M2E Too! Mellick's Multimedia EduBlog

The M2E Too! Blog by Larry Mellick, MD, presents important clinical pearls using multimedia.

By its name, M2E Too! acknowledges that it is one of many emergency medicine blogs, but we hope this will serve as a creative commons for emergency physicians.

Tuesday, November 1, 2016

Post-Tonsillectomy and Adenoidectomy Bleeding Emergencies

I have immense respect for a few pediatric emergency conditions. Post-surgical bleeding following a tonsillectomy and adenoidectomy (T&A) has given me several memorable patient care experiences over the years. Honestly, the word "memorable" is actually a euphemism for terrifying.

Part of the problem with post-T&A bleeding is the patient. Typically, it's a pediatric patient who for hours has been quietly bleeding into the posterior pharynx while quietly swallowing the evidence (e.g., blood). By the time the patient presents to the ED, a significant but unknown percentage of the child's total blood volume has been lost. We cannot begin to guess how much blood has actually been lost until the patient starts vomiting. Suddenly realizing that your pediatric patient is already in compensated shock is a frightening experience.

The problem with T&A surgery is that bleeding can come from four locations. Two adenoids and two tonsils are removed. The bleeding can occur immediately after the surgery or, more commonly, days to weeks later. Bleeding can occur in the nose and the mouth, and these are not easily accessible for applying direct pressure to stop the bleeding.

My most recent patient was a 5-year-old who presented with a nosebleed three weeks after her tonsillectomy and adenoid surgery. The nosebleed had already been going on for three hours by that time. Her mother had already applied oxymetazoline, an adrenergic receptor agonist, eight to 10 times her nose without success. Then the vomiting began. Emesis after emesis of large amounts of blood continued for the next hour while we waited for the ENT consultant to arrive.

The ENT's initial advice was to apply more oxymetazoline, a potentially dangerous medication, and he asked over the phone if we had tried to pack the nose, a silly question as far as I was concerned. Packing the nose of a frightened little girl with nares smaller than the tip of my little finger just wasn't going to happen without sedation. Nasal packing also didn't seem like the correct therapeutic intervention for bleeding from a post-surgical adenoidectomy site.

How do you stop bleeding from a post-surgical adenoidectomy site? This scenario is similar to stopping the bleeding of posterior epistaxis. My plan, if her condition deteriorated, was to insert a pediatric Foley catheter, blow up the balloon, and apply traction. Besides placing two of the largest intravenous catheters possible, I ordered a 20 mL/kg normal saline bolus and a blood type and cross. Her initial hemoglobin was 11.1 g/dL, and I briefly considered O-negative blood as her heart rate climbed and her pulse pressure narrowed. Thankfully, the signs of compensated shock subsided and the bleeding slowed before she was taken to the operating room to have her left bleeding adenoidectomy site treated. I checked a day or two later, and her hemoglobin had settled at 8.0 g/dL, a 3 g/dL drop.

What else could I have done? Using forceps to apply an epinephrine-soaked gauze to the posterior pharynx apparently works for bleeding tonsillectomy sites. Access to the adenoidectomy site is not guaranteed, however. Next time, I will use a laryngotracheal mucosal atomization device placed through the bleeding nares to deposit 1:10,000 or 1:100,000 epinephrine to my patient's posterior nasopharynx. Another potential but unproven option is the topical application of hemostatic agents such as fibrin sealant or thrombin with the mucosal atomization device. Intravenous tranexamic acid is also a consideration. The topical application of tranexamic acid has been used successfully in surgery to stop or slow bleeding.

Watch a video of a patient with post-T&A bleeding.​

tonsil mellick photo.JPG