Presiding Officer Training module 2024 lok sabha elections
Ludwig's Angina Case Presentation and Emergency Tracheostomy
1. CASE PRESENTATION OF
LUDWIG’S ANGINA –
INCISION & DRAINAGE
-Dr .Arthi
-Dr.Madhula
OT CONSULTANT- Dr .Gayathri(ASSO.PROF)
2. Name – Harikrishnan
Age – 35/M
Brief History
Past History
No h/o URI,LRI
No previous surgical history
c/o swelling & pain in floor of mouth for 4 days.
h/o difficulty in mouth opening,h/o difficulty in
protruding tongue, Trismus present.
Recently Diagnosed DM on Insulin
Recently Diagnosed AKI
No other Comorbities
6. PERI-OP RISK FACTORS
PATIENT FACTORS
Ludwig’s
angina
Compromised
airway
Sepsis
Diabetic
AKI
SURGICAL FACTORS
Infection
Bleeding
Distortion of plane
Spread of abscess
Post surgical edema
Extension of
resection
ANAESTHESIA FACTORS
Difficult airway
Difficult extubation
Risk of aspiration
Airway obstruction
7. In Pre-op room,patient was assessed & history noted.
Prepared the patient for awake fibreoptic
Nasal packing was done with 2% lignocaine with adrenlaine
Nebulisation given with 4% lignocaine with adrenaline
IV line secured with 18g venflon.
Shifted the patient inside ot,monitors connected,baseline vitals noted
HR – 102/min, BP – 120/70mmHg,Spo2-100%
Midaz -1mg, Glyco – 0.4mg,Buprenorphine -90mcg
Transtracheal block was given with 2%lignocaine
8. Awake fibreoptic nasal intubation done with 7 size ET Tube fixed with 19cm.
Propofol – 100mg, vec – 4mg given,dexa-8mg,
Agent – sevoflurane 2,O2 & N2O on low flow
500ml fluid on flow
Hemodynamics were stable throughout surgery
At the end of surgery,agent cut off, patient started breathing, reversal given,
nasopharyngeal airway 7 size introduced, patient opened the eyes,
swallowing reflex present, extubation done.
Patient was monitored on ot table for 15 minutes.Throughout patient was
conscious,oriented,vitals stable. Nasoppharyngeal airway was kept.airway
removed on patient request not able to tolerate
9. After extubation,patient was shifted ,nasopharyngeal airway removed,
suddenly patient has some abnormal breathing noticed,then shifted the
patient to on table become hypoxic may be due to airway obstruction,spo2
falls to 70%
Mask ventilation done with 100% oxygen.CPAP was given.
Nasopharyngeal airway was introduced,from that blood &mucous with pus
were spilling out,then we could not ventilate,we could not able to intubate
we started getting ready for emergency tracheostomy fastrack.
Consent for tracheostomy obtained.
Explained the condition to patient attenders about patient condition
Immediate Tracheostomy done
10. After Tracheostomy ,ABG done
Diagnosed Respiratory acidosis
On auscultation-B/L creps +
Mask ventilation done with 100%oxygen,ventilator parameters settings done with
PEEP – 8. peak airway pressure -34 ,propofol-30,midaz-2mg,
Continous ooze from tracheostomy site
Fibreoptic was done to rule out source of bleeding ,
Suspect of negative pressure pulmonary edema ,?aspiration
Morphine – 6mg, Lasix – 20mg given.
Before shifting patient to ICU, patient sedated with propofol 40, midaz 3mg,
On auscultation – B/L creps +,
PH-7.24,pco2-61,po2-90,Fio2-100%
16. On post op day 1,morning ABG done
Hemodynamics stable,
on auscultation – minimal creps present.
At 12pm – patient was extubated in ICU,ABG repeated,
Hemodynamics stable,
On auscultation- B/LAE+, no creps,no secretions.
PH-7.46,pco2-39,Hco3-27,po2-153
PH-7.58,pco2-38,HCO3-35PO2-58
17. On post op day 2,patient shifted to A0 post op ward.
On morning,patient was not cooperative,went out from ward,mild
disoriented, agitated behaviour,patient pulled tracheostomy tube, chronic
alcoholic ,got psychiatry opinion.
Psychiatry opinion – Alcohol dependence syndrome,adviced
Inj.Thiamine,Inj.Haloperidol
Patient was restrained in bed.Tracheostomy care was given.
Hemodynamics stable.
18.
19.
20. DISCUSSION
Ludwig’s angina is a life threatening condition.
Airway obstruction may lead to negative pressure pulmonary edema
