The following document was written by Mr Vik Veer MBBS(lond) MRCS(eng) DoHNS(eng) in Dec 2007. You may use the information here for personal use but if you intend to publish or present it, you must clearly credit the author and www.clinicaljunior.com
This site is not intended to be used by people who are not medically trained. Anyone using this site does so at their own risk and he/she assumes any and all liability. ALWAYS ASK YOUR SENIOR IF YOU ARE UNSURE ABOUT A PROCEDURE. NEVER CONDUCT A PROCEDURE YOU ARE UNSURE ABOUT.
Patients tend to bleed about 5-10 days after a tonsillectomy, and this is normally secondary to infection of the tonsillar fossae. Typically they bleed a little and then pour blood afterwards and so this must be considered seriously in all cases. It is a life threatening condition, which requires resuscitation management in all cases (even if they spat out a little blood and then it stopped again – all these cases should be dealt with caution – particularly the children).
The management plan with these patients should be:
On examination you could see several different situations:
There is no active bleeding and there is a hint of blood in a corner of one of the tonsillar fossa. The fossae will have a white slough over them, which is normal. You are looking for a small grey or clotted blood area. In this situation you follow the plan given above and add to the drug chart 20mls of hydrogen peroxide, gargle which should be diluted with water in a ratio of 1:6. this gargle should be used every 4 hours and the patient admitted to the ward and be kept nil by mouth with IV fluids. You should inform your ENT registrar as there maybe an emergency operation to do that night.
Again there could be no bleeding but this time you see a large clot overlying one of the tonsil beds. In this situation you should follow the advice given above including the hydrogen peroxide gargle. The difference now would be that you would get the patient prepared for an operation immediately as you will need to remove this clot to see if it is bleeding behind it. Inform the ENT registrar and the anaesthetic teams and then prepare yourself with a Magill’s forceps, some gauze, 1:10,000 adrenaline, tongue depressor and a headlight. Now with everything set up use the magill’s to pull off the clot and watch what happens. If there is no bleeding then you can follow the advice given above and admit the patient with H2O2, IV fluids, and NBM.
If the patient then starts bleeding you quickly soak a gauze with the 1:10,000 adrenaline. Grip the gauze tightly with the tip of your magill’s forceps and push the gauze into the fossa and hold it there for as long as your patient can cope with it. The idea is to soak the fossa with adrenaline whilst also stemming the flow of blood. Lean the patient forward so he/she can spit out the blood and saliva (they won’t be able to swallow with a big instrument in their mouth). The direction of the pressure should be directly into wall of the mouth (so laterally rather than any posterior or inferior pressure which will cause the patient to gag).
Continue this until either the bleeding stops or help arrives in the form of a registrar or someone who can take the patient to theatre.
Some people say they sometimes use silver nitrate sticks to cauterise the bleeding spot. However I’ve not needed to use this before so I can’t give you any precise direction with this.
If you have a patient who is bleeding uncontrollably and you don’t have any equipment you can buy some time with gauze and a firm finger on the bleeding point. With a little luck the proper equipment and adrenaline will be at hand soon.