Bleeding after tonsillectomy
Primary: within 24 hours of surgery. Secondary: 24 hours to 14 days after surgery (most often days 6 to 10). Children swallow blood, so loss is often more than it looks.
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OtolaryngologyEmergency
Post-Tonsillectomy Haemorrhage: ED Management
Post-Tonsillectomy Haemorrhage: ED Management: Bleeding after tonsillectomy → Triage ATS 1 or 2: resuscitation area, call ENT now → Anticoagulant, antip...
Pathway Overview
20 steps
Algorithm Steps
20 total
01Start 02Action Triage ATS 1 or 2: resuscitation area, call ENT now
ATS 1 if the airway is at immediate risk or the patient is severely shocked. ATS 2 if active bleeding or circulatory compromise. Call the ENT registrar now; call anaesthesia if bleeding is active.
- Deaths are from airway obstruction and hypovolaemic shock
- Children compensate, then decompensate suddenly: watch for a rising heart rate
- Sit upright, leaning forward; let the patient spit out blood; suction ready
- Nil by mouth. Difficult airway equipment ready
- Ask: time since surgery, ibuprofen or aspirin, own or family bleeding disorder, recent infection
03Warning Anticoagulant, antiplatelet, bleeding disorder or thrombosis?
Check quickly. Do not delay airway care, resuscitation or theatre for this.
- Anticoagulant or antiplatelet: life-threatening bleed, stop and reverse now. Otherwise, with a recent coronary stent, mechanical valve or recent VTE, decide with cardiology or haematology before stopping
- Known or suspected bleeding disorder (for example von Willebrand disease): coagulation screen and von Willebrand screen; haematology advice
- Active DVT, PE or cerebral thrombosis: tranexamic acid is contraindicated. Past thrombosis: senior decision
04Decision Major bleeding, airway risk or shock?
Yes: heavy ongoing bleeding, blood or clot threatening the airway, drowsiness, or signs of shock (rising heart rate, pallor, prolonged capillary refill, low blood pressure). No: minor ooze, or bleeding has stopped, with a safe airway and stable observations.
- If Yes
05Warning Major bleed: senior ENT and anaesthetist now, go to theatre
Surgical emergency. Go directly to theatre. No gargles and no delay for bedside measures. No ENT or theatre on site: call the retrieval service and regional ENT now.
- Call ENT consultant and the most senior anaesthetist now
- Sit up and lean forward (child: position of comfort, keep calm); suction
- Unstable: activate the major haemorrhage protocol
06Action Major bleed: resuscitate while theatre is prepared
Two large-bore IV cannulas (intraosseous if no IV access). FBC, coagulation screen, crossmatch. Inform blood bank.
- Child: 0.9% sodium chloride 10-20 mL/kg bolus; reassess after each bolus
- Still unstable after fluid, or major blood loss: red cells (O negative or group-specific). Adult in shock: red cells early; crystalloid only until blood arrives
- IV tranexamic acid: adult 1 g slow IV over 10 minutes; child 15 mg/kg (max 1 g)
- Adrenaline 1:10,000 (1 mg/10 mL) soaked swab on forceps to the bleeding fossa only if tolerated and a skilled operator is present
07Decision Airway failing or cannot be protected?
Yes: reduced consciousness, cannot clear blood, respiratory distress, or bleeding too heavy to protect the airway. No: awake, sitting up and clearing blood.
- If Yes
08Action Airway failing: intubate now (most experienced operator)
Rapid sequence induction by the most experienced airway doctor available. Expect blood in the airway and a difficult view. Resuscitate before and during induction.
- Two working large-bore suction units
- Front-of-neck access equipment open and ready
- Then theatre for surgical haemostasis
09Warning Bleeding not controlled or major bleed: theatre
ENT haemostasis under general anaesthesia (cautery, suture of the tonsillar pillars). Life-threatening bleeding not controlled in theatre: interventional radiology embolisation or external carotid ligation. No ENT or theatre on site: stabilise, secure the airway if needed, and transfer with a senior airway doctor.
10Outcome After theatre: HDU or ICU as needed
ICU or HDU if intubated, large blood loss or airway concern. Monitor haemoglobin; transfuse to need. Coagulation and bleeding-disorder screen if not done.
If No11Action Airway maintained: to theatre with anaesthetist and ENT
Keep the patient sitting up with suction. Anaesthetist and ENT stay with the patient during transfer. Do not lay flat until the airway is secured in theatre.
- Path rejoins step 09Shared downstream outcome
If No12Action Not major: IV access, bloods, nil by mouth
IV cannula (intraosseous if no IV access). FBC, coagulation screen, group and hold (crossmatch if bleeding continues). Nil by mouth.
