What are the return precautions in the emergency department (ED) for a patient with a tonsil hematoma from trauma?

Return Precautions for Tonsil Hematoma from Trauma in the ED

Patients with tonsil hematoma from trauma should be instructed to return immediately to the ED if they develop active bleeding, difficulty breathing, or worsening pain, as these may indicate progression to potentially life-threatening hemorrhage requiring urgent surgical intervention.

Assessment of Bleeding Severity

When evaluating a patient with tonsil hematoma from trauma, it's important to assess the extent of bleeding using established clinical grading systems:

• Use the American College of Surgeons Advanced Trauma Life Support (ATLS) classification to assess hemorrhage severity based on vital signs, mental status, and clinical presentation 1
• Evaluate for signs of active bleeding, oozing, or clots in the tonsillar fossa 2
• Monitor vital signs closely, as tachycardia, decreased blood pressure, and narrowed pulse pressure may indicate significant blood loss 1

Initial Management in the ED

The initial management should focus on:

• Control of obvious bleeding points using local compression 1
• Obtain IV access with large-bore catheters in case rapid fluid resuscitation becomes necessary 1
• Baseline laboratory studies including complete blood count, coagulation studies (PT/INR, fibrinogen) 1
• Consider nebulized tranexamic acid (TXA) for initial hemostasis in cases of active bleeding 3

Return Precautions

Before discharge, provide clear instructions to return to the ED immediately if any of the following occur:

• Active bleeding from the mouth or throat 2
• Difficulty breathing or swallowing 1
• Increasing pain or sensation of fullness in the throat 4
• Hematemesis (vomiting blood) or spitting blood 2
• Signs of hypovolemic shock: lightheadedness, dizziness, syncope, or palpitations 1
• Fever, which may indicate infection that could worsen bleeding 4, 5

Risk Factors for Progression

Certain factors may increase the risk of progression to significant hemorrhage:

• History of chronic tonsillitis or inflammation 5, 6
• Older age (adolescents and adults have higher risk than young children) 6
• Elevated blood pressure 6
• Evidence of significant initial bleeding 6
• Coagulopathy or use of anticoagulant/antiplatelet medications 1

Disposition Decision-Making

The decision for discharge versus admission should be based on:

• Patients with active bleeding or hemodynamic instability require immediate surgical consultation and likely admission 2
• Patients with visible clots but no active bleeding may be discharged with close follow-up if they can reliably return if symptoms worsen 2
• Patients with no visible signs of bleeding and normal vital signs are appropriate for discharge with return precautions 2

Follow-up Recommendations

• Schedule follow-up with otolaryngology within 24-48 hours 1
• Advise patients to avoid physical exertion, hot foods/beverages, and NSAIDs which may increase bleeding risk 1
• Recommend cold foods/beverages and ice water gargles which may help reduce local inflammation 3

Special Considerations

• Spontaneous tonsillar hemorrhage can occur from infection leading to vessel erosion, so patients with signs of infection require close monitoring 5
• Patients with known bleeding disorders require more cautious management and lower threshold for admission 4
• Secondary hemorrhage (occurring >24 hours after initial trauma) can present up to 10 days later, so extended vigilance is necessary 2