Topics in this EM Quick Hits podcast

Kevin Wasko on post-tonsillectomy hemorrhage management (1:06)

Brit Long on assessment and management of post-CABG surgical incision infections (15:40)

Anand Swaminathan on evidence, pitfalls and tips on using Bougies (23:07)

Leah Flannigan on when to suspect vascular injury in patients with low energy mechanism pelvic fractures (31:05)

Andrew Petrosoniak on debriefing after cases: why, when and how (38:35)

Podcast production, editing and sound design by Anton Helman

Podcast content, written summary & blog post by Anton Helman, October, 2024

Cite this podcast as: Helman, A. Wasko, K. Long, B. Swaminathan, A. Flannigan, L. Petrosoniak, A. EM Quick Hits 60 – Post-Tonsillectomy Hemorrhage, Post-CABG Infections, Bougie Tips, Pelvic Fracture Bleeds, Debriefing: Why, When & How. Emergency Medicine Cases. October, 2024. https://emergencymedicinecases.com/em-quick-hits-october-2024/. Accessed February 18, 2025.

Post-Tonsillectomy Hemorrhage Management

Best of University of Toronto EM

  • Primary vs. Secondary post-tonsillectomy hemorrhage:
    • Primary post-tonsillectomy hemorrhages occur within the first 24 hours post-op, usually related to intraoperative factors like surgical technique or undiagnosed coagulopathies (e.g., von Willebrand disease). These bleeds are more likely in the immediate post-op period.
    • Secondary post-tonsillectomy hemorrhages occur after 24 hours, typically around post-op days 5 to 7, but can occur up to 14 days. They are caused by the sloughing off of the fibrin clot, exposing underlying tissue, which can lead to ongoing oozing or trickling bleeding. These are more insidious and can escalate quickly into life-threatening hemorrhages.
  • Key point:
    • Even if the bleeding is minor, like a small trickle, it should be considered a potential herald bleed—a precursor to a larger, more dangerous bleed. In these cases, early ENT consultation is crucial as definitive source control is needed, especially if bleeding persists for several hours.
  • Management approach (3-pronged):
    1. Resuscitation:
      • Ensure the patient is sitting upright in a comfortable position to prevent aspiration and make visualization easier.
      • Establish IV access and consider starting IV TXA 1-2g in adults, 15mg/kg in children if appropriate.
    2. Get help early:
      • Contact ENT early, especially if you’re in a rural or resource-limited setting where transfer may be delayed.
      • Arrange for transport to a tertiary care center if no ENT is available locally.
    3. Temporizing measures (until definitive management in the operating room):
      • Direct pressure with gauze and topical medications: Use lidocaine spray for local analgesia, and gauze soaked in epinephrine and/or TXA
      • Tranexamic Acid (TXA) options:
        • Nebulized TXA: Consider while other preparations are made. It’s a low-risk, easy intervention.
        • Topical TXA: Soak gauze in TXA and apply it directly to the bleeding site.
        • IV TXA: 15 mg/kg in children or 1-2 grams in adults over 10 minutes.
        • While evidence is limited, it is a reasonable adjunct in these cases, given the low risk of harm.
  • Airway Management in the post-tonsillectomy bleed
      • If the patient starts to aspirate blood, or if bleeding becomes severe enough to cause respiratory distress (e.g., desaturation, altered level of consciousness), intubation may be required.
      • Preparation is key: Have 2 suctions ready (meconium aspirator or DuCanto catheter) and a second person to help manage the airway.
      • RSI with video laryngoscopy is the usually the airway strategy of choice as described in our Episode 188 Hemoptysis: ED Approach and Management
  • Lab Workup and other medications:
    • Obtain labs to assess for blood loss (hemoglobin, group and screen, and crossmatch if significant bleeding).
    • Fibrinogen levels should be obtained in massive hemorrhage, as fibrinogen concentrate may be required in massive transfusion situations.
    • Consider giving IV DDAVP 0.3 mcg/kg in patients with ongoing brisk bleeding as they may have an undiagnosed von Willebrand disease contributing to the hemorrhage.

=> Key take homes: for patients with delayed post-tonsillectomy bleeds >24 post-op, even if they seem minor and settle in the ED, emergency ENT consultation for definitive treatment is indicated. Utilize gauze-soaked with epinephrine and/or TXA for source control, nebulized or IV TXA, consider DDAVP for unrecognized von Willebrand and be prepared for RSI with double Decanto or meconium aspirator suctioning.

