18. Bleeding tonsil Flashcards
You are called to see a 4-year-old boy on the paediatric ward. He had a
tonsillectomy 4 hours ago and has been vomiting blood for the last hour.
His heart rate is 150 and his blood pressure is 95/60.
What are the problems in managing this case?
Problems with primary post-tonsillectomy haemorrhage (<24 hours):
- Frightened child and anxious parents
- Hypovolaemia
- Full stomach
- Residual effects of the anaesthetic 4 hours earlier
- Difficult intubation –
bleeding and possible upper airway oedema from the
previous intubation and surgery
Review of the previous anaesthetic chart
and history and examination are, of course, mandatory.
The consultant anaesthetist should be informed.
It is vital to ensure he is adequately resuscitated
before embarking on another anaesthetic.
Intravenous access (or interosseous if needed) should be
established and resuscitation commenced with crystalloid/colloid 20 ml/kg
(APLS recommends crystalloid).
You are called to see a 4-year-old boy on the paediatric ward. He had a
tonsillectomy 4 hours ago and has been vomiting blood for the last hour.
His heart rate is 150 and his blood pressure is 95/60.
What are the problems in managing this case?
Problems with primary post-tonsillectomy haemorrhage (<24 hours):
- Frightened child and anxious parents
- Hypovolaemia
- Full stomach
- Residual effects of the anaesthetic 4 hours earlier
- Difficult intubation –
bleeding and possible upper airway oedema from the
previous intubation and surgery
Review of the previous anaesthetic chart
and history and examination are, of course, mandatory.
The consultant anaesthetist should be informed.
It is vital to ensure he is adequately resuscitated
before embarking on another anaesthetic.
Intravenous access (or interosseous if needed) should be
established and resuscitation commenced with crystalloid/colloid 20 ml/kg
(APLS recommends crystalloid).
How would you estimate blood loss?
The most helpful indicators of hypovolaemia are:
Heart rate
Pulse volume
Capillary refill time (pressure for 5 seconds then release, normal refill
<2 seconds)
Skin colour (mottling/pallor/peripheral cyanosis)
Blood pressure (80 + (2 × age in years), hypotension is a late sign
Conscious level
Other ways of estimating loss outside clinical parameters
The degree of blood loss is often under-estimated.
Looking at the amount of blood vomited will be inaccurate
because much of it is likely to have been swallowed.
Haemoglobin and haematocrit estimations may help.
Postural hypotension suggests significant hypovolaemia
but measuring this would not be practical in a frightened child.
Core:peripheral temperature difference >2 ◦C is a sign of poor perfusion to skin.
Respiratory rate may be high as a compensatory response
to hypovolaemic metabolic acidosis.
He should have blood cross-matched and available in theatre.
FBC and clotting should be checked pre-operatively
What anaesthetic technique would you employ?
There are two schools of thought as to the method of induction:
Rapid sequence induction with cricoid pressure
Gas induction in the head-down, left lateral position
A rapid sequence induction with cricoid pressure
RSI In the supine position is likely to be the most familiar technique.
Although it is recognised that cricoid pressure
does not protect the airway from bleeding in the pharynx,
it is the technique most likely to secure the airway quickly.
(A gas induction in the
head-down, left lateral position may be fraught with potential problems.)
Other things peri intubation
There should be two suction devices
in case one becomes blocked with clot and
a variety of tube sizes and laryngoscope blades.
The ENT surgeon needs to be scrubbed and
prepared to perform a tracheostomy should the need arise.
Following intubation, a nasogastric tube may be inserted to empty the
stomach. This is then removed prior to extubation. Once haemostasis is
achieved, the child is extubated awake and in the head-down, left-lateral
position.
