A DCT station on MedMock, start to finish

You are the DCT1 on call in the Emergency Department. What is your diagnosis, why is this patient at immediate risk, and what are your first actions?

This patient has Ludwig's angina—a rapidly progressive, bilateral cellulitis of the submandibular, sublingual and submental spaces secondary to a lower molar odontogenic infection—complicated by impending upper airway obstruction and sepsis. The red flags are stridor-equivalent airway threat: sitting upright leaning forward, drooling saliva, a raised floor of the mouth pushing the tongue superiorly and posteriorly, a muffled 'hot potato' voice and severe trismus of 10 millimetres. My immediate priority is airway safety. I will move him into the Emergency Department Resuscitation bay, keep him sitting upright in the position of comfort, never lay him flat or attempt blind oral instrumentation, and put out an immediate senior airway call to the on-call Consultant Anaesthetist, my OMFS Registrar and Consultant on call, and the Emergency Department senior.

While the anaesthetic and OMFS seniors are on their way to Resuscitation, how do you manage him using an ABCDE approach?

Under Airway and Breathing, I will keep him calm and upright, administer high-flow humidified oxygen titrated to saturations of 94 to 98 per cent, and ensure difficult-airway equipment—including fibreoptic awake intubation kit and a surgical front-of-neck access set—is prepared at the bedside. Under Circulation, I will site two wide-bore intravenous cannulae, take bloods for full blood count, urea and electrolytes, C-reactive protein, coagulation screen, venous blood gas with lactate, blood cultures and a group and save, and begin Sepsis Six bundle resuscitation within one hour: intravenous broad-spectrum antibiotics per trust microbiology guidelines (such as intravenous co-amoxiclav and metronidazole, after checking allergy status), intravenous dexamethasone to reduce airway oedema, intravenous crystalloid fluid resuscitation, and catheter/urine output monitoring.

The Emergency Department foundation doctor suggests sending him to the radiology department now for a contrast CT of the neck before calling theatres. How do you respond?

I would politely but firmly stop that transfer. A patient with bilateral submandibular swelling, raised floor of mouth, drooling and a muffled voice can lose their airway completely if laid supine inside a CT scanner—the radiology suite is a classic place for fatal airway obstruction in Ludwig's angina. The airway must be secured first in theatre by a senior anaesthetist—typically via awake fibreoptic nasal intubation or tracheostomy under local anaesthesia with the OMFS surgical team scrubbed and ready for emergency surgical airway—before any supine CT imaging is performed, followed by formal extra-oral surgical decompression, drainage of the involved fascial spaces and extraction of the causative lower molar.

Thank you. That is the end of the station.