Laboratory tests, although not essential for initial management, are recommended to assess the patient’s baseline status and prepare the receiving facility. Hemoglobin, type and screen, and crossmatch should be prioritized for significant blood loss and potential transfusion requirements. Fibrinogen levels should also be obtained, where available, if severe hemorrhage suggests the potential need for administration of fibrinogen concentrate.

For patients with ongoing brisk bleeding despite the above measures, a coagulopathy should be suspected, and desmopressin (DDAVP) at a dose of 0.3 mcg/kg IV may be considered, especially if von Willebrand disease is suspected. DDAVP is shown to enhance platelet adhesion, potentially stabilizing bleeding until surgical intervention is available.¹¹

Summary

The next time you’re faced with a post-tonsillectomy bleed, remember that primary hemorrhage occurs within 24 hours post-operatively and may indicate surgical causal factors or undiagnosed coagulopathies. Secondary hemorrhage, typically occurring between days five and seven, but as many as 14, can start as a trickle and escalate quickly. Even if you are successful in stopping the bleed in the ED, these patients need rapid ENT consultation for urgent definitive management in the operating room.

Using the three-pronged approach outlined here—resuscitation, early ENT consultation with expedited transport, and temporizing measures—while preparing for airway management and ordering appropriate laboratory investigations, will save your post-tonsillectomy patients from a potentially life-threatening hemorrhage.

Special thanks to Dr. Kevin Wasko, guest expert on the EM Cases podcast on this topic, who inspired this column.

Dr. Helman is an emergency physician at North York General Hospital in Toronto. He is an assistant professor at the University of Toronto, Division of Emergency Medicine, and the education innovation lead at the Schwartz/Reisman Emergency Medicine Institute. He is the founder and host of the Emergency Medicine Cases podcast and website.

References

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