Paediatrics – post-tonsillectomy haemorrhage

 

Issues:

Airway difficulty

Problems:

·     Bloody

·     Swollen

·     Shared

·     Stomach full of blood

Assessment:

·     Hx: difficult intubation last time?

·     Ex: work of breathing, stridor, drooling?

Plan:

·     Two suckers

·     Two assistants

·     Direct laryngoscopy

·     South RAE ETT

·     Secure +++

·     Decompress stomach with orogastric tube prior to emergence

Hypovolaemia

Problems:

·     Bleeding

·     Dehydration

Assessment:

·     Hx: volume of blood, oral intake, wet nappies

·     Ex: behaviour, vital signs, CRT

·     Ix: FBE, VBG, coags, G&H vs XM

Plan:

·     2 x IVC + pump set

·     Forced air warmer

·     20mL/kg crystalloid pre-induction

·     Metaraminol 10mcg/kg PRN

·     Tranexamic acid 15mg/kg

·     NIBP q2mins

Bleeding

Timing of surgery:

·     If active and fast bleeding: surgery then resuscitation

·     If inactive or slow bleeding: resuscitation then surgery

Plan:

·     Substrate: rarely needed

·     Adjuncts: TXA 15mg/kg

·     Warming

Induction conflict

Problems:

·     Risk of aspiration -> want big dose

·     Risk of cardiovascular toxicity -> want little dose

Plan:

·     Crystalloid 20mL/kg pre-induction if time

·     Propofol 3mg/kg

·     Rocuronium 1.2mg/kg

·     Metaraminol 10mcg/kg q1min PRN

 

 

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