Clinical Assessment and Risk Stratification

History

When assessing a patient with suspected post-tonsillectomy bleed, ask about the following signs:

• Haematemesis/haemoptysis
• Bleeding from the nose
• Patient reporting tasting blood/metallic taste
• Excessive swallowing in young children
• Parents of younger children may describe finding blood on the child’s pillowcase
• Estimated amount of blood loss

In addition, ask about the surgical and medical history:

• Time of operation
• Post-operative analgesia – specifically ibuprofen or aspirin
• Past medical history – specifically inherited or acquired bleeding disorders
• Inter-current illnesses – especially upper respiratory tract infections or other febrile illnesses

A full set of observations should be recorded. Be aware that young patients can compensate for large amounts of blood loss before registering a tachycardia or a drop in blood pressure.

Perform an ABCDE assessment specifically looking for:

• Airway compromise
• Haemodynamic instability
• Evidence of bleeding

To examine the tonsils, use a headlamp (if available). Otherwise, examine the patient in a well-lit environment:

• It is normal for the operative site to look yellow-white and sloughy after the operation. This does not mean there is infection.
• Examine the tonsillar fossae and the patient’s throat for fresh bleeding. Excess blood may need to be removed with suction under direct supervision. Do not disturb a formed clot.  If active bleeding is present, try to localise the source as left or right, and inferior or superior pole.
• If the patient is not actively bleeding, look for an old bleeding point or a blood clot in the tonsillar fossae.

Be aware that a small, self-limiting bleed (a ‘herald bleed’) may be a prelude to a larger bleed.

Learning bites

• It is easy to underestimate blood loss, especially in children who are unable to give a full history and can compensate well haemodynamically.
• Small bleeds may be a prelude to a larger bleed.