A 35 year old man is admitted to the Accident and Emergency department after being found fitting outside a nightclub. On arrival he is no longer fitting, but has a partially obstructed airway, oxygen saturations of 91% on air, heart rate of 91 beats per minute and a blood pressure of 160/90. He is unconscious, but groans to painful stimulus and his left pupil is fixed and dilated.

What is the likely cause for this clinical picture?

Is there likely to be any underlying pathology?

What is your approach to the management of this patient?

Many thanks to Dr Ed Mellanby for this case. Dr Mellanby will be moderating the discussion in the classroom this week, so be sure to add your thoughts.

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.