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

Don’t Wait to Make the Call

Early ENT consultation is crucial, particularly in rural settings with limited access to specialized care. Secondary post-tonsillectomy hemorrhages often require surgical intervention. The literature suggests that approximately 85 percent of these cases require procedural source control in the operating room, highlighting the importance of expediting transport arrangements.⁵

Temporizing Measures

Temporizing measures are vital while awaiting transport, as they help to stabilize the patient and prevent further deterioration. First, lidocaine spray can be used for local analgesia, increasing patient tolerance.⁶ Apply direct pressure to the bleeding site with gauze soaked in TXA and epinephrine as a first-line intervention.⁷ Epinephrine acts as a local vasoconstrictor, aiding hemostasis, and TXA helps to stabilize clot formation on the exposed tissue and delay hemorrhage progression. For topical application of medications, a hack that I’ve found useful is utilizing a see-through plastic vaginal speculum with a built-in light; it gives great exposure, great lighting, and great access to the point of maximal bleeding.

TXA can be administered in three ways: nebulized, topical, or intravenous. Each method has a role in managing secondary post-tonsillectomy bleeds, although evidence is limited to case studies and small observational trials with variable results.^7,8 Nebulized TXA can be thought of as a “set it and forget it” intervention. Put it on early while you’re managing other tasks; it requires minimal involvement and frees you up for other essential steps. Gauze soaked in TXA applied to the tonsillar fossa provides localized bleeding control. IV TXA one to two grams in adults, or 15 mg/kg in children over 10 minutes, offers another layer of control, particularly when topical TXA alone does not suffice. The evidence may be sparse, but TXA in any form is generally safe in patients without obvious thrombotic contraindications.

Lastly, an antiemetic such as IV ondansetron is recommended to prevent vomiting, which can exacerbate bleeding or dislodge forming clots. Controlling nausea may also reduce the risk for gag reflex activation during oropharyngeal manipulation, further minimizing trauma.

Airway Management

If bleeding worsens and the patient shows signs of aspiration or respiratory distress, such as desaturation or altered mental status, securing the airway may become necessary. Be prepared for all but the most trivial bleeds with a double suction setup and video rapid sequence intubation (RSI) as you might in the setting of massive hemoptysis.⁹ Have two suction devices ready—ideally meconium aspirators or DuCanto catheters, which allow for superior fluid clearance from the oropharynx compared with Yankauer catheters.¹⁰ Careful, smooth RSI with video laryngoscopy is the preferred airway strategy, as it is likely to give you the best view while minimizing the need for multiple attempts, which may increase bleeding from localized trauma.

Laboratory tests, although not essential for initial management, are recommended to assess the patient’s baseline status and prepare the receiving facility. Hemoglobin, type and screen, and crossmatch should be prioritized for significant blood loss and potential transfusion requirements. Fibrinogen levels should also be obtained, where available, if severe hemorrhage suggests the potential need for administration of fibrinogen concentrate.

For patients with ongoing brisk bleeding despite the above measures, a coagulopathy should be suspected, and desmopressin (DDAVP) at a dose of 0.3 mcg/kg IV may be considered, especially if von Willebrand disease is suspected. DDAVP is shown to enhance platelet adhesion, potentially stabilizing bleeding until surgical intervention is available.¹¹

Summary

The next time you’re faced with a post-tonsillectomy bleed, remember that primary hemorrhage occurs within 24 hours post-operatively and may indicate surgical causal factors or undiagnosed coagulopathies. Secondary hemorrhage, typically occurring between days five and seven, but as many as 14, can start as a trickle and escalate quickly. Even if you are successful in stopping the bleed in the ED, these patients need rapid ENT consultation for urgent definitive management in the operating room.

Using the three-pronged approach outlined here—resuscitation, early ENT consultation with expedited transport, and temporizing measures—while preparing for airway management and ordering appropriate laboratory investigations, will save your post-tonsillectomy patients from a potentially life-threatening hemorrhage.

Special thanks to Dr. Kevin Wasko, guest expert on the EM Cases podcast on this topic, who inspired this column.

Dr. Helman is an emergency physician at North York General Hospital in Toronto. He is an assistant professor at the University of Toronto, Division of Emergency Medicine, and the education innovation lead at the Schwartz/Reisman Emergency Medicine Institute. He is the founder and host of the Emergency Medicine Cases podcast and website.

References

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9. Helman A, Weingart S, Tillmann B. Hemoptysis – ED approach and management. Emergency Medicine Cases. Published November 2023. Accessed October 31, 2024.
10. Andreae MC, Cox RD, Shy BD, et al. 319 Yankauer outperformed by alternative suction devices in evacuation of simulated emesis. Ann Emerg Med. 2016;68(4):S123.
11. Swieringa F, Lancé MD, Fuchs B, et al. Desmopressin treatment improves platelet function under flow in patients with postoperative bleeding. J Thromb Haemost. 2015;13(8):1503-1513.