It’s 4 a.m., and you’re three hours from the nearest tertiary care center. A young woman, 13 days post-tonsillectomy, comes into your rural emergency department (ED) coughing up blood. On exam, you see bright red blood trickling down her left tonsillar fossa. Her vital signs are normal, except for a heart rate of 115 bpm. It’s going to take time to get her to a tertiary center.

Managing post-tonsillectomy hemorrhage in the ED can be challenging, especially in rural or resource-limited settings. The key is a stepwise, three-pronged approach—resuscitation, early ENT consultation with transport arrangements, and temporizing measures applied to control bleeding—to keep the patient safe until she’s transferred to definitive care. Additionally, one must be prepared for definitive airway management and know when laboratory investigations will prove valuable to guide further management. By learning a simple approach, you will be better prepared for the next post-tonsillectomy bleed that rolls through your ED doors.

Know What You’re Dealing With

Understanding the distinction between primary and secondary post-tonsillectomy hemorrhage is fundamental to management and prognostication. Primary hemorrhage occurs within 24 hours after surgery, typically from surgical technique issues or an undiagnosed bleeding disorder, such as von Willebrand disease.

A patient’s mouth packed with gauze after tonsillectomy surgery. CREDIT: Dr. P. Marazzi – Science Source (Click to enlarge.)

Secondary hemorrhage occurs between days five and 14 post-operatively, peaking around days five to seven.¹ Secondary bleeds occur because the fibrin clot sloughs off, exposing underlying tissue. Secondary bleeds, often characterized by low-volume bleeding initially—like in this case—can be deceptive but can suddenly increase, causing airway compromise. With any secondary bleed, always keep in mind the “herald bleed” concept. A small trickle from a secondary bleed can be a warning sign for a significant bleed to come, akin to a sentinel bleed from a cerebral aneurysm prior to a large subarachnoid hemorrhage.

Early intervention for all post-tonsillectomy bleeds, whether primary or secondary, is recommended to prevent progression.² Recognizing secondary hemorrhage and initiating early ENT consultation for potential surgical source control is essential, even if bleeding initially appears mild.³

A three-pronged management approach provides a framework for addressing post-tonsillectomy bleeds: resuscitation, early ENT consultation with transport arrangements, and temporizing measures applied to control bleeding.

Resuscitation

Begin by positioning the patient upright in their position of comfort to reduce the risk for aspiration and improve visualization of the bleeding site. Obtain IV access as soon as possible and consider intravenous (IV) tranexamic acid (TXA), which may help stabilize the clot and buy you time. Although evidence for TXA in post-tonsillectomy bleeds remains limited, studies in postsurgical hemorrhage in general have suggested it is a reasonable intervention with a low risk of adverse effects.⁴