Post Tonsillectomy Hemorrhage management on EM Cases

  1. Morgenstern, J. Massive Hemorrhage Post-Tonsillectomy, First10EM, August 6, 2018. Available at: https://doi.org/10.51684/FIRS.6175
  2. Schwarz, W., Ruttan, T., & Bundick, K. (2019). Nebulized Tranexamic Acid Use for Pediatric Secondary Post-Tonsillectomy Hemorrhage. Annals of Emergency Medicine, 73 3, 269-271 .
  3. Dalesio N. Management of post-tonsillectomy hemorrhage. In: Berkow LC, Sakles JC. Cases in Emergency Airway Management Cambridge. Cambridge University Press; 2015.
  4. Ker K, Edwards P, Perel P, Shakur H, Roberts I. Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. BMJ (Clinical research ed.). 2012; 344:e3054.
  5. Dermendjieva, M., Gopalsami, A., Glennon, N., & Torbati, S. (2021). Nebulized Tranexamic Acid in Secondary Post-Tonsillectomy Hemorrhage: Case Series and Review of the Literature. Clinical Practice and Cases in Emergency Medicine, 5, 1 – 7.
  6. Fields RG, Gencorelli FJ, Litman RS. Anesthetic management of the pediatric bleeding tonsil. Paediatric Anaesthesia. 2010; 20(11):982-6.
  7. Collins MP, Grillo RG, Romero JR. Management of post-tonsillectomy hemorrhage in the emergency department. J Emerg Med. 2001 Jul;21(1):43-8.
  8. Wall, J., & Tay, K. (2018). Postoperative Tonsillectomy Hemorrhage.. Emergency medicine clinics of North America, 36 2, 415-426.
  9. Peterson, J., & Losek, J. (2004). Post-Tonsillectomy Hemorrhage and Pediatric Emergency Care. Clinical Pediatrics, 43, 445 – 448.
  10. Arora, R., Saraiya, S., Niu, X., Thomas, R., & Kannikeswaran, N. (2015). Post tonsillectomy hemorrhage: who needs intervention?. International journal of pediatric otorhinolaryngology, 79 2, 165-9 .
  11. Sarny S, Ossimitz G, Habermann W, Stammberger H. Hemorrhage following tonsil surgery: A multicenter prospective study The Laryngoscope. 2011; 121(12):2553-2560.

Post-CABG Surgical Site Infection

Post CABG surgery infectious complications can be severe, with significant morbidity and mortality in the first 30 days. One such complication is a surgical site infection, which may be classified as superficial or deep.

  • Surgical site infection is a clinical diagnosis; both superficial and deep infections can present with chest pain and fever, but deep infections typically have purulent drainage from the mediastinum and/or sternal instability.
    • Superficial infections involve only the skin, subcutaneous tissue, and fascia, and they usually present with localized redness, tenderness, and drainage at the sternotomy site.
    • Deep sternal infections involve mediastinum, pericardium, and myocardium. These infections, particularly mediastinitis, can lead to life-threatening complications, with a mortality rate of 10-30%.
  • All post CABG wound infections should be considered to be deep infections until proven otherwise
  • Blood cultures + wound/sternal cultures help with organism identification
  • CT chest with IV contrast is the diagnostic modality of choice; it helps differentiate superficial infections from deep space infections, assesses the depth of the infection, identifies sternal dehiscence, and helps plan operative treatment.
  • Treatment of deep surgical site infections includes empiric antibiotics (broad spectrum beta-lactam, vancomycin +/- aminoglycoside) and consultation with CV surgery for debridement in the OR.

=> Key take home: All post-CABG surgical incision infections should be considered deep chest infections until proven otherwise, and managed as such in the ED.

  1. emdoc.net: http://www.emdocs.net/the-sick-post-cabg-patient/
  2. Montrief T, Koyfman A, Long B. Coronary artery bypass graft surgery complications: A review for emergency clinicians. Am J Emerg Med. 2018 Dec;36(12):2289-2297. doi: 10.1016/j.ajem.2018.09.014.

