Post-Tonsillectomy Hemorrhage: ReBaked Morsel

Previously, we covered Post-Tonsillectomy Hemorrhage and how we hope that “all bleeding eventually stops: ideally, by means that we have imposed rather than by exhaustion of the patient’s RBC resources.” Since the original morsel (way back in 2012), the literature has shown that there are a few extra ingredients that we can add to our morsel recipe when we care for children with post-tonsillectomy hemorrhage. Since tonsillectomy is one of the most common pediatric surgeries in the US (~500,000 per year) and the rate of post-tonsillectomy hemorrhage is about 1-5%, it is a good idea that we all are familiar with how to manage this issue! The definitions, typical healing course, timing of bleed, indications for tonsillectomy and the procedure itself have not changed much since our original morsel. The tonsillectomy has been called “the ultimate test of hemostasis” which is not surprising as it involves removal of the entire palatine tonsil and its capsule from branches of the carotid, lingual, facial and maxillary arteries. Once removed, if bleeding starts, there isn’t much anatomically left to prevent a horrific hemorrhage. With that in mind, let’s review how to manage the post-tonsillectomy hemorrhage in children:

Post-Tonsillectomy Hemorrhage: Management

General Preparation

Call for help… no time for your pride to get in the way!
- Your support staff…depending on the amount of bleeding, you are about to have your hands full and may need IV access, medications, airway management, etc.
- Get a hold of ENT early as OR management and/or admission are common.
Set up suction x2 in the room!

Patient Assessment

Start with your ABCs
Vitals are VITAL; tachycardia, hypotension, and hypoxia are ominous signs.
- If hemodynamically unstable give emergency release blood.
Look in the mouth!
- Get good light and exposure!
  - Using a Mac Laryngoscope as a tongue blade can be helpful!
  - Headlamps can also be helpful!
  - DON’T forget to put on your Personal Protective Equipment as well!
- Is there active bleeding, clot, or no bleeding?
Get IV access!
- If bleeding has completely stopped, most of these children still come into the hospital for observation so access will likely be necessary and helpful should patient have rebleed event.
- If bleeding, the only lab that is needed in the Emergency Department is a type and cross.
- CBC, coagulation panels, von Willebrand factor etc are less useful.
  - Anemia can lag on the CBC in the setting of active hemorrhage so treat the patient not the lab value!
  - A recent study showed that the discovery of an undiagnosed coagulopathy in the setting of post-tonsillectomy hemorrhage is rare.

For Major Bleeding

Position your patient upright in the bed and ask them the lean forward.
Suction and remove as much blood as much as you can in order to get a good view.
Tranexamic Acid (TXA)
- IV TXA
  - 15 mg/kg for a child
  - 1 g for adult (that’s right…this isn’t just a presentation seen in children. The rate of post-tonsillectomy hemorrhage in adults is about 14%)
- Nebulized TXA:
  - Recent study showed 29% of group that received nebulized TXA returned to the OR vs 73% that did not receive nebulized TXA.
  - < 25 kg = 250 mg up to 3x
  - > 25 kg = 500 mg up to 3x
Direct Pressure
- Always the best way to stop bleeding.
- Don’t await for fancy meds to arrive from pharmacy.
- Load gauze onto Magill forceps.
- Soak the gauze with epinephrine (1:10,000) or TXA (our THIRD route of administration)
- Apply pressure laterally to the tonsillar fossa with the gauze covered Magill forceps.
Anxiolysis
- Most children don’t even want to show you the inside of their mouth when you promise to just look with a light… now imagine how much they are going to love you for putting Magill forceps in there…
- Ketamine is a great agent in this scenario!
Airway Management
- While all pediatric airways should be considered to potentially be difficult, the one that is actively bleeding certainly deserves the highest of respect!
- SUCTION, SUCTION, SUCTION!
- Have all of your options available!
  - Videoscopic techniques are wonderful, in general, but the blood may obscure the camera.
  - Have traditional, direct laryngoscopes available as well.
  - Have your rescue and back-up devices available and ready.

