Bleeding Tonsil

Airway: ETT RSI
Access: Large IV
Pain: Moderate
Position: Supine
Time: 30-60 minutes
Blood loss: May be massive, and require transfusion
Special: Soiled airway: Two suction, intubate head down or lateral

This covers anaesthesia for the bleeding tonsil. Tonsillectomy is covered elsewhere.

Post-tonsillectomy haemorrhage is a surgical emergency. * Bleeding may be: * Primary
Occurs within 24 hours. * Secondary
Occurs within 2 weeks. Adverse outcomes include: * Death * Haemorrhage * Aspiration * Airway obstruction * Emergent tracheotomy * Hypoxic brain injury

Considerations

  • A
    • Primary challenge is securing a soiled airway in a hypovolaemic and anaemic patient
      Evaluate:
      • Airway maintained?
      • **Active bleeding?
      • Conscious state?
      • Previous grade of laryngoscopy
        Usually will drop one grade.
  • B
    • Aspiration risk
      • Blood in airway
      • Fasting and vomitus
  • C
    • Haemodynamic instability
  • D
    • Residual anaesthetic effect
    • Emergency surgery
      Inherit risks.
  • G
    • Fasting status
      May be unfasted. Blood in stomach is profoundly emetogenic.
    • Pre-induction nasogastric tube if possible
  • H
    • Anaemia

Preparation

  • Standard ANZCA monitoring

  • Consider invasive monitoring

  • A

    • Two large-bore suction
    • RAE or reinforced ETTs
    • Two laryngoscope blades
    • Consider video laryngoscopy
    • Size-smaller tube

  • C

    • Volume resuscitate prior

  • H

    • Ensure G+H sent and available
    • Consider blood

Induction

  • Avoid premedication
  • Preoxygenate as well as possible
  • Requires rapid sequence and ETT
    Drug choice dependent on haemodynamic stability.
  • Consider intubating:
    • Lateral position
      Facilitates drainage of blood out of the mouth.
    • Head-down position
      Avoid tracheal soiling.
  • Chest pressure can be used to identify the trachea by producing bubbles

Emergence

  • Awake extubation preferred
    Requires intact laryngeal reflexes.
  • Antiemetics

Postoperative

Consideration of ICU admission if:

  • High volume transfusion
  • Difficult airway
  • Haemodynamic instability

References