Paediatric Acute care Guidelines PMH Emergency Department

Background

General

  • Post tonsillectomy bleeding is an uncommon, but potentially devastating event
    • The main difficulties arise from airway obstruction and hypovolaemic shock
  • The risk is reduced if on antibiotics, adequate oral intake and adequate analgesia
  • Haemorrhages can occur in 1-2% of operations (less in paediatric than in adult cases)
    • Primary (most common) – within 24 hours and rarely dealt with in ED
    • Secondary – from 24 hours to 14 days post operation, most commonly 6-10 days
  • At PMH, approximately 20% of patients will go to the operating theatre from the ED. From those who go to the ward directly from ED approximately 7.5% will have further bleeding requiring theatre.

Assessment

  • Management of bleed occurs concurrently with history and examination
  • Bleeding is often occult in children as they swallow blood rather than spit it out
  • The amount of blood loss is usually more than you estimate
  • Children can tolerate blood loss up to a certain point then will decompensate

History

  • Timing of operation
  • Analgesia given (especially if ibuprofen or aspirin has been given)
  • Past history, especially of bleeding disorders
  • Intercurrent illnesses, especially URTI or other febrile illnesses
  • Estimated amount of blood observed to be lost

Examination

  • Calm manner and reassuring tone (for parents and child)
  • Heart rate, respiratory rate, blood pressure, capillary refill, pallor, fever
    • If prolonged central capillary refill or low BP, then major blood loss has already occurred
    • Watch pulse changes closely – beware of an increasing tachycardia
  • Look at the back of the throat (within limits of patient cooperation) for signs of active bleeding and/or clot

Management

  • Potentially life threatening event
  • Contact the ENT registrar +/- anaesthetics as soon as condition is recognised
  • For patients being transferred, ETA should be determined and ENT made aware of time they are needed 
  • Transferred patients may need a medical escort from the transferring hospital

Initial management

  • Manage patient in resuscitation bay or appropriate high acuity area
  • Early intravenous access
    • Aim to put in a large cannula if possible but any access is better than none
    • IO access if no IV access can be obtained
  • Make preparations for a second IV line to be inserted (waiting for Emla® is acceptable if stable)
  • Obtain bloods for:
    • FBC – baseline Hb and platelets (this may not be representative of blood loss)
    • Coagulation profile and von Willebrand’s screen (for unrecognised coagulopathy)
    • Group and Hold +/- crossmatch (depending on severity of symptoms/signs)
      • Inform blood bank if ongoing bleeding or unstable patient
  • IV fluids: 10-20mL/kg boluses of 0.9% saline to correct physiologic parameters
  • If unstable, give packed cells (O negative/group specific)
  • Apply co-phenylcaine spray to the oropharynx or adrenaline 1:10 000
    • Apply a swab held in artery forceps or similar instrument to an area of bleeding or over the tonsillar beds and push laterally not posteriorly (requires cooperation of patient and skilled operator)
  • Administer intravenous tranexamic acid
    • DDAVP may also be given on advice of ENT or senior ED doctor 
  • Further treatment of bleeding in the pharynx such as removal of clot and cautery (e.g. silver nitrate) needs to be done by a skilled individual (i.e. experienced doctor or ENT registrar/Consultant) 
  • Keep NBM
  • Allow to sit upright, leaning forward if necessary (to help keep blood out of airway)
  • Intubation in an emergency is extremely difficult and should be done by the most experienced airway doctor available in the hospital

Admission criteria

  • All post tonsillectomy bleeding will need admission for observation or operating theatre

Nursing

  • If airway, breathing or circulation is compromised move the patient to the resuscitation room and activate the resuscitation team
  • Set up for insertion of two IV cannula
  • Prepare 0.9% saline IV infusion
  • Ensure rapid infusers are on hand
  • If initially well, apply Emla® on arrival

Observations

  • Heart rate, respiratory rate and effort, blood pressure, capillary refill, pallor and neurological observations
  • Monitor closely
    • A minimum of hourly observations are required
 

References

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