Title: Post-Tonsillectomy Hemorrhage (submitted by Chrissie Tupe, MD)<br/>Author: Mimi Lu<br/><a href='http://umem.org/profiles/faculty/185/'>[Click to email author]</a><hr/><div>
        <ul dir="ltr">
                <li>
                        <div dir="ltr">
                                Large vascular supply to the tonsil and the surrounding tissues that do not compress on themselves which can lead to hemorrhage</div>
                </li>
                <li>
                        <div dir="ltr">
                                2 types of hemorrhage - primary and secondary</div>
                        <ul>
                                <li>
                                        <div>
                                                primary - within 24 hours</div>
                                </li>
                                <li>
                                        <div dir="ltr">
                                                secondary - after 24 hours</div>
                                        <ul style="list-style-type:disc;">
                                                <li>
                                                        <div dir="ltr">
                                                                most commonly POD 5-10</div>
                                                </li>
                                                <li>
                                                        <div dir="ltr">
                                                                median time to bleed is POD 7</div>
                                                </li>
                                        </ul>
                                </li>
                        </ul>
                </li>
                <li>
                        <div dir="ltr">
                                Bleeding occurs as the fibrin clot sloughs off from the tonsillar pillar (which occurs on day 5-10)</div>
                </li>
                <li>
                        <div dir="ltr">
                                Surgery in older children and acute peritonsillar abscess are at increased risk for bleeding</div>
                </li>
                <li>
                        <div dir="ltr">
                                Due to the proximity to arteries and the possibility of pseudoaneurysm formation, bleeding post-procedure can result in significant, life-threatening hemorrhage.</div>
                </li>
                <li>
                        <div dir="ltr">
                                When assessing these patients, start with the ABCs</div>
                        <ul>
                                <li>
                                        <div dir="ltr">
                                                Assess the airway for compromise, some patients have heavy bleeding that requires intubation to secure the airway</div>
                                </li>
                                <li>
                                        <div dir="ltr">
                                                Obtain access if needed due to the concern for exsanguination from these areas</div>
                                </li>
                        </ul>
                </li>
                <li>
                        <div dir="ltr">
                                Patients that have active bleeding or a clot should be referred to surgery (ENT) for cautery of bleeding area</div>
                </li>
                <li>
                        <div dir="ltr">
                                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)</div>
                </li>
                <li>
                        <div dir="ltr">
                                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</div>
                </li>
                <li>
                        <div dir="ltr">
                                Topical hemostatic agents may help with bleeding, however, more severe bleeding requires surgery</div>
                </li>
        </ul>
</div>
<p>
         </p>
<fieldset><legend>References</legend>

                <p dir="ltr" style="font-family: arial, sans-serif; font-size: 13px; line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;">
        <span style="font-size: 15px; font-family: Arial; color: rgb(51, 51, 51); font-style: italic; vertical-align: baseline; white-space: pre-wrap;">1) Fox, S. (2012, <span class="aBn" data-term="goog_672909544" style="border-bottom-width: 1px; border-bottom-style: dashed; border-bottom-color: rgb(204, 204, 204); position: relative; top: -2px; z-index: 0;" tabindex="0"><span class="aQJ" style="position: relative; top: 2px; z-index: -1;">August 17</span></span>). Post-Tonsillectomy Hemorrhage. Retrieved April 8, 2015, from <a href="http://pedemmorsels.com/post-tonsillectomy-hemorrhage/" style="color: rgb(17, 85, 204);" target="_blank">http://pedemmorsels.com/post-<wbr />tonsillectomy-hemorrhage/</a></span></p>
<p dir="ltr" style="font-family: arial, sans-serif; font-size: 13px; line-height: 1.38; margin-top: 0pt; margin-bottom: 0pt;">
        <span style="font-size: 15px; font-family: Arial; color: rgb(0, 0, 0); background-color: transparent; font-style: italic; vertical-align: baseline; white-space: pre-wrap;">2) Isaacson G. Tonsillectomy Care for the Pediatrician. Pediatrics. 2012; 130(2): pp. 324-334.</span></p>
<p dir="ltr" style="margin-top: 0pt; margin-bottom: 0pt;">
        <span style="font-family: Arial; font-size: 15px; line-height: 1.38; color: rgb(0, 0, 0); background-color: transparent; font-style: italic; vertical-align: baseline; white-space: pre-wrap;">3)</span><span style="background-color: transparent; vertical-align: baseline; line-height: 17px;"><font face="arial, sans-serif" size="2"> </font></span><span style="font-family: Arial; font-size: 15px; line-height: 1.38; background-color: transparent; color: rgb(0, 0, 0); font-style: italic; white-space: pre-wrap;">Perterson J, Losek JD. Post-tonsillectomy hemorrhage and pediatric emergency care. Clin. Pediatr. Jun 2004; 43(5): pp. 445-448.</span></p>
</fieldset>