1. Bleeding Tonsil Flashcards
Outline Important facts in Preop assesment of a 4 year old bleeding tonsil 5 hours post op
7 marks
- Visit on ward
resuscitation / rapport / history / exam / invx / consent
History
Timing events
previous chart
-doses / ETT /technique
Exam
Hypovolaemia
HR / CRT / Mentation / Skin turgor
Blood loss - greater than estimated - swallowed blood / physiological reserved
Residual anaesthetic
Invx
Obtain IV access (if not still in)
FBC / Clotting / U+E / X-Match
Resuscitation
20ml/kg bolus
Observe physiological parameters for response
Repeat PRN
PRBC ?no improvement
Induction
- Senior anaesthetist
- Technique - familiarity
- Aspiration
- Surgeons scrubbed ready
- Patient
- Laryngoscopy
- Induction drugs
- Laryngoscopy / intubation / tube
- Ventilation
Technique
IV RSI supine
-or-
Inhalation head down left lateral advocated
If familiar with same
Aspiration
High risk regurg & aspiration 2nd swallowed blood
RSI if IV Induction
Attempt adequate pre o2 >3min & cricoid
Patient
Challenging
active bleeding / uncooperative
Laryngoscopy
2 suction under pillow ( one block)
Difficult blood / clots obscure laryngoscopy
Induction
IV - RSI propofol 2-4mg/kg / sux 1mg /kg
care as may be hypovolaemic
Intubatation
Predicted to be 5 south RAE
check a/e bilaterally
May require smaller tube if oedmea from instrumentation
Ventiation
Spont or IPPV
Maintenance - sevo/tiva
Analgesia
Intraop opiate
Iv Fentanyl 15-50mcg (1-4mcg/kg)
cution hypovolaemia & second GA
Postop
Paracetamol
NSAID
morphine (.1-.4mg/kg)
Anti emesis
Empty stomach w/ wide bore OG
IV crystaolloid resus + maintenance
Consider anti emetics
Ondansteron -15mg/kg
iv dexamethasone 0.15mg/kg -
may mask tonsil bleeding ongoing so caution
