> [!references]- > - [royal victorian eye & ear - Post Tonsillectomy Bleeding](x-devonthink-item://5C5D5744-9FAD-492C-B48A-F5F448EE7A4B) > - [Cameron - post tonsillectomy bleeding](x-devonthink-item://2F5AAFBF-B8F5-46F6-953B-854212EA156D?page=4&istart=4234&ilength=26&search=Post-tonsillectomy%20bleeding) > - [Dunn - Other oropharyngeal conditions](x-devonthink-item://F33AC361-1352-491C-B1B1-D0D28F83BD0B) > - [Cameron Paeds - posttonsillectomy haemorrhage](x-devonthink-item://F7180C8F-40EE-4F1F-870E-5FDEAFF694AB?page=38&istart=941&ilength=28&search=Posttonsillectomy%20haemorrhage) #OSCE [OSCE 2021.1 station 9 - post-tonsillectomy bleed](x-devonthink-item://15AE464A-CB62-4C78-B68B-C39D383C19CF?page=18&istart=59&ilength=43&search=Station%209%2E%20SCBD%20%E2%80%93%20Paediatric%20resuscitation%0D%0A) > [!key points] > - This makes for a great OSCE station (asked 2021.1) > - Generally needs 24 hours monitoring even if ceased — don’t discharge! > - ~40% require return to theatre for control of haemorrhage > - The main principles are referral to ENT, recognition of serious bleeds, and escalation of techniques to manage bleeding - Primary post-tonsillectomy bleeds usually occur within 24 hours of operation - Secondary post-tonsillectomy bleeds usually occur from >24 hours to 2 weeks post op (usually 6-10 days) , often due to an infection ## Management overview - sit patient upright - get IV access - in most cases TXA 15mg/kg IV - examine tonsils and try and get a sense of: - rate of bleeding - source of bleeding - generally give antiemetic eg maxalon for swallowed blood - co-phenylcaine is a low risk easy intervention - if source of bleeding seen, can use magill's forceps with adrenaline 1:10,000 (1mg/10mL) or co-phenylcaine-soaked gauze - often requires removal/ suction of a clot to allow adrenaline directly onto bleeding point . be caution with suction though, it can become a self-fulfilling prophecy. ongoing suction can promote ongoing bleeding as well - apply pressure laterally to the wall of the mouth - some guidelines recommend *dilute* hydrogen peroxide gargles (prepared from 3% solution diluted in 3 parts water) if the bleeding is not too severe, but most ED patients I see I'd be concerned about them swallowing the H2O2 - nebulised adrenaliene 5mg in 5mL may help; if you're getting to this stage an import aspect needs to be an endpoint, i.e. this is not a "try nebulised adrenaline and put in SSU" situation but rather "the patient is still bleeding; ENT need to come and review" - can also use silver nitrate cautery if source of bleeding identified - antibiotics are usually prescribed (ben pen + metronidazole); this is because infection is a common -- but not universal -- cause of post tonsillectomy bleeding. In the absence of obvious sepsis, this is not a resus priority but certainly worth doing. > All patients discuss with ENT and admit for 24 hours observation ### In severe cases - refer to [[Airway#epistaxis|Epistaxis Airway]] approach then airway packing awaiting theatre - assess for shock and resuscitate if needed