Management (general and specific)

In a patient with active bleeding

1.Call for help

This may include seniors in the emergency department, ENT, or anaesthetics as soon as condition is recognised. The latter, if not for immediate intubation, would help to mobilise the theatre team and get them prepared if the patient requires an emergency operation. Have the difficult airway trolley available.

2.Patient positioning

If appropriate, move patient to the resuscitation area. Sit the patient up. Most patients will be alert and have intact airway reflexes. Maintain a calm manner and reassuring tone (for parents and child).

3.Volume resuscitation

• Two large-bore cannulae
• Consider resuscitation with packed cells
• Administer tranexamic acid at 15 mg/kg in children or 1 gram in adults, given intravenously over 10 minutes
• Correct any coagulopathy. This may require discussion with haematology, especially if there is a diagnosed or suspected clotting disorder.

4.Stem the bleeding

Evacuate as much blood as possible from the mouth with suction under direct vision. This should be done by an experienced senior clinician or ENT.

Consider applying co-phenylcaine (lidocaine with phenylephrine) spray or topical adrenaline to the oropharynx. The latter can be done by soaking a dental roll or gauze with 1:10,000 adrenaline and applying it to the bleeding point, firmly held with Magill’s forceps and directing the pressure laterally (not posteriorly) and with a tail of gauze held outside the mouth.

5.Additional measures/considerations

• Ensure the patient is nil by mouth
• Intravenous analgesia if required
• Consider intravenous antibiotics if indicated
• Consider sedation. This would be dependent on local set-up. In some instances, it may be better to intubate the patient to achieve airway control.
• Consider early intubation if haemostasis is not achieved. Intubation will be compounded by the lack of pre-oxygenation, difficult view (obscured by blood/oedema), distended stomach (filled with blood) and haemodynamic instability.

Learning bites

• Escalate early, especially if ENT is not on-site.
• Airway protection and bleeding control should occur simultaneously with volume resuscitation.