You are doing a critical care attachment in a small district general hospital. The anaesthetic registrar is busy with a case in theatre. You are bleeped by the emergency department and told they have a normally fit and well 55 year old man who has presented with a two day history of sore throat, cough and dysphagia. He has now developed ‘noisy breathing’.

You arrive in the emergency department to find a slightly overweight 55 year old who is drooling and clearly in distress. Initial assessment and baseline observations reveal:

A: Patient is maintaining and protecting their airway, but has audible stridor and is drooling.

B: Respiratory rate is 32, SaO2 92% on a non-rebreathe mask, there is use of accessory muscles and patient is able to speak in half sentences only.

C: Peripheries are warm, capilliary refill less than 2 seconds. Pulse rate is 120, Blood Pressure is 140/90

D: Patient is conscious, but in severe distress complaining of a very sore throat and difficulty breathing. The patient’s temperature is 38.2 degrees C.

• What is the diagnosis?
• What is the likely organism responsible?
• What will you do next, and in what order?

Thanks to Dr Ed Mellanby for this case. Dr Mellanby will be leading the discussion this week so be sure to join in.