For Minor Oozing or Visible Clot

Position your patient upright in the bed and ask them the lean forward.
Suction and remove as much blood as much as you can in order to get a good view.
Cold Water Gargles
- This may have been tried at home prior to arrival as advised by ENT.
- This is worth a shot in a well appearing child that is old enough to gargle and spit.
Silver Nitrate:
- Can be applied directly to the area of bleeding
- Requires a cooperative patient
Nebulized TXA:
- This is an ideal situation to trial nebulized TXA!
- Cold water gargles and topical silver nitrate can slow bleeding down but have not been shown to reduce the need for OR management…nebulized TXA has!

Resolved Bleeding on Arrival

Nebulized TXA:
- Even in the setting of bleeding that has stopped, nebulized TXA has been shown to reduce rebleeding events.
Observation:
- Most children, even with resolution of bleed, will need to be admitted for observation.
- Rate of rebleed when the initial bleed as resolved on arrival is between 1-10%
- Average time to rebleed is about 10 hours

Post-Tonsillectomy Hemorrhage: Recurrent

All bleeding eventually stops right?! Well… sometimes it starts again.
4-17% will rebleed
No difference in rebleed rate between those that are treated operatively and those that are observed
On average, the second bleed occurs 3-4 days after the first bleed
Some bleeds are considered “delayed post-tonsillectomy hemorrhage” and can occur over 14 days after tonsillectomy.

Moral of the Morsel

ABC and TXA! In addition to doing good basic assessments, TXA helps manage all versions of post-tonsillectomy hemorrhage.
TXA by any means! It and can be used in a variety of routes from topical to nebulized to intravenous!
Be prepared for badness! Have suction and airway supplies in the room and ENT on the phone.
Don’t trust the post-tonsillectomy hemorrhage! Even those that are no longer bleeding on arrival, will often require observation in the hospital.

Resources

Konanur A, McCoy JL, Shaffer A, Kitsko D, Maguire R, Padia R. Detecting coagulopathy in pediatric patients with post-tonsillectomy hemorrhage. Int J Pediatr Otorhinolaryngol. 2021 Aug;147:110807. doi: 10.1016/j.ijporl.2021.110807. Epub 2021 Jun 24. PMID: 34192615.

Shin TJ, Hasnain F, Shay EO, Ye MJ, Matt BH, Elghouche AN. Treatment of post-tonsillectomy hemorrhage with nebulized tranexamic acid: A retrospective study. Int J Pediatr Otorhinolaryngol. 2023 Aug;171:111644. doi: 10.1016/j.ijporl.2023.111644. Epub 2023 Jul 6. PMID: 37423163.

Erwin DZ, Heichel PD, Wright LM BS, Goldstein NA, McEvoy TP, Earley MA, Meyer AD. Post-tonsillectomy hemorrhage control with nebulized tranexamic acid: A retrospective cohort study. Int J Pediatr Otorhinolaryngol. 2021 Aug;147:110802. doi: 10.1016/j.ijporl.2021.110802. Epub 2021 Jun 12. PMID: 34146910.

Spencer R, Newby M, Hickman W, Williams N, Kellermeyer B. Efficacy of tranexamic acid (TXA) for post-tonsillectomy hemorrhage. Am J Otolaryngol. 2022 Sep-Oct;43(5):103582. doi: 10.1016/j.amjoto.2022.103582. Epub 2022 Aug 6. PMID: 35988367.

Assadi T. Nebulized tranexamic acid for post-tonsillectomy hemorrhage in children: a promising game changer. Am J Emerg Med. 2020 Sep;38(9):1943. doi: 10.1016/j.ajem.2020.01.042. Epub 2020 Jan 29. PMID: 32024591.

Rohe E, Gresham M, Rohde R, Cass L, Brinkmeier JV, Childers A. Efficacy of Topical Silver Nitrate for Control of Post-tonsillectomy Hemorrhage. Cureus. 2022 Mar 4;14(3):e22857. doi: 10.7759/cureus.22857. PMID: 35399399; PMCID: PMC8982499.

Alsalamah S, Alraddadi J, Alsulaiman A, Alsalamah R, Alaraifi AK, Alsaab F. Incidence and predictors of readmission following tonsillectomy in pediatric population. Int J Pediatr Otorhinolaryngol. 2024 Feb;177:111859. doi: 10.1016/j.ijporl.2024.111859. Epub 2024 Jan 10. PMID: 38219296.