How can bleeding secondary to a tonsillectomy be controlled in the Emergency Department (ED)?

Management of Post-Tonsillectomy Bleeding in the Emergency Department

In the emergency department, post-tonsillectomy bleeding should be managed with direct pressure to the bleeding site using a TXA-soaked gauze, followed by nebulized TXA (500 mg) for initial stabilization, while simultaneously arranging for definitive surgical management. 1

Assessment and Classification of Post-Tonsillectomy Bleeding

Post-tonsillectomy bleeding (PTB) is a potentially life-threatening complication occurring in approximately 4.2% of cases and can be classified as:

• Primary bleeding: Occurs within 24 hours after surgery (0.1-5.8%)
• Secondary bleeding: Occurs >24 hours after surgery (0.2-7.5%), typically between days 5-10 when the primary eschar sloughs 2

Risk Factors for Post-Tonsillectomy Bleeding

• Increasing patient age (higher in older patients)
• Male gender
• History of recurrent tonsillitis (3.7%) or peritonsillar abscess (5.4%)
• Elevated postoperative blood pressure
• Excessive intraoperative blood loss (>50 mL) 2, 3

Emergency Management Algorithm

1. Initial Assessment

• Rapidly assess airway and hemodynamic stability
• Determine severity of bleeding (minor self-resolving vs. active severe bleeding)
• Obtain IV access and draw blood for CBC and coagulation studies 4

2. Immediate Interventions for Active Bleeding

First-Line Measures:

• Apply direct pressure to bleeding site with gauze soaked in tranexamic acid (TXA) 1
• Administer nebulized TXA 500 mg (has shown hemostatic benefit in 75% of cases with complete cessation in 62.5%) 1

Additional Measures:

• Ice water gargle to promote vasoconstriction
• Nebulized racemic epinephrine as adjunctive therapy
• Position patient upright and leaning forward to prevent aspiration 4

3. Medical Management

• For significant bleeding with hemodynamic compromise:
  • Initiate fluid resuscitation with crystalloids
  • Consider IV tranexamic acid (10 mg/kg) to stabilize bleeding while preparing for definitive management 5
  • Blood transfusion may be necessary in severe cases

4. Definitive Management

• Immediate otolaryngology consultation for all cases of active bleeding
• Prepare for possible return to operating room for surgical hemostasis under general anesthesia
• If transfer to another facility is required, stabilize bleeding first with above measures 4

Special Considerations

Airway Management

• For severe bleeding with airway compromise, prepare for possible rapid sequence intubation
• Have suction readily available to prevent aspiration of blood
• Consider early intubation in cases with significant bleeding to secure the airway 4

Monitoring Requirements

• Continuous vital sign monitoring
• Serial hemoglobin measurements in significant bleeding
• Observe for at least 6 hours after bleeding has stopped 6

Pitfalls to Avoid

1. Underestimating minor bleeding: Even minor bleeding can precede severe hemorrhage and should be taken seriously 4
2. Delaying surgical consultation: Early involvement of otolaryngology is crucial for all cases of active bleeding
3. Inadequate airway management: Blood in the posterior pharynx can quickly compromise the airway
4. Overlooking medication effects: NSAIDs may increase bleeding risk, though evidence is equivocal 2

Remember that post-tonsillectomy hemorrhage is unpredictable and potentially life-threatening. While the emergency measures described can help stabilize the patient, definitive surgical management is typically required for active bleeding.