Don’t Wait to Make the Call

Early ENT consultation is crucial, particularly in rural settings with limited access to specialized care. Secondary post-tonsillectomy hemorrhages often require surgical intervention. The literature suggests that approximately 85 percent of these cases require procedural source control in the operating room, highlighting the importance of expediting transport arrangements.⁵

Temporizing Measures

Temporizing measures are vital while awaiting transport, as they help to stabilize the patient and prevent further deterioration. First, lidocaine spray can be used for local analgesia, increasing patient tolerance.⁶ Apply direct pressure to the bleeding site with gauze soaked in TXA and epinephrine as a first-line intervention.⁷ Epinephrine acts as a local vasoconstrictor, aiding hemostasis, and TXA helps to stabilize clot formation on the exposed tissue and delay hemorrhage progression. For topical application of medications, a hack that I’ve found useful is utilizing a see-through plastic vaginal speculum with a built-in light; it gives great exposure, great lighting, and great access to the point of maximal bleeding.

TXA can be administered in three ways: nebulized, topical, or intravenous. Each method has a role in managing secondary post-tonsillectomy bleeds, although evidence is limited to case studies and small observational trials with variable results.^7,8 Nebulized TXA can be thought of as a “set it and forget it” intervention. Put it on early while you’re managing other tasks; it requires minimal involvement and frees you up for other essential steps. Gauze soaked in TXA applied to the tonsillar fossa provides localized bleeding control. IV TXA one to two grams in adults, or 15 mg/kg in children over 10 minutes, offers another layer of control, particularly when topical TXA alone does not suffice. The evidence may be sparse, but TXA in any form is generally safe in patients without obvious thrombotic contraindications.

Lastly, an antiemetic such as IV ondansetron is recommended to prevent vomiting, which can exacerbate bleeding or dislodge forming clots. Controlling nausea may also reduce the risk for gag reflex activation during oropharyngeal manipulation, further minimizing trauma.

Airway Management

If bleeding worsens and the patient shows signs of aspiration or respiratory distress, such as desaturation or altered mental status, securing the airway may become necessary. Be prepared for all but the most trivial bleeds with a double suction setup and video rapid sequence intubation (RSI) as you might in the setting of massive hemoptysis.⁹ Have two suction devices ready—ideally meconium aspirators or DuCanto catheters, which allow for superior fluid clearance from the oropharynx compared with Yankauer catheters.¹⁰ Careful, smooth RSI with video laryngoscopy is the preferred airway strategy, as it is likely to give you the best view while minimizing the need for multiple attempts, which may increase bleeding from localized trauma.