for signs: Increased redness, swelling, or purulent discharge.
  • Follow-up: Ensure a follow-up appointment with the healthcare provider.
• Breathing:
  • Monitor breathing at home, especially during sleep.
  • Consider having a caregiver sleep in the same room or check on the child several times at night for the first few post-operative nights.
• General Discomfort:
  • Sore ears, mouth, and neck, bad breath, and a ‘gunky’ mouth are common.
  • Voice changes may occur but should resolve over time.
• Activity:
  • Rest: Ensure plenty of rest during the recovery period.
  • Avoid strenuous activities and rough play for at least two weeks post-surgery.

Important Reminders for Parents

• Bleeding Risk: Be aware that the risk of bleeding persists for up to 14 days post-surgery.
• Pain Peaks: Pain often worsens around days 4-7 before it starts to improve.
• Care Requirements: Expect to provide one-to-one care similar to looking after a young baby for the first 7-10 days post-op.