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Post tonsillectomy hemorrhage: who needs intervention?
Rajan Arora1, Sonal Saraiya2, Xun Niu3
1Wayne State University School of Medicine, Carman and Ann Adam Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Michigan, 3901, Beaubien Blvd, Detroit, MI 48201, United States.
Insights
Secondary post-tonsillectomy hemorrhage (PTH) in children often leads to admission and intervention. Healthy children under 6 with normal throat exams may be safe for discharge from the pediatric emergency department (PED).
Area of Science:
- Pediatric Emergency Medicine
- Otolaryngology
- Hemorrhagic Complications
Background:
- Post-tonsillectomy hemorrhage (PTH) is a significant complication in children.
- Current guidelines are lacking for pediatric emergency department (PED) disposition of secondary PTH cases.
Purpose of the Study:
- To determine the incidence and clinical features of secondary PTH in children presenting to a PED.
- To identify factors associated with the need for operative or inpatient intervention for secondary PTH.
- To inform disposition decisions for children with secondary PTH.
Main Methods:
- Retrospective chart review of healthy children aged 1-18 years with secondary PTH from 2005-2012.
- Data collected included demographics, clinical findings, laboratory results, interventions, and disposition.
- Oropharyngeal examination findings were specifically analyzed.
Main Results:
- The incidence of secondary PTH was 2.3% among 121 analyzed patients.
- Most patients did not present with hypotension or severe anemia.
- A positive oropharyngeal exam (clot, ooze, or active bleeding) was present in 65.3% of patients.
- 71.9% of patients were admitted, and 61.1% required intervention (medical or surgical).
- Age ≥6 years and a positive oropharyngeal exam were associated with increased need for intervention.
- No patient with a normal initial oropharyngeal exam required intervention.
- Recurrence rates were similar for admitted and discharged patients, with no life-threatening recurrences.
Conclusions:
- The majority of children with secondary PTH require admission and intervention.
- Healthy children under 6 years with a normal oropharyngeal exam may be suitable for discharge from the PED.
- Ensuring reliable return for potential recurrence is crucial for discharged patients.
Background:
Post-tonsillectomy hemorrhage (PTH) remains a significant complication. There are no guidelines for Pediatric Emergency Department (PED) disposition of children with secondary PTH.
Objectives:
To describe the incidence, clinical characteristics and interventions required by children presenting to a PED with secondary PTH. To identify patient and clinical characteristics associated with need for operative/inpatient intervention.
Methods:
Retrospective chart review of healthy children 1-18 years with secondary PTH from 2005 to 2012. Demographics, clinical and oropharynx findings, laboratory data, intervention type and ED disposition were recorded.
Results:
We encountered 181 children with 193 episodes of PTH. One hundred and twenty one patients were included in the final analysis. Secondary PTH rate was 2.3%. Only a minority of patients were hypotensive (3.3%) or had hemoglobin<10g/dl (9.5%) at presentation. 65.3% Children had positive oropharyngeal exam: clot 39 (49.4%) patients; ooze 17 (21.5%) patients; ooze+clot in 5 (6.3%) patients or active bleeder in 18 (22.8%) patients. Eighty seven (71.9%) patients were admitted; 74 (61.1%) patients required active intervention: medical 14.8%, surgical 74.4% or both 10.8%. Thirty seven children needed immediate operative intervention. Only positive oropharyngeal exam and age ≥6 years were significantly associated with need for intervention. None of the patients with a confirmed normal oropharyngeal exam at the initial visit required any intervention either medical or surgical. The rate of return visit for recurrent PTH was found to be similar for both the admitted and the discharged group. No patient returned with a life threatening hemorrhage.
Conclusions:
Majority of children with secondary PTH were admitted and nearly 3/5th of them required an intervention. Our data suggests that healthy children <6 years with a confirmed normal oropharyngeal exam are less likely to require an intervention and may be candidates for safe discharge from the ED provided reliability of return for recurrence can be assured.
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