Post-Tonsillectomy Bleeding — the Emergency Case
| Type | Timing | Cause |
|---|---|---|
| Primary | On the table (intra-operative) | Surgical bleeding |
| Reactionary | < 24 h | Slippage of a ligature, dislodged clot, rise in BP as the patient recovers |
| Secondary | > 24 h (usually 5–10 days) | Sepsis / secondary infection, sloughing of the eschar |
⚠️ The child with a post-tonsillectomy bleed — five problems
- Hypovolaemic shock — much blood is swallowed, so loss is underestimated.
- Residual anaesthetic effect from the recent GA.
- Full stomach (swallowed blood) → aspiration risk → needs RSI.
- Difficult intubation — oedema and active bleeding obscure the view.
- May need repeat blood products.
1
Initial resuscitation
- Maintain ABC; two good wide-bore IV cannulae; head-down position; resuscitation cart ready.
- Replace blood loss with colloid/crystalloid → blood; monitor vital signs; send CBC & coagulation; cross-match.
2
Definitive procedure — anaesthetic plan
- Treat as hypovolaemic shock with a full stomach; resuscitate before induction — induction agent chosen by haemodynamic stability.
- RSI with cricoid pressure; two large-bore suction devices ready; a smaller-size ETT; pre-oxygenate.
- Decompress the stomach (NG) once secured; temperature monitoring; dexamethasone for oedema.
- Extubate in the lateral position, awake; recheck Hb & coagulation post-op.
"Coroner's clot": a clot hidden in the nasopharynx that is not visible and can obstruct the airway after extubation → always suction the nasopharynx under vision before waking.