- Child with tachycardia or poor perfusion: 0.9% sodium chloride 10-20 mL/kg bolus; reassess
- Any deterioration or heavy bleeding: treat as a major bleed and go to theatre
- Continuous monitoring in ED; watch for a rising heart rate
13Action Minor or stopped bleed: local measures while ENT comes
Only for a calm, cooperative patient with a safe airway. No gargles if drowsy or bleeding heavily (aspiration risk).
- IV tranexamic acid: adult 1 g slow IV over 10 minutes; child 15 mg/kg (max 1 g)
- Lidocaine 5% with phenylephrine 0.5% spray (Co-Phenylcaine Forte) to the oropharynx, if tolerated, before the swab
- Adrenaline 1:10,000 (1 mg/10 mL) soaked swab on forceps to the tonsil bed; press sideways, not backwards; skilled operator, only if tolerated
- Nebulised tranexamic acid: off-label, case-series evidence only; ENT or senior decision, dose per local protocol
- Ice-water gargle: minor ooze in a cooperative older child or adult only
14Action ENT assessment of the tonsil bed
ENT or an experienced doctor removes clot and finds the bleeding point. Silver nitrate cautery if a bleeding point is seen and the patient cooperates.
- Consider antibiotics (infection often precedes a secondary bleed)
- Desmopressin only on ENT, senior or haematology advice
15Decision Bleeding stopped and patient stable?
Yes: no active bleeding after local measures or cautery, and stable observations. No: bleeding continues or recurs, or observations worsen.
- If Yes
16Action Bleeding stopped: admit for observation
Admit every patient with a post-tonsillectomy bleed, even if bleeding has stopped. A further, larger bleed can follow. ENT decides the duration.
- Nil by mouth until ENT review; IV fluids
- At least hourly full observations; watch for a rising heart rate
- Repeat haemoglobin if bleeding recurs or observations change
17Decision Safe for discharge? (ENT decision)
Yes: no further bleeding during observation, eating and drinking, pain controlled, stable haemoglobin, can return to hospital quickly, and the patient or carer understands when to return. No: any of these is missing.
- If Yes
18Outcome No rebleed and criteria met: discharge with return advice
Any fresh bleeding: call 000 or return to ED at once. Sit up and spit out blood. Regular analgesia per ENT. ENT follow-up as arranged.
If No19Outcome Not ready or rebleed: stay in hospital
Continue observation. Any rebleed: call ENT and consider theatre. Recurrent bleeding: haematology review for a bleeding disorder.
If No20Action Bleeding not controlled: theatre now
Call ENT consultant and anaesthetist. Keep sitting up with suction, nil by mouth, IV access and crossmatch. Treat any deterioration as a major bleed. No ENT or theatre on site: call the retrieval service now.
- Path rejoins step 09Shared downstream outcome
Guideline Source
Perth Children's Hospital ED Guideline: Post tonsillectomy haemorrhage (CAHS, March 2023)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Main source is a paediatric ED guideline; adult care follows the same principles, with more anticoagulant and antiplatelet use.
- Local measures and nebulised tranexamic acid rest on case-series evidence; theatre is the definitive treatment.
- Anticoagulant reversal and bleeding-disorder work-up: use local guidelines and haematology advice.
- Blood product and interventional radiology availability varies by hospital.
Contraindicated Populations
Bleeding after oropharyngeal cancer or transoral robotic surgery (major vessel injury risk; use a head and neck surgery pathway)
Applicable Regions
AUNZUSEUUK
AU: Triage with the Australasian Triage Scale (ACEM G24). Nebulised tranexamic acid is off-label: registered routes are oral and IV. Emergency number 000.
US: ESI is used for triage in the US; the steps are otherwise the same.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Post-Tonsillectomy Haemorrhage: ED Management?
The Post-Tonsillectomy Haemorrhage: ED Management is a emergency clinical algorithm for Otolaryngology. It provides a structured decision tree to guide clinical decision-making, based on Perth Children's Hospital ED Guideline: Post tonsillectomy haemorrhage (CAHS, March 2023).
What guideline is the Post-Tonsillectomy Haemorrhage: ED Management based on?
This algorithm is based on Perth Children's Hospital ED Guideline: Post tonsillectomy haemorrhage (CAHS, March 2023).
What are the limitations of the Post-Tonsillectomy Haemorrhage: ED Management?
Known limitations include: Main source is a paediatric ED guideline; adult care follows the same principles, with more anticoagulant and antiplatelet use.; Local measures and nebulised tranexamic acid rest on case-series evidence; theatre is the definitive treatment.; Anticoagulant reversal and bleeding-disorder work-up: use local guidelines and haematology advice.; Blood product and interventional radiology availability varies by hospital.. Individual patient factors may require deviation from these recommendations.
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