POST TONSILLECTOMY BLEED

PromptInitial assessment of post tonsillectomy bleed

ResponseAmount/timing of blood loss. Ooze vs clot, duration (note bleeding may be occult with swallowed blood)
B/G ? bleeding disorder, or co existant illness
Symptoms of significant blood loss

Airway/breathing - signs of aspiration or compromise - hypoxia, tachypnoea, focal lung findings
Circulation - signs of shock - pallor, tachycardia, hypotension is a late sign
ENT - active bleeding from tonsilar bed
Other - Fever/evidence of infection

Inv: G+H, FBC, Coags VBG for rapid Hb

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PromptManagement of non massive post tonsillectomy bleed

ResponseIce gargles
Hydrogen peroxide gargles
Co-phenylcaine forte spray
Adrenaline soaked gauze on Macgill forceps
Intubation and packing

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PromptManagement of massive/Unstable bleed post tonsillectomy

ResponseUrgent ENT notification with view to theatre, notify anaesthetics of imminent intubation in theatre
Stop bleeding - Adrenaline soaked gauze on end of magills forceps to tonsillar bed (alternative is nebulised)
Resuscitate

2 IVC largest possible
O negative blood 10 mL/kg bolus +/- activate MTP
Bolus 20 mL/kg (acceptable but not essential)
HR <120, BP >90 (12 yo child in stem)

IVABx - Benpen 1.2g +/- metronidazole
TXA 15 mg/kg to 1g

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PromptList anticipated difficulties in intubating a child with a post tonsillectomy bleed

ResponseDifficulty laryngoscopy due to blood

Double suction devices
Extra assistant
Backup airway equipment ready especially LMA
Video laryngoscope may be difficult due to blood

Haemodynamic collapse on induction

Fluid load pre-induction 20 mL/kg N/S (or blood), O neg blood ready for use

Hypoxia - difficulty preoxygenation, post induction, aspiration lung injury

BVM through induction to minimise apnoea (? not sure if i agree with this)
15L O2 via NRB + Nasal prongs at maximum flow
Sit up until stops breathing
Apnoeic intubation as fast as possible.

IV access

Have dedicated clinician to help with this, IO if IVC fails

Difficult BVM due to blood

Early change to LMA, aim to have apnoeic intubation

Scared/uncooperative child

Parents for support, dedicated nurse for family/child support

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PromptRETROPHARYNGEAL ABSCESS

Response

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PromptPosterior neck pain differential

ResponseDeep infection

Discitis
Retropharyngeal abscess

Cervical artery dissection (Carotid/vertebral)
SAH
Meningitis
Muscular (trapezius)
Nerve - occipital neuralgia, nerve impingement
Pharyngeal infection - quinsy
EBV (Glandular fever)

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PromptRed flags of neck pain

ResponseAny trauma including minor (chiropractic manipulation)
Associated features

Headache
Neurologic deficit
Fevers
pain/difficulty swallowing

Recent LP - post procedure headache
PMHx - immunosuppression, IVDU, malignancy

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Prompt

ResponsePrevertebral soft tissue widening
Large retropharyngeal swelling (>1 vertebral body width)
Loss of normal cervical lordosis
Marked soft tissue swelling anterior to C1-C4
Diagnosis = retropharyngeal abscess

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PromptOther important investigations

ResponseBloods - Inflammatory markers CRP, WCC
Blood culture
CT neck

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PromptManagement

ResponseIV access
Avoid upsetting child
IV antibiotics to cover strep and anaerobes (see below)
IV dexamethasone 0-15-0.6mg/kg
Surgical drainage
Admission under ENT/Paeds

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PromptBacteria causing retropharyngeal abscess

ResponseS. Pyogenes, Group A strep - Augmentin 25+5mg/kg QID
S. Aureus, Anaerobes (Bacteroides), haemophylus - Cefazolin + metronidazole OR clindamycin.

Rch - IV Augmentin 25mg/kg TDS - Sep ‘24

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PromptComplications of retropharyngeal abscess

ResponseAirway compromise
Extension to mediastinitis
Sepsis
IJV thrombosis (Lemierre’s syndrome)

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PromptSings indicating airway obstruction

ResponseCough
Stridor
Reduced activity or adgitation
Hypoxia
Respiratory distress - accessory muscles/retraction/recession
Drooling/inability to swallow
Change in voice

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