UMEM Educational Pearls

Title: Post-Tonsillectomy Hemorrhage (submitted by Chrissie Tupe, MD)

Posted: 5/22/2015 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Large vascular supply to the tonsil and the surrounding tissues that do not compress on themselves which can lead to hemorrhage
2 types of hemorrhage - primary and secondary
- primary - within 24 hours
- secondary - after 24 hours
  - most commonly POD 5-10
  - median time to bleed is POD 7
Bleeding occurs as the fibrin clot sloughs off from the tonsillar pillar (which occurs on day 5-10)
Surgery in older children and acute peritonsillar abscess are at increased risk for bleeding
Due to the proximity to arteries and the possibility of pseudoaneurysm formation, bleeding post-procedure can result in significant, life-threatening hemorrhage.
When assessing these patients, start with the ABCs
- Assess the airway for compromise, some patients have heavy bleeding that requires intubation to secure the airway
- Obtain access if needed due to the concern for exsanguination from these areas
Patients that have active bleeding or a clot should be referred to surgery (ENT) for cautery of bleeding area
Most patients are not bleeding when they reach the ED. If a patient presents with a history of bleeding, they should be observed (no standardized time frame)
If the patient has severe bleeding and awaiting the OR, can place gauze soaked with lidocaine with epinephrine on the bleeding area with Magill forceps
Topical hemostatic agents may help with bleeding, however, more severe bleeding requires surgery

1) Fox, S. (2012, August 17). Post-Tonsillectomy Hemorrhage. Retrieved April 8, 2015, from http://pedemmorsels.com/post-tonsillectomy-hemorrhage/

2) Isaacson G. Tonsillectomy Care for the Pediatrician. Pediatrics. 2012; 130(2): pp. 324-334.

3) Perterson J, Losek JD. Post-tonsillectomy hemorrhage and pediatric emergency care. Clin. Pediatr. Jun 2004; 43(5): pp. 445-448.