title: Post tonsillectomy hemorrhage: who needs intervention?
abstract: BACKGROUND
  Post-tonsillectomy hemorrhage (PTH) remains a significant complication. There are no guidelines for Pediatric Emergency Department (PED) disposition of children with secondary PTH.
  
  
  OBJECTIVE
  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.
authors.affiliation: Wayne 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. Electronic address: rarora@dmc.org.
authors.forename: Rajan
authors.initials: R
authors.lastname: Arora
authors.affiliation: Michigan State University College of Osteopathic Medicine, Department of Otolaryngology, Head Neck Surgery, Children's Hospital of Michigan, 3901, Beaubien Blvd, Detroit, MI 48201, United States.
authors.forename: Sonal
authors.initials: S
authors.lastname: Saraiya
authors.affiliation: Biostatistician Center for Quality and Innovation Children's Hospital of Michigan, 3901, Beaubien Blvd, Detroit, MI 48201, United States.
authors.forename: Xun
authors.initials: X
authors.lastname: Niu
authors.affiliation: Wayne State University, Department of Pediatrics, Children's Research Center of Michigan, 3901, Beaubien Blvd, Detroit, MI 48201, United States.
authors.forename: Ronald L
authors.initials: RL
authors.lastname: Thomas
authors.affiliation: Wayne 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.
authors.forename: Nirupama
authors.initials: N
authors.lastname: Kannikeswaran
mesh_terms: D000293:Adolescent; D000367:Age Factors; D002648:Child; D002675:Child, Preschool; D004636:Emergency Service, Hospital; D005260:Female; D006470:Hemorrhage / Q000209:etiology / Q000628:therapy*; D006801:Humans; D007223:Infant; D008297:Male; D010343:Patient Admission / Q000706:statistics & numerical data; D018579:Patient Selection; D012189:Retrospective Studies; D014068:Tonsillectomy / Q000009:adverse effects*
keywords: Children; Disposition; Emergency; Hemorrhage; Intervention; Tonsillectomy