A single small haematemesis after tonsillectomy is routinely treated as a herald bleed to be observed, and that is right — but observation is not a plan on its own. The window between the herald and the real bleed is when everything useful can be done, and it is often spent waiting.
Use it. Get intravenous access while the child is calm and cooperative, send a group and save, and give the analgesia and antiemetic that will keep them from retching. Then decide, explicitly and out loud, what happens if it bleeds again — who is called, which theatre, and whether nebulised tranexamic acid is available on the ward and who is authorised to give it.
The practical failure in these cases is rarely the decision to operate. It is that the cannula goes in during the second bleed, in a frightened child who is swallowing blood, at two in the morning.
- Site intravenous access at the herald bleed, not at the second one
- Send a group and save on arrival
- Treat pain and nausea actively — retching provokes rebleeding
- Write the escalation plan in the notes, naming who is called
- Check whether nebulised tranexamic acid is stocked and who can prescribe it
Why it matters
The observation period is usually treated as waiting when it is the only calm working time you get.
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