Paediatrics – post-tonsillectomy haemorrhage

 

Issues:

Airway

Problems:

·      Airway: soiled, swollen, shared, remote

·      Stomach: full of emetogenic blood

Assessment of threat:

·      Hx: prev difficult intubation?

·      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

Circulation

Problems:

·      Blood loss

·      Dehydration (poor appetite)

Assessment of volume status:

·      Hx: how much bleeding, 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

·      Tranexamic acid 15mg/kg

·      NIBP q2mins

Induction

Problems:

·      Rock: risk of aspiration -> want big dose

·      Hard place: risk of cardiovascular toxicity -> want little dose

·      Even worse: intolerance of awake IVC

Considerations:

·      Airway: expect difficulty otherwise?

·      CVS: quantity and rate of blood loss?

Preferred plan:

·      Discussion + rapport

·      Amethocaine topicalization

·      Consider pre-med: midazolam 0.5mg/kg

·      Awake IVC 22g

·      Crystalloid 20mL/kg pre-induction if time

·      Metaraminol 50mcg/kg/h throughout

·      Propofol 3mg/kg

·      Rocuronium 1.2mg/kg

Timing

·      If active and fast bleeding: surgery then resuscitation

·      If inactive or slow bleeding: resuscitation then surgery

 

 

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