ED Mgmt of Post-Tonsillectomy Bleeding?

[FDNewbie]

So the recent unfortunate case of the young girl who went into cardiac arrest from post-tonsillectomy hemorrhage (despite receiving blood transfusions, per the accounts I read) stirred my memory of 2 or 3 really hairy post-tonsillectomy bleeds I had come across over the past few years. And I remember feeling helpless in dealing with them. Aside from airway management (as needed), pre-op workup, and transfusing the patient, anyone know of any measures available in the ED to help temporize the situation until definitive help (OR staff and ENT) is available?

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[dotcb]

Airway, transfusion, hemorrhage control. After intubation and paralysis, I'd probably stick my hand in the mouth and see if I could apply direct pressure with gauze. Early ENT and anesthesia involvement.

 

[Hamhock]

I too have been thinking about this case a lot (mostly after reading the discussion in the anesthesiology fourm).

I was wondering if IR would be of any use and if they would be easier to access in some places than ENT.

HH

 

[Daiphon]

Agree with above - transfuse, fix coagulopathy if present, tube early if needed.

I also like direct pressure with epi-soaked gauze +/- careful injection with lido/epi.

I've also used thrombin powder directly applied (after tubing) with good control (n=4).

But yeah, ENT is key.

-d

 

[em1234]

same ideas as mentioned above. I used surgical once as my "gauze" to hold pressure over the source of bleeding and it was a little slippery but worked great. I've never been so happy to see ENT in my life.

 

[Rendar5]

had one of these back in residency, none since. **** my pants, xfused blood and got ENT to come in (academic institute). Where I'm at now, I have no ENT, and if it's an adult with a post-tonsillectomy bleed, they're screwed. Thankfully, dedicated peds hospital with super easy transport set up is right down the road and would be able to snatch the kid from me within 15 minutes. How is it intubating these patients with a bloody airway? I never had to on mine.

 

[ORL10]

I had a 20 y/o post-tonsillectomy bleed whose crit was 18, and he was still coughing up blood clots. I put a cordis gave blood and called ENT, who said he couldnt come in and I needed to transfer the patient. I intubated him placed some epi soaked pledgets around his tonsillectomy site (injected some epi as well) watched his MAP dip into the 50's and the bleeding stopped (imagine that).

I called my dept head in the ED (I was moonlighting as a resident during this case mind you), and my attendings back at my home institution (WTF do you doI was pretty desperate with a young kid who was trying to die) Turns out the on-call ENT is an alcoholic and was intoxicated while on-call. The ENT chair came in and took him to the OR, but F*** was I scared.

 

[Groove]

Yea, I read about that case and discussed it with my retired ENT dad... He was focused more on getting them back to the OR and unlike us... not quite thinking about the ABC's. Personally, I would have probably intubated and simply packed the posterior oropharynx with surgical lap sponges/towels/anything. Throughout, I would have been paging ENT to get them to the OR. Resuscitate.

 

[deuist]

Turns out the on-call ENT is an alcoholic and was intoxicated while on-call. The ENT chair came in and took him to the OR, but F*** was I scared.

Whatever happened to the on-call ENT in that case?

 

[ORL10]

I was moonlighting and the director told me that the ENT was "retiring". I worked maybe 12 shifts there at the end of my residency and definitely do not work there anymore.

 

[Dr.CCM]

Stable Patient ---> Type and screen, fix coags, call ENT
Unstable Patient ---> epi soaked gauze vs surgicel, direct pressure with magill forceps, pressure laterally not posteriorly, fluids vs. transfuse, intubate?, OR with ENT

Why lateral pressure vs posterior pressure?

 

[Missorleans]

I had a tonsillectomy at 22 and a week after surgery woke up at 3 am with blood dripping from the back of my throat. Was more than 20 mL and showed no signs of stopping, so I went to the ER. They gave me Tylenol with codeine and an albuterol nebulizer. As a second year med student I have no idea what the rationale was. Bleeding stopped on its own, though.

 

[Rendar5]

You sure it was accuracy and not nebulized saline or epi

Albuterol, not accuracy . Hateither my phone

 

[Missorleans]

They told me albuterol

 

[Rendar5]

They told me albuterol

that's just kinda weird then...

 

[southerndoc]

that's just kinda weird then...

I never put anything past another doc doing. Yesterday I got a transfer where the only antibiotic given for a patient with community-acquired pneumonia with no allergies was vancomycin. Gave nitroglycerin for her high-risk chest pain before they realized she had pneumonia, but didn't give aspirin.

You see some weird practices when you get transfers.

 

[TooMuchResearch]

I had a tonsillectomy at 22 and a week after surgery woke up at 3 am with blood dripping from the back of my throat. Was more than 20 mL and showed no signs of stopping, so I went to the ER. They gave me Tylenol with codeine and an albuterol nebulizer. As a second year med student I have no idea what the rationale was. Bleeding stopped on its own, though.

Don't go to EDs staffed by moonlighting derm residents :emoticon:

 

[deleted547339]

I never put anything past another doc doing. Yesterday I got a transfer where the only antibiotic given for a patient with community-acquired pneumonia with no allergies was vancomycin. Gave nitroglycerin for her high-risk chest pain before they realized she had pneumonia, but didn't give aspirin.

You see some weird practices when you get transfers.

We had a transfer recently from an outside hospital that made my jaw drop. I looked at my attending and kinda laughed - mind you, I'm only an intern, but it was shocking. My attending reminded me that they're shipping asking for help. She told me to show them the same respect you'd like your consults to show you. When you consult, you're asking for help. Should the outside ER have done x, y or z and not a, b, c? Yea, but they knew they were in over their head....just be glad their not still shoveling.

Not saying you don't do that, but is just never thought of it that way.

 

[Missorleans]

Don't go to EDs staffed by moonlighting derm residents :emoticon:

From speaking to local EM docs afterward, it sounds like my experience is about par for the course at that ER.

 

[Siggy]

I never put anything past another doc doing. Yesterday I got a transfer where the only antibiotic given for a patient with community-acquired pneumonia with no allergies was vancomycin. Gave nitroglycerin for her high-risk chest pain before they realized she had pneumonia, but didn't give aspirin.

You see some weird practices when you get transfers.

There's a local hospital that will get a BNP and a cardiac echo on just about anything, human and the presence of a pulse options, just because "acute on chronic systolic diastolic heart failure" brings in the money.

 

[WilcoWorld]

There's a local hospital that will get a BNP and a cardiac echo on just about anything, human and the presence of a pulse options, just because "acute on chronic systolic diastolic heart failure" brings in the money.

Outside Hospital..we can cath you.

But, of course, TNR is also right. When I get a transfer from St. Elsewhere and they've been treating the SAH's headache with toradol, or cellulitis with cipro, my first thought is "I'm glad the patient's here."

However, when they send someone with 3 years of hand pain, acute dilaudopenia and no ride home for a "Neuro consult" I'm less inclined to feel that way.

 

[diphenyl]

Besides airway management: viscous lido soaked gauze, electrical/ chemical cautery or local lido injection while transfusing and praying to god surgery gets their butt in the dept.

 

[10outof10]

We had a transfer recently from an outside hospital that made my jaw drop. I looked at my attending and kinda laughed - mind you, I'm only an intern, but it was shocking. My attending reminded me that they're shipping asking for help. She told me to show them the same respect you'd like your consults to show you. When you consult, you're asking for help. Should the outside ER have done x, y or z and not a, b, c? Yea, but they knew they were in over their head....just be glad their not still shoveling.

Not saying you don't do that, but is just never thought of it that way.

I absolutely love this. So easy where I work (academic children's hospital) for folks to dismiss prior management of the "outside hospital" and I am always trying to instill a little humility in my colleagues. Having staffed those "outside hospitals" I remember situations like ORL10's and I use all those times that I *** my pants to be humble and graceful.

 

[FDNewbie]

I too have been thinking about this case a lot (mostly after reading the discussion in the anesthesiology fourm).

Got a link? I musta missed that one.

I was wondering if IR would be of any use and if they would be easier to access in some places than ENT.

This is an uneducated guess, but I doubt post-tonsillectomy bleeding is from a major vessel; it's typically the scab s/p cautery has fallen off, and a superficial bleeder (venous or a small arteriole) continues to bleed. IR is typically for large vessel bleeding, if I'm not mistaken. And if you're shooting for a small target (arteriole) via a large branch (vessel), especially when it comes to HEENT vessels, I'd think the side effects would be horrendous (poss. CVA?). I could be wrong, but I'd guess that IR is def. not the way to go.

As simple as it sounds, I haven't tried direct pressure before. That's a great idea. Granted, all my cases have been young kids, so there's no way I can get my hand past their mouth. But maybe a sponge stick using some QuikClot gauze? And Epi injection sounds good too.

diphenyl, you mentioned cautery. In my experience, chemical cautery sucks in the face of something actively bleeding; it needs a dry surface to burn. Electrical may very well work, but you wanna be VERY careful not to apply too much pressure, given how many major vessels coarse around there (remember the concern with I&Ding peritonsillar abscesses is hitting the carotid).

 

[Hamhock]

http://forums.studentdoctor.net/threads/girl-brain-dead-after-tonsil-surgery.1046034/