Gum Elastic Bougie: Evidence, Training, Microskills Tips & Pitfalls

  • Bougie Benefits:
    • Studies, such as the BEAM trial (2018) suggest a significant improvement in first-pass intubation success when using a bougie—96% vs. 82% in the standard approach, while other studies suggest no significant difference. The difference in outcomes is most likely explained by provider experience and training with bougies.
    • The key to bougie success is regular practice; it’s most beneficial in skilled hands.
  • Practical Tips for Bougie Use:
    • Scissor Grip technique: This method allows real-time control of the coudé tip direction, especially when navigating through difficult airways.
    • Keep visual contact with the cords while advancing the bougie—don’t take your eyes off the bougie, as it can inadvertently slip out.
  • Overcoming Common Bougie Challenges:
    • If the bougie tip gets caught on tracheal rings, simply rotate the bougie 90 degrees to release it.
    • If the ETT gets stuck on the arytenoids, back up slightly and rotate the tube 90 degrees counterclockwise to guide it through the cords.

=> Key take home: The bougie can improve first-pass success in airway management but requires regular practice of the nuanced techniques and microskills.

Scissor Grip short video

Single Operator Technique

  1. Driver BE et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA 2018.
  2. Driver BE et al. Effect of Use of a Bougie vs Endotracheal Tube with Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial (BOUGIE Trial). JAMA 2021.
  3. Barnicle RN, Bracey A, Weingart SD. Managing emergency endotracheal intubation utilizing a bougie. Ann Emerg Med 2024.

Pelvic Fracture Vascular Injury in Ground Level Falls

  • There exists a small but significant bleeding risk with low-energy mechanism pelvic fractures:
    • Even ground-level falls in elderly patients can lead to retroperitoneal hematomas and significant pelvic hemorrhage.
    • An elevated shock index (SI > 1), dropping hemoglobin or signs of metabolic acidosis (e.g., increased lactate) should raise suspicion for occult bleeding.
  • Imaging and Workup:
    • CT angiogram of the pelvis is essential in diagnosing vascular injuries such as the corona mortis (a vascular connection between the external iliac and obturator arteries, aptly nicknamed the “crown of death” due to its high bleeding risk).
    • Early blood transfusion is indicated if there are signs of active hemorrhage.
  • Management:
    • Patients with significant bleeding may require interventional radiology for embolization of the bleeding vessel.
    • Consideration of DOAC reversal (e.g., PCCs) is indicated if the patient is anticoagulated.

=> Key take home: consider vascular injury when clinical clues of hemorrhage are present even in pelvic fractures from a low energy mechanism

More on pelvic fracture in older patients

Clinical Debriefing: Why, When and How

  • Why debriefing is important:
    • Regular debriefing has been shown to improve team performance by 20-25%.
    • It fosters team learning and provides an opportunity to reflect on both what went well and what could be improved.
    • Debriefs also help build team cohesion and allow space to process emotionally challenging cases.
  • When to debrief:
    • Do not limit debriefing to cases with bad outcomes. Debrief a variety of cases—ones that went well, ones that didn’t, and those where the outcome didn’t match the expected trajectory.
  • Common barriers to debriefing and solutions:
    1. Time constraints: Make debriefing part of the patient care process. Keep debriefs short (around 10-15 minutes), and debrief immediately after critical cases.
    2. Lack of skills: You do not need formal training to start debriefing. Just gather the team and ask simple questions like, “What went well?” and “What could be improved?”
    3. Cultural barriers: Start small. Lead by example, and over time, debriefing can become part of the routine culture in your ED.
  • How to debrief: The INFO Framework:
    • I: Immediate—do it soon after the event.
    • N: Not for personal assessment—focus on system and team performance, not individual critiques.
    • F: Fast—keep it concise and focused.
    • O: Opportunity—ensure everyone can ask questions or offer suggestions.

Debriefing INFO framework

PEARLS debriefing framework

=> Key take home: Debriefing after cases is relatively simple to do and may improve team and individual performance as well as improve ED work culture.

More on Strategies to Improve EM Culture

  1. Petrosoniak A, Gabriel J, Purdy E. Stop asking if it works, start making it happen: exploring barriers to clinical event debriefing in the ED. CJEM. 2022 Nov;24(7):673-674. doi: 10.1007/s43678-022-00396-9. Epub 2022 Oct 24.

None of the authors have any conflicts of interest to declare