Postoperative Tonsillectomy and Adenoidectomy (T&A) Bleed Clinical Pathway – Emergency Department, Inpatient and PICU

Activate Local Emergency Response for Active Bleeding
Inpatient units and PACU

History and Physical

Estimate blood loss
Vital signs, mental status
Evaluate for:
- Tonsillar bleeding
- Tonsillar clot
- Presence of eschar

NPO
Avoid unnecessary suctioning
Labs, IVF:
- CBC
- BMP, as indicated
- NS bolus, repeat as indicated
- Maintenance IVF, as indicated

No Active Bleeding

Active Bleeding

History of minimal blood loss and no tonsillar clot present

Tonsillar clot present or > 1 episode of bleeding

ENT Consult

Urgent ENT consult
Consider inhaled tranexamic acid (TXA)
Additional labs
- T&C if Hgb < 10 mg/dL
Bag and mask at bedside

ED Resuscitation room
Immediate ENT consult
Administer inhaled and IV TXA
Consider racemic epinephrine
Oxymetazoline for nasal bleeding
PRBC transfusion as indicated
Prepare LMA
Consider difficult airway cart
Control airway as indicated
Place 2 IVs
Additional labs
- PT/PTT, T&C
Notify OR x54444

Discharge

Admit EDECU

Admit ENT Service
OR as indicated

OR as Soon As Available

Well-appearing
Stable Hgb, vital signs
Tolerating PO
Age > 2 yrs
Discharge

Stable vital signs
No current bleeding
Minimal blood loss per ENT
No clot
Normal Hgb, no coagulaopathy

Posted: July 2008
Last Revised: February 2026
Authors:
- C. Jacobstein, MD
- T. Giordano, DNP
- K. Dedhia, MD
- D. Lee, MD
- G. Galioto, PharmD
- A. Dragon, RN
- L. Walsh, PharmD
- E. Hardy, CRNP
Editors: Clinical Pathways Team

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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Emergency Department, Inpatient and PICU Clinical Pathway for the Evaluation/Treatment of Children with Postoperative Tonsillectomy and Adenoidectomy (T&A) Bleed

